Original Notice.

Preproposal statement of inquiry was filed as WSR 99-06-086.

Title of Rule: WAC 388-550-6000 Payment--Outpatient hospital services.

Purpose: To comply with the Governor's Executive Order 97-02 which mandates that rules be reviewed for clarity, foundation in law, etc. To clarify department policy without changing policy.

Statutory Authority for Adoption: RCW 74.08.090, 42 U.S.C. 1395x(v), 42 C.F.R. 447.271, 42 C.F.R. 11303.

Statute Being Implemented: 42 U.S.C. 1395x(v), 42 C.F.R. 447.271, 42 C.F.R. 11303.

Summary: No substantive change has been made. The rule has been rewritten in order to clarify depart policy and comply with the Governor's Executive Order 97-02.

Reasons Supporting Proposal: To comply with the Governor's Executive Order 97-02.

Name of Agency Personnel Responsible for Drafting, Implementation and Enforcement: Amy White, DOSS, 623 8th Avenue S.E., Olympia, WA 98501, (360) 586-2599.

Name of Proponent: Department of Social and Health Services, Medical Assistance Administration, governmental.

Rule is not necessitated by federal law, federal or state court decision.

Explanation of Rule, its Purpose, and Anticipated Effects: The rule lists department-covered outpatient hospital care and services, with limitations and requirements for payment. No effects from the rewording are anticipated.

Proposal does not change existing rules.

No small business economic impact statement has been prepared under chapter 19.85 RCW. No substantive change is being made to the rule, so there is no economic impact on small businesses.

RCW 34.05.328 applies to this rule adoption. This rule does meet the definition of a significant legislative rule and a cost benefit analysis has been prepared. To receive a copy contact Amy White, DOSS, 623 8th Avenue S.E., Olympia, WA 98501, (360) 586-2599.

Hearing Location: Lacey Government Center (behind Tokyo Bento Restaurant), 1009 College Street S.E., Room 104-B, Lacey, WA 98503, on May 25, 1999, at 10:00 a.m.

Assistance for Persons with Disabilities: Contact Paige Wall by May 14, 1999, phone (360) 902-7540, TTY (360) 902-8324, e-mail pwall@dshs.wa.gov.

Submit Written Comments to: Identify WAC Numbers, Paige Wall, Rules Coordinator, Rules and Policies Assistance Unit, P.O. Box 45850, Olympia, WA 98504-5850, fax (360) 902-8292, by May 25, 1999.

Date of Intended Adoption: May 26, 1999.

April 19, 1999

Marie Myerchin-Redifer, Manager

Rules and Policies Assistance Unit

(1)(a) Excluding nonallowable revenue codes and the services specified in subsection (2) below MAA determines allowable costs for hospital outpatient services((, excluding nonallowable revenue codes,)) by the application of the hospital-specific outpatient ratio of costs to charges (RCC)((, except as specified in subsection (2) below)).

(b) MAA does not pay separately for ancillary hospital services which are included in the hospital's RCC reimbursement rate.

(2) MAA pays the lesser of billed charges or MAA’s published maximum allowable fees for the following outpatient services:

(a) Laboratory/pathology;

(b) Radiology, diagnostic and therapeutic;

(c) Nuclear medicine;

(d) Computerized tomography scans, magnetic resonance imaging, and other imaging services;

(e) Physical therapy;

(f) Occupational therapy;

(g) Speech/language therapy; and

(h) Other hospital services as identified and published by the department.

(3) MAA is not responsible for payment of hospital care and/or services provided to a client enrolled in a MAA-contracted, prepaid medical plan when the client fails to use:

(a) For a nonemergent condition, a hospital provider under contract with the plan;

(b) In a bona fide emergent situation, a hospital provider under contract with the plan; or

(c) The provider whom MAA has authorized to provide and receive payment for a service not covered by the prepaid plan, but covered under the client's medical assistance program.

(4) Providers or managed care entities that charge Medicare beneficiaries excess amounts are subject to sanctions as listed in 42 U.S.C. 1320A-7b (d)(1). These sanctions include a fine of up to twenty-five thousand dollars or imprisonment of up to five years, or both.

(5) MAA considers a hospital stay of twenty-four hours or less as an outpatient short stay.   MAA does not pay an outpatient short stay under the ((diagnosis-related group)) DRG system except when it involves one of the following situations:

(a) Death of a client;

(b) Obstetrical delivery;

(c) Initial care of a newborn; or

(d) Transfer of a client to another acute care hospital.

(((5))) (6) MAA does not pay for patient room and ancillary services charges beyond the twenty-four period for outpatient stays.

(((6))) (7) MAA does not cover short stay unit, emergency room facility ((charges)), and labor room charges in combination when ((the billed)) these billing periods overlap.

(((7))) (8) MAA requires that the hospital's bill to the department shows the admitting, principal, and secondary diagnoses((, and)). Include the attending physician's name and MAA provider number.

(((8))) (9) Payments for trauma services may be enhanced per WAC 246-976-935.

[Statutory Authority: RCW 74.08.090, 42 USC 1395 x(v), 42 CFR 447.271, 447.11303, and 447.2652.  99-06-046, § 388-550-6000, filed 2/26/99, effective 3/29/99.  Statutory Authority: RCW 74.08.090, 74.09.730, 74.04.050, 70.01.010, 74.09.200, [74.09.]500, [74.09.]530 and 43.20B.020.  98-01-124, § 388-550-6000, filed 12/18/97, effective 1/18/98.]

Reviser's note: The bracketed material preceding the section above was supplied by the code reviser's office.

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