Original Notice.

Preproposal statement of inquiry was filed as WSR 99-20-048.

Title of Rule: WAC 388-502-0160 Billing the client.

Purpose: To describe the circumstances under which MAA allows a contracted provider to bill a medical assistance client directly.

Statutory Authority for Adoption: RCW 74.08.090, 74.09.520.

Statute Being Implemented: RCW 74.08.090, 74.09.520.

Summary: The proposed rule explains when a provider (a person who has an agreement with the department to provide services, equipment, and/or supplies to medical assistance clients) may and may not bill a client. This rule includes some policy changes.

Reasons Supporting Proposal: To update policy in WAC and to comply with the clear writing standards in the Governor's Executive Order 97-02.

Name of Agency Personnel Responsible for Drafting: Leslie Saeger, P.O. Box 45533, Olympia, WA 98504, (360) 725-1347; Implementation and Enforcement: Alan Himsl, P.O. Box 45533, Olympia, WA 98504, (360) 725-1347.

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

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

Explanation of Rule, its Purpose, and Anticipated Effects: The proposed rule will replace portions of chapter 388-87 WAC that pertain to client billing, and includes provisions not currently in rule. It specifies that a provider may not bill a client for copying and transferring the client's records to another health care provider. It includes requirements for a provider to follow in order to bill a client who represents himself/herself as a private pay patient.

Proposal does not change existing rules. This rule replaces information found in several sections in chapter 388-87 WAC. Those sections are being repealed in a separate action.

No small business economic impact statement has been prepared under chapter 19.85 RCW. The department has determined that the cost imposed on businesses will be minor.

RCW 34.05.328 applies to this rule adoption. The proposed rule meets the definition of a significant legislative rule, and the department has prepared a cost/benefit analysis as required by RCW 34.05.328. A copy may be obtained by contacting the person listed above.

Hearing Location: Lacey Government Center (behind Tokyo Bento Restaurant), 1009 College Street S.E., Room 104-B, Lacey, WA 98503, on May 23, 2000, at 10:00 a.m.

Assistance for Persons with Disabilities: Contact Paige Wall by May 12, 2000, phone (360) 664-6094, TDD (360) 664-6178, e-mail wallpg@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) 664-6185, by May 23, 2000.

Date of Intended Adoption: May 24, 2000.

April 12, 2000

Marie Myerchin-Redifer, Manager

Rules and Policies Assistance Unit

(1) A provider may not bill or accept payment directly from a client or the client's representative for a service included in the scope of benefits of the client's medical program. If the medical assistance administration (MAA) does not pay for a service because the provider failed to bill according to MAA's conditions of payment, the client is not responsible to pay.

(2) The provider is responsible to verify whether the client has medical coverage for the date of service and to check the limitations of the client's medical program.

(3) A provider may bill a client only if one of the following situations apply:

(a) The client is enrolled in a managed care plan and the client and provider comply with the requirements in WAC 388-538-095;

(b) The client is enrolled in a program other than managed care, and the client and provider sign an agreement. It must be translated or interpreted into the client's primary language and signed before the service is rendered. The provider must give the client a copy and maintain the original in the client's file for department review upon request. The agreement must include each of the following elements to be valid:

(i) The specific service to be provided;

(ii) The service is not included in the scope of benefits of the client's medical program;

(iii) The client chooses to receive and pay for the specific service; and

(iv) The client is not obligated to pay for the service if it is later found to have been included in the scope of benefits of the client's medical program at the time the service was provided.

(c) The client or the client's representative was reimbursed for the service directly by a third party;

(d) The provider has documentation that the client represented himself/herself as a private pay patient and not an MAA client. The documentation must be signed by the client or the client's representative. The provider must maintain the original documentation in the patient's file for department review upon request. If the patient later becomes eligible for the service(s) due to delayed or retroactive eligibility, the provider must comply with subsection (4) of this section;

(e) The client refuses to complete and sign insurance forms, billing documents, or other forms necessary for the provider to bill insurance for the service. Medical assistance is not insurance;

(f) The bill counts toward a spenddown liability, emergency medical expense requirement, deductible, or copayment required by MAA, such as required by chapter 388-542 WAC for the children's health insurance program.

(4) If a client becomes eligible for a service that has already been provided due to:

(a) Delayed eligibility, the provider may bill MAA for the service and must:

(i) Not bill or accept payment from the client or the client's representative for the service; and

(ii) Refund the total payment received directly from the client for the service.

(b) Retroactive eligibility, the provider:

(i) Must not bill or accept payment from the client or the client's representative for any unpaid charges for the service; and

(ii) May refund any payment received directly from the client or the client's representative, and then bill MAA for the service.

(5) Hospitals may not bill or accept payment directly from a medically indigent, GA-U, or ADATSA client, or anyone on the client's behalf, for inpatient or outpatient hospital services during a period of eligibility.

(6) A provider may not bill a client or MAA for copying or otherwise transferring health care information, as that term is defined in chapter 70.02 RCW, to another health care provider. This includes, but is not limited to:

(a) Medical charts;

(b) Radiological or imaging films; and

(c) Laboratory or other diagnostic test results.

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