WSR 25-10-082
PERMANENT RULES
HEALTH CARE AUTHORITY
[Filed May 6, 2025, 12:11 p.m., effective June 6, 2025]
Effective Date of Rule: Thirty-one days after filing.
Purpose: The health care authority (agency) revised this rule section to update language allowing the agency to adjust fees using market research as necessary to align with other reimbursement WAC and the medicaid state plan.
Citation of Rules Affected by this Order: Amending WAC 182-531-0850.
Adopted under notice filed as WSR 25-07-009 on March 6, 2025.
Changes Other than Editing from Proposed to Adopted Version:
Proposed/Adopted | WAC Subsection | Reason |
WAC 182-531-0850(2) |
Proposed | (2) The ((department)) agency updates budget-neutral fees each July by: | To allow for changes annually in various months as necessary. |
Adopted | (2) The agency updates budget-neutral fees each year by: |
WAC 182-531-0850 (3)(d) |
Proposed | (3)(d) If appropriate, the agency may adjust fees using market research. The ((department)) agency reimbursement for clinical laboratory ((diagnostic)) procedures does not exceed the regional ((MCDLF schedule)) CLFS. | As a result of stakeholder comment, the agency added in a definition for market research. |
Adopted | (3)(d) If appropriate, the agency may adjust fees using market research. The agency reimbursement for clinical laboratory procedures does not exceed the regional CLFS. (i) "Market research" means the systematic collection and analysis of relevant and verifiable data related to the healthcare marketplace, including commercial benchmarks, medicaid rates from other states, and relevant economic indicators. (ii) Market research will be appropriate when a material change in market conditions is demonstrated or is directed by the legislature. |
WAC 182-531-0850(4) |
Proposed | (4) The ((department increases)) agency may change fees ((if the legislature grants a vendor rate increase or other increase)) based on legislative direction. If the legislatively authorized ((increase)) change becomes effective at the same time as the ((department's)) agency's annual update, the ((department)) agency applies the ((increase)) change after calculating budget-neutral fees. | The agency added "if applicable" because a legislative directive may not pertain to budget-neutral fees. |
Adopted | (4) The agency may change fees based on legislative direction. If the legislatively authorized change becomes effective at the same time as the agency's annual update, the agency applies the change after calculating budget-neutral fees if applicable. |
Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.
Number of Sections Adopted at the Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.
Number of Sections Adopted on the Agency's own Initiative: New 0, Amended 1, Repealed 0.
Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 1, Repealed 0.
Number of Sections Adopted using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 1, Repealed 0.
Date Adopted: May 6, 2025.
Wendy Barcus
Rules Coordinator
RDS-6148.4
AMENDATORY SECTION(Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)
WAC 182-531-0850Laboratory and pathology physician-related services reimbursement.
(1) The ((department))agency pays for clinical diagnostic laboratory procedures based on the medicare clinical ((diagnostic)) laboratory fee schedule ((MCDLF)) (CLFS) ((for the state of Washington. The department)). The agency obtains information used to update fee schedule regulations from ((Program Memorandum and Regional Medicare Letters as published by HCFA))the CMS CLFS website.
(2) The ((department))agency updates budget-neutral fees each ((July))year by:
(a) Determining the units of service and expenditures for a base period. Then,
(b) Determining in total the ratio of current ((department))agency fees to existing medicare fees. Then,
(c) Determining new ((department))agency fees by adjusting the new medicare fee by the ratio. Then,
(d) Multiplying the units of service by the new ((department))agency fee to obtain total estimated expenditures. Then,
(e) Comparing the expenditures in ((subsection (14)))(d) of this ((section))subsection to the base period expenditures. Then,
(f) Adjusting the new ratio until estimated expenditures equals the base period amount.
(3) The ((department))agency calculates maximum allowable fees (MAF) by:
(a) Calculating fees using methodology described in subsection (2) of this section for procedure codes that have an applicable ((medicare clinical diagnostic laboratory fee (MCDLF)))CLFS.
(b) Establishing RSC fees for procedure codes that have no applicable ((MCDLF))CLFS.
(c) Establishing maximum allowable fees, or "flat fees" for procedure codes that have no applicable ((MCDLF))CLFS or RSC fees. ((The department updates flat fee reimbursement only when authorized by the legislature.))
(d) If appropriate, the agency may adjust fees using market research. The ((department))agency reimbursement for clinical laboratory ((diagnostic)) procedures does not exceed the regional ((MCDLF schedule))CLFS.
(i) "Market research" means the systematic collection and analysis of relevant and verifiable data related to the health care marketplace, including commercial benchmarks, medicaid rates from other states, and relevant economic indicators.
(ii) Market research will be appropriate when a material change in market conditions is demonstrated or is directed by the legislature.
(4) The ((department increases))agency may change fees ((if the legislature grants a vendor rate increase or other increase))based on legislative direction. If the legislatively authorized ((increase))change becomes effective at the same time as the ((department's))agency's annual update, the ((department))agency applies the ((increase))change after calculating budget-neutral fees, if applicable.