PROPOSED RULES
SOCIAL AND HEALTH SERVICES
(Medical Assistance Administration)
Original Notice.
Preproposal statement of inquiry was filed as WSR 98-22-058.
Title of Rule: New WAC 388-546-0001, 388-546-0100, 388-546-0150, 388-546-0200, 388-546-0250, 388-546-0300, 388-546-0400, 388-546-0450, 388-546-0500, 388-546-0600, 388-546-0700, 388-546-0800, and 388-546-1000, transportation services (ambulance transportation).
Repealing WAC 388-86-086 Ambulance services and 388-87-036 Payment methodology -- Ambulance.
Purpose: The department is establishing a new chapter to consolidate rules regarding transportation and transportation related equipment. The proposed rules reflect long-standing department policy. They are more readable, and they comply with the Governor's Executive Order 97-02 on regulatory reform. The proposed rules have been reviewed in consultation with the regulated parties. WAC 388-86-086 and 388-87-036 are being repealed in order to avoid duplication.
Statutory Authority for Adoption: RCW 74.08.090 and 74.09.500.
Statute Being Implemented: RCW 74.04.050, 04-055 [74.04.055] and 04-057 [74.04.057].
Summary: The proposed rules define terms associated with transportation services, define the program scope of coverage, state provider and client requirements, and program limitations.
Reasons Supporting Proposal: To ensure that department rules reflect current and accurate department policy, to eliminate confusion by consolidating related rules, and to comply with the Governor's Executive Order 97-02 on regulatory reform.
Name of Agency Personnel Responsible for Drafting: L. Mike Freeman, MAA/RIP, P.O. Box 45533, Olympia, WA 98504, (360) 725-1350; Implementation: Ayuni Hautea-Wimpee, MAA/DOSS, P.O. Box 45510, Olympia, WA 98504, (360) 725-1835.
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 proposed rules define terms associated with ambulance services, define the program scope of coverage, state provider and client requirements, and program limitations.
The purpose of the rules is to consolidate all rules related to this program in one chapter of WAC and ensure that current department policy and practice is clearly reflected in rule.
The anticipated effect is to promote clarity and understanding of the program.
Proposal Changes the Following Existing Rules: The rules proposed above repeal existing rules and establish a new WAC chapter for ambulance services. The proposed rules reflect the programs's operational policies and provide greater detail into long-standing policy.
No small business economic impact statement has been prepared under chapter 19.85 RCW. MAA reviewed the proposed rules and concluded that the impact of the proposed rules will not place "a more than minor impact on businesses." MAA program managers held discussions with service providers to discuss the impact of these clarifications, who agreed with MAA's assessment of the impacts. Therefore, no small business economic impact statement is required.
RCW 34.05.328 applies to this rule adoption. MAA has determined that the proposed rules qualify as "significant legislative rules." Therefore, MAA has analyzed the probable costs and the probable benefits of the proposed rules, taking into account both the qualitative and quantitative benefits and costs. MAA's analysis revealed that no new costs will be imposed, existing costs will not be increased, and benefits to businesses will not be decreased. The analysis may be obtained from Ayuni Hautea-Wimpee, MAA/DOSS, P.O. Box 45510, Olympia, WA 98504, (360) 725-1835.
Hearing Location: Blake Office Building East, 4500 10th Avenue S.E., Rose Room, Lacey, WA 98503, on October 3, 2000, at 10:00 a.m.
Assistance for Persons with Disabilities: Contact Kelly Cooper, Rules Coordinator, by September 26, 2000, phone (360) 664-6094, TTY (360) 664-6178, e-mail coopeKD@dshs.wa.gov.
Submit Written Comments to: Identify WAC Numbers, Kelly Cooper, Rules Coordinator, Rules and Policies Assistance Unit, P.O. Box 45850, Olympia, WA 98504-5850, fax (360) 664-6185, by October 3, 2000.
Date of Intended Adoption: Not sooner than October 4, 2000.
August 14, 2000
Marie Myerchin-Redifer, Manager
Rules and Policies Assistance Unit
2776.8The following definitions and abbreviations, and those found in WAC 388-500-0005, apply to sections WAC 388-546-0150 through 388-546-4000. Defined words and phrases are bolded the first time they are used in the text:
"Advanced life support (ALS)" means that level of care that calls for invasive emergency medical services requiring advanced medical treatment skills.
"Aid vehicle" means a vehicle used to carry aid equipment and individuals trained in first aid or emergency medical procedure.
"Air ambulance" means a rotary blade (helicopter) or fixed-wing aircraft (airplane) designed and used to provide transportation for the ill and injured, and to provide personnel, facilities, and equipment to treat patients before and during transportation.
"Ambulance" means a ground or air vehicle designed, licensed per RCW 18.73.140 and used to provide transportation to the ill and injured; and to provide personnel, facilities, and equipment to treat patients before and during transportation.
"Base rate" means the medical assistance administration's (MAA) minimum reimbursement amount per covered trip, which includes allowances for emergency medical personnel and their services, the costs of standing orders, reusable supplies and equipment, hardware, stretchers, some disposable supplies, normal waiting time, and the normal overhead costs of doing business. The base rate excludes mileage and MAA specified disposable supplies that can be billed separately.
"Basic life support (BLS)" means that level of care that justifies ambulance transportation but requires only basic medical treatment skills. It does not include the need for or delivery of invasive medical services.
"Broker" (see "transportation broker").
"Brokered transportation" means nonemergent transportation arranged by a broker, under contract with MAA, to or from covered medical services for an eligible client (also, see "transportation broker").
"Border area hospitals" (see WAC 388-501-0175).
"Emergency medical service" means medical treatment and care that may be rendered at the scene of any medical emergency or while transporting any patient in an ambulance to an appropriate medical facility, including ambulance transportation between medical facilities.
"Emergency medical transportation" means ambulance transportation during which a client receives needed emergency medical services en route to an appropriate medical facility.
"Fixed wing aircraft" means an airplane.
"Ground ambulance" means a ground vehicle designed and primarily used to provide transportation to the ill and injured and to provide personnel, facilities, and equipment to treat patients before and during transportation.
"Invasive procedure" means a medical intervention that intrudes on the client's person or breaks the skin barrier.
"Liftoff fee" means either of the two base rates MAA pays to air ambulance providers for transporting a client. MAA establishes one liftoff fee for rotary aircraft and one liftoff fee for fixed wing aircraft.
"Medical control" means the medical authority upon whom an ambulance provider relies to coordinate pre-hospital emergency services, triage and trauma center assignment/destination for the person being transported. The medical control is designated in the trauma care plan by the approved medical program director of the region in which the service is provided.
"Nonemergent ambulance transportation" means the use of a ground ambulance to carry a client who may be confined to a stretcher but typically does not require the provision of emergency medical services en route. Nonemergent ambulance transportation is usually scheduled or prearranged. See also "prone or supine transportation."
"Prone or supine transportation" means transporting a client confined to a stretcher, with or without emergency medical services being provided en route.
"Rotary blade aircraft" means a helicopter.
"Scheduled transportation" means prearranged transportation for an eligible client, typically in a vehicle other than an ambulance, with no emergency medical services being required or provided en route to and from a covered medical service.
"Standing order" means an order remaining in effect indefinitely until canceled or modified by an approved medical program director (regional trauma system) or the ambulance provider's medical control.
"Transportation broker" means a person or organization contracted by MAA to arrange, coordinate and manage the provision of necessary but nonemergent transportation services for eligible clients to and from covered medical services.
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The medical assistance administration (MAA) covers medically necessary transportation to and from the provider of MAA covered services that is closest and most appropriate to meet the client's medical need. See WAC 388-546-0150 through 388-546-1000 for ambulance transportation and WAC 388-546-5000 through 388-546-5600 for brokered/nonemergency transportation. See WAC 388-546-0150 for client eligibility for ambulance transportation. See WAC 388-546-5100 for client eligibility for brokered/nonemergency transportation.
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(1) MAA covers medically necessary ambulance transportation to MAA covered services for medical assistance clients, including clients enrolled in MAA's managed care program(s) (e.g., Healthy Options). The exception is that MAA does not cover ambulance services for clients eligible for "family planning only."
(2) MAA does not cover out-of-state ambulance services for clients who are eligible for:
(a) The medically indigent program; or
(b) The general assistance - unemployable program.
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(1) All ambulance transportation to and from medical services covered under the client's medical assistance program must be:
(a) Medically necessary based on the client's condition at the time of the ambulance trip;
(b) Appropriate to the client's actual medical need;
(c) To the closest available MAA contracted medical provider of MAA covered services; and
(d) Documented in the provider's client record as to medical necessity.
(2) MAA limits coverage to that medically necessary ambulance transportation required because the client cannot be safely or legally transported any other way. If a client can safely travel by car, van, taxi, or other means, the ambulance trip is not medically necessary and the ambulance service is not covered by MAA.
(3) If Medicare or another third party is the client's primary health insurer and that primary party denies coverage of an ambulance trip due to a lack of medical necessity, MAA relies on that determination that the trip does not meet the medical necessity criteria of MAA.
(4) MAA covers the following ambulance transportation for its eligible clients:
(a) Emergency medical transportation by air ambulance when justified under the conditions of this chapter; and
(b) Medical transportation by ground ambulance when the client:
(i) Has an emergency medical need for the transportation;
(ii) Needs medical attention to be available during the trip; or
(iii) Must be transported by stretcher or gurney.
(5) MAA covers (through the healthy options managed care plan) medically necessary ambulance transportation for clients enrolled in the plan. This coverage is included in the prepaid plan premium (see WAC 388-546-0400(2)).
(6) MAA covers medically necessary ambulance transportation for clients enrolled in MAA's primary care case management (PCCM) program. Ambulance services that are emergency medical services or that are approved by the PCCM in accordance with MAA requirements are reimbursed by MAA according to MAA's published billing instructions.
(7) MAA covers ambulance trips transporting patients from one hospital to another when the transferring or discharging hospital has inadequate facilities to provide the necessary medical services required. MAA covers air ambulance transportation for hospital transfers only if transportation by ground ambulance would endanger the client's life or health.
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(1) MAA does not cover ambulance services when the transportation is:
(a) Not medically necessary based on the client's condition at the time of service (see exception at WAC 388-546-1000);
(b) Refused by the client;
(c) For a client who is deceased at the time the ambulance arrives on-scene;
(d) For a client who dies after the ambulance arrives on-scene but prior to transport and the ambulance crew did not provide any significant medical services on-scene (see WAC 388-546-0500(2));
(e) Requested for the convenience of the client or the client's family;
(f) More expensive than arranging to bring the necessary medical service to the client's location;
(g) To transfer a client from a medical facility to the client's home (see exception at WAC 388-546-1000);
(h) Requested solely because a client has no other means of transportation;
(i) Provided by other than licensed ambulance providers (e.g., wheelchair vans, cabulance, stretcher cars); or
(j) Not to the nearest appropriate medical facility (e.g., the client's destination is an urgent care clinic or freestanding outpatient facility rather than a hospital emergency room) (see exception at WAC 388-546-1000).
(2) MAA does not cover ambulance services for hospital to hospital transportation if the transportation is requested:
(a) To accommodate a physician's or other health care provider preference for facilities;
(b) To move the client closer to family or home (e.g., for personal convenience); or
(c) To meet insurance requirements or hospital/insurance agreements.
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(1) Air and ground ambulances must be licensed, operated, and equipped according to federal, state, and local statutes, ordinances and regulations.
(2) Air and ground ambulances must be staffed and operated by appropriately trained and certified personnel. Personnel who provide any invasive procedure/emergency medical services for a client during an ambulance trip must be properly authorized and trained per RCW 18.73.150 and 18.73.170.
(3) MAA requires providers of ambulance services to show medical justification on billing documents for transportation and related services/supplies billed to MAA. Documentation in the provider's client record must include adequate descriptions of the severity and complexity of the client's condition (including the circumstances that made the conditions acute and emergent) at the time of the transportation. MAA may review the client record to ensure MAA's criteria are met.
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(1) MAA reimburses providers of covered ambulance transportation services on the basis of usual and customary charges or the rates established by MAA, whichever is lower.
(2) MAA does not reimburse providers directly for ambulance services provided to a client who is enrolled in an MAA Healthy Options managed care plan. Payment in such cases is the responsibility of the prepaid managed care plan.
(3) MAA includes certain covered ambulance services in its payments to inpatient hospitals. MAA does not reimburse ambulance providers for ambulance transportation services if the client remains as an inpatient in a hospital and the transportation is for temporary transfer to another facility for diagnostic or treatment services (e.g., MRI scanning, kidney dialysis). Transportation of an inpatient for such services is included in MAA's payment to the hospital. It is the responsibility of the hospital where the client is an inpatient to reimburse ambulance providers for these transports.
(4) MAA reimburses for the actual mileage incurred for covered trips by paying from the client's point of origin to the point of destination. MAA does not reimburse mileage for any distances traveled to the pick-up point or any other distances traveled when the client is not on board the ambulance.
(5) MAA does not reimburse for ambulance services if:
(a) The client is not transported to an appropriate treatment facility; or
(b) The client dies before the ambulance trip begins (see the single exception for ground ambulance providers at WAC 388-546-0500(2)).
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(1) MAA reimburses at two levels of service for ground ambulance emergency transportation: Basic life support (BLS) and advanced life support (ALS):
(a) A BLS emergency ambulance trip is one in which the client requires and receives basic medical services on-scene and/or en route from the scene of the acute and emergent illness or injury to a hospital or other appropriate treatment facility. Examples of basic medical services are: Controlling bleeding, splinting fracture(s), treating for shock, and cardiopulmonary resuscitation (CPR).
(b) An ALS trip is one in which the client requires and receives more complex services on-scene and/or en route from the scene of the acute and emergent illness or injury to a hospital. Examples of more complex medical services are: the initiation of intravenous therapy, airway intubation, or heart defibrillation. To qualify for reimbursement at the ALS level, certified paramedics or other ALS-qualified personnel on-board must provide the advanced medical services in a properly equipped vehicle.
(2) MAA reimburses for ambulance services (BLS or ALS) based on the client's actual medical condition and the level of medical services needed and provided during the trip. Local ordinances or standing orders that require all ambulance trips be ALS equipped do not qualify a trip for MAA reimbursement at the ALS level of service.
(3) MAA reimburses separately for: Oxygen and oxygen administration; and/or intravenous supplies and IV administration. All other reusable supplies, disposable supplies, required equipment and up to thirty minutes of waiting time are included in MAA's base rate. MAA includes in the base rate equipment and/or supplies that are not specifically listed as separately payable in the medical transportation billing instructions. MAA does not reimburse for separately chargeable items that are provided to the client based on standing orders.
(4) The provider must document each trip to reflect the level of care needed by the patient, the training and qualifications of the personnel on board and the types of medical interventions provided by the personnel on-board. A ground ambulance trip is classified and paid at a BLS level, even if certified paramedics or ALS-qualified personnel are on board the ambulance, if no ALS-type interventions are needed and provided en route.
(5) MAA reimburses ground ambulance providers one mileage reimbursement rate, regardless of the level of service. Ground ambulance mileage is reimbursed when the client is transported to and from medical services within the local community only, unless necessary medical care is not available locally. The provider must fully document the circumstances that make medical care outside of the client's local community necessary.
(6) MAA reimburses for an extra attendant, when the ground ambulance provider submits justification to MAA for an extra attendant along with the claim for trip reimbursement, and that extra attendant is on-board for the trip because of one or more of the following:
(a) The client weighs three hundred pounds or more;
(b) The client is violent or difficult to control;
(c) The client is being transported for Involuntary Treatment Act (ITA) purposes and the client must be restrained; or
(d) More than one client is being transported, and each requires medical attention and/or close monitoring.
(7) The first thirty minutes of waiting time is included in MAA's base rate. MAA reimburses ground ambulance providers for additional waiting time if the time:
(a) Is extensive, as determined by MAA;
(b) Constitutes unusual circumstances, as determined by MAA; and
(c) Is documented in the provider's records and on the billing form. Documentation must include the reason for the wait, the actual length of time spent waiting and the amount of waiting time being billed to MAA.
(8) MAA does not reimburse providers for waiting time if:
(a) The waiting time is to provide a return trip pickup; or
(b) The waiting time is to provide a second trip for the same client for the same date of service.
(9) MAA reimburses ambulance providers for ferry tolls incurred when transporting MAA clients. The ferry toll(s) must be thoroughly documented on the claim form. MAA reimburses:
(a) One standard reimbursement rate for all Puget Sound ferry trips (each way); and
(b) Actual cost, based on invoice, for all San Juan Island ferry trips.
(10) MAA reimburses ambulance providers for bridge tolls based on actual cost. To be reimbursed, the provider must submit the receipt(s) for the bridge toll(s) incurred during the trip.
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(1) When more than one client is transported in the same ground ambulance at the same time, the provider must bill MAA:
(a) At a reduced base rate for the additional client, and
(b) No mileage charge for the additional client.
(2) MAA may reimburse a provider at the appropriate base-rate (no mileage and no separate supplies) if there is no transportation provided because the client died on scene. MAA allows reimbursement only if the ambulance crew provides necessary and substantial medical care to the client on-scene and prior to the client's death.
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Ground ambulance providers must use procedure code modifiers published by MAA when billing MAA for ground ambulance trips. The same modifiers that describe the ambulance trip's place of origin and the client's destination must be used for all services related to the same trip.
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(1) MAA reimburses for air ambulance services only when all of the following apply:
(a) The necessary medical treatment is not available locally or the client's pick up point is not accessible by ground ambulance;
(b) The vehicle and crew meet the provider requirements in WAC 388-546-0300 and 388-546-0800;
(c) The client's destination is an acute care hospital; and
(d) The client's physical/medical condition requires immediate and rapid ambulance transportation that cannot be provided by ground ambulance.
(2) MAA reimburses one liftoff fee per client, per trip.
(3) MAA reimburses mileage for air ambulance services based on air miles and not on highway mileage charts.
(4) MAA reimburses a lift-off fee for each client when two or more clients are transported on a single air ambulance trip. In such a case, the provider must divide equally the total air mileage by the number of clients transported and bill MAA for the mileage portion attributable to each eligible client.
(5) If a client's transportation requires use of more than one ambulance to complete the trip to the hospital or other approved facility, MAA limits its reimbursement as follows:
(a) If more than one air ambulance is used, MAA reimburses one lift-off fee per client and the total of air miles. Mileage reimbursement will be based on the mode of air transport used for the greater distance traveled.
(b) If both an air ambulance and a ground ambulance must be used, MAA reimburses one lift-off fee and total air miles to the air ambulance provider, and one base rate and ground mileage to the ground ambulance provider, except as provided in WAC 388-546-0800 (4)(b).
(6) MAA does not reimburse separately for individual services or an extra attendant for air ambulance transportation. MAA's lift-off fee and mileage reimbursement includes all personnel, services, supplies, and equipment related to the trip.
(7) MAA does not reimburse private organizations for volunteer medical air ambulance transportation services, unless the transportation services and fees are prior authorized by MAA. If authorized, MAA's reimbursement is based on the actual cost to provide the service or at MAA's established rates, whichever is lower. MAA does not reimburse separately for items or services that MAA considers included in the established rate(s).
(8) If MAA determines, upon review, that an air ambulance trip was not:
(a) Medically necessary, MAA may deny or recoup its payment and/or limit reimbursement based on MAA's established rate for a ground ambulance trip (if that would result in a lower cost to MAA); or
(b) To the nearest available and appropriate hospital, MAA may deny or recoup its payment and impose a maximum reimbursement for the trip based on the nearer facility.
(9) Providers must have prior authorization from MAA for any nonemergency air transportation whether by air ambulance or other mode of air transportation.
(10) MAA uses commercial airline companies (i.e., limits air ambulance services) whenever the client's medical condition permits the client to be transported by nonmedical and/or scheduled carriers.
(11) MAA does not reimburse for air ambulance services if there is no transportation provided.
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MAA reimburses emergency transportation provided to MAA's eligible clients who are out-of-state at the time of service (see WAC 388-546-0150(2) for exceptions).
(1) MAA requires any out-of-state ground or air ambulance provider who provides covered services to an MAA client to:
(a) Meet the licensing requirements of the ambulance provider's home state (United States of America and its territories only);
(b) Be participating in the Medicaid program of the ambulance provider's home state; and
(c) Sign an MAA core provider agreement.
(2) MAA requires any out-of-state ground ambulance provider who is transporting MAA clients within the state of Washington to comply with RCW 18.73.180 regarding stretcher transportation.
(3) Air ambulance providers who provide emergency transportation that takes a client out-of-state or that brings a client in state from an out-of-state location must obtain MAA's prior authorization.
(4) MAA reimburses air ambulance providers the agreed upon rate for each medically necessary interstate air ambulance trip:
(a) The rate is agreed upon as a part of MAA's authorization and the rate is a condition of the authorization; and
(b) The agreed upon rate may be inclusive of ground ambulance services.
(5) MAA does not reimburse for an interstate trip if the client is eligible for in-state services only.
(6) MAA reimburses out-of-state providers at the lower of:
(a) The provider's billed amount; or
(b) The rate established by MAA.
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(1) MAA reimburses for nonemergency ground ambulance transportation at the BLS ambulance level of service under the following conditions:
(a) The client needs to have basic ambulance level medical attention available during transportation; or
(b) The client must be transported by stretcher or gurney (in the prone or supine position) for medical or safety reasons.
(2) MAA requires ambulance providers to thoroughly document the circumstances requiring nonemergency ground ambulance transportation.
(3) Ground ambulance providers may choose to enter into contracts with MAA's transportation brokers to provide nonemergency transportation at a negotiated payment rate. Any such subcontracted rate may not exceed the costs MAA would incur under subsection (1) of this section.
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The following sections of the Washington Administrative Code are repealed:
| WAC 388-86-086 | Ambulance services. |
| WAC 388-87-036 | Payment -- Ambulance services. |