WSR 00-17-157

PROPOSED RULES

DEPARTMENT OF

SOCIAL AND HEALTH SERVICES
(Health and Rehabilitative Services Administration)

[ Filed August 22, 2000, 3:20 p.m. ]

Original Notice.

Preproposal statement of inquiry was filed as WSR 00-08-048.

Title of Rule: Chapter 275-16 WAC, Liability for costs of care and hospitalization of the mentally ill.

Purpose: Compliance with the executive order on regulatory improvement and to update references to law and other regulations, add one definition and modify two others, delete part of one section and increase the monthly exempt income of a patient. The rewritten rules will be renumbered into chapter 388-855 WAC.

Statutory Authority for Adoption: RCW 43.20B.335, 43.20B.325, 72.01.090, 71.05.560.

Statute Being Implemented: RCW 71.20.090.

Summary: Patients who are financially able to do so must pay for care at the state psychiatric hospitals. This rule describes how costs and ability to pay are determined. It also sets the consequences of failing to cooperate with the department, and gives the right to petition for review of the department's decision.

Reasons Supporting Proposal: Efficient use of state resources.

Name of Agency Personnel Responsible for Drafting: Paul Bigelow, OB-2, Olympia, (360) 902-0817; Implementation and Enforcement: Camille Pedersen, Office of Financial Recovery, (360) 664-5470.

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: This proposal allows the state to collect payment for care in the state psychiatric hospitals from patients who are able to pay for their care. The proposal describes how state hospital costs are determined, and how ability to pay is determined. The proposal also describes the consequences for failure to cooperate with the department, and to appeal departmental decisions.

Proposal Changes the Following Existing Rules: The proposal defines "responsible relative" and further defines gross income.

No small business economic impact statement has been prepared under chapter 19.85 RCW. Health and Rehabilitative Services Administration has analyzed the proposed chapter and concludes the proposed changes do not impact small businesses. Therefore, a small business economic impact statement is not required.

RCW 34.05.328 applies to this rule adoption. The proposed changes make significant amendments to a policy or regulatory program. However, the department is exempt from the analysis required under RCW 34.05.328 for rules that relate only to client medical or financial eligibility and rules concerning liability for care of dependents. Therefore no analysis was prepared. Other changes made were technical corrections only.

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

Assistance for Persons with Disabilities: Contact Kelly Cooper, DSHS Rules Coordinator, by October 3, 2000, phone (360) 664-6094, TTY (360) 664-6178, e-mail myercme@dshs.wa.gov [coopekd@dshs.wa.gov].

Submit Written Comments to: Identify WAC Numbers, DSHS Rules Coordinator, Rules and Policies Assistance Unit, P.O. Box 45850, Olympia, WA 98504-5850, fax (360) 664-6185, by October 10, 2000.

Date of Intended Adoption: No sooner than October 11, 2000.

August 15, 2000

Marie Myerchin-Redifer, Manager

Rules and Policies Assistance Unit

2806.2
AMENDATORY SECTION(Amending Order 1627, filed 3/25/81)

WAC 275-16-015
Definitions.

(((1))) "Adjusted charges" are those charges levied upon a patient who is or has been confined to a state hospital for the mentally ill, either by voluntary or involuntary admission, and their estates and responsible relatives, which are less than the actual cost of hospitalization as reflected in the schedule of charges herein and which has been established by the issuance of a notice of finding of responsibility.

     (((2))) "Adjusted gross income" is that gross income of the estate of the patient and responsible relatives less any deductions, contributions or payments mandated by law including, but not necessarily limited to, income tax and social security.

     (((3))) "Dependent" means any spouse, minor son or daughter, or permanently disabled son or daughter, of the patient living in the patient's household.      If the patient is a minor, then the same definitions shall apply in determining the dependency of members of the parent's household.      If a minor son or daughter is not living in the patient's household, that son or daughter shall not be considered a dependent unless the patient is in fact contributing more than fifty percent of that child's support in accordance with a court order or court-recognized agreement.

     (((4))) "Department" means the department of social and health services.

     (((5))) "Determination officer" is that duly appointed and qualified claims investigator who is delegated authority by the secretary to conduct or cause to have conducted an investigation of the financial condition of the estate of the patient and responsible relatives; to evaluate the results of such investigations; to make determinations of the ability to pay hospitalization changes from such investigations and evaluations; and to issue notices of findings of responsibility to the responsible parties.

     (((6))) "Estate of patient and responsible relative" means the total assets available to the patient and his responsible relatives to reimburse the department for hospitalization charges incurred by the patient in a state hospital for the mentally ill in accordance with these regulations.

     (((7))) "Gross income" means the total assets available to the estate of the patient and responsible relatives expressed in terms of their cash equivalent on a monthly basis. ((It)) The total assets available to the estate of the patient and responsible relatives are converted to a monthly cash equivalent figure by dividing those assets by twelve months. Gross income includes all of the following calculated prior to any mandatory deductions; gross wages for service; net earnings from self-employment; and all other assets ((of the estate prior to any mandatory deductions)) divided by twelve months.

     (((8))) "Responsible relative" includes the spouse of a patient, or the parent of a patient who is under eighteen years of age.

     "Secretary" means the secretary of the department of social and health services.

[Statutory Authority: RCW 81.02.412 [71.02.412].      81-08-020 (Order 1627), § 275-16-015, filed 3/25/81.]


AMENDATORY SECTION(Amending Order 1627, filed 3/25/81)

WAC 275-16-035
Available assets of estate of patients and responsible relatives.

(1) The department will include, but not necessarily be limited to, in their determination of the assets of the estates of present and former patients of state hospitals for the mentally ill and their responsible relatives, cash, stocks, bonds, savings, security interests, insurance benefits, guardianship funds, trust funds, governmental benefits, pension benefits and personal property.

     (2) Real property shall also be an available asset to the estate: Provided, That the patient's home shall not be considered an available asset if that property is owned by the estate and serves as the principal dwelling and actual residence of the patient, the patient's spouse, and/or minor children and disabled sons or daughters: Provided further, That if the home is not being used for residential purposes by the patient, the patient's spouse, and/or minor children and disabled sons or daughters, and in the opinion of two physicians, there is no reasonable expectancy that the patient will be able to return to the home during the remainder of his life, the home shall be considered an asset available to the estate((.

     (3) In determining if a particular asset is available to the estate of a patient who is eligible or potentially eligible for Medicaid, the determination officer will apply the standards of WAC 388-92-045)).

[Statutory Authority: RCW 81.02.412 [71.02.412].      81-08-020 (Order 1627), § 275-16-035, filed 3/25/81.]


AMENDATORY SECTION(Amending Order 1270, filed 2/17/78)

WAC 275-16-045
Exempt income.

Patients whose total resources are insufficient to pay for the actual cost of care shall be entitled to a monthly exemption from income in the amount of (($25)) forty-one dollars and sixty-two cents or such amount as specified in WAC ((388-29-125)) 388-478-0040.

[Statutory Authority: RCW 72.01.090.      78-03-029 (Order 1270), § 388-16-045 (codified as WAC 275-16-045), filed 2/17/78.]


AMENDATORY SECTION(Amending Order 3083, filed 10/9/90, effective 11/9/90)

WAC 275-16-055
Notice and finding of responsibility (NFR) -- Appeal procedure.

(1) The determination officer's assessment of the ability and liability of a person or of the person's estate to pay hospitalization charges shall be issued in the form of a notice and finding of responsibility (NFR) as prescribed by RCW 43.20B.340.

     (2) When the NFR is for full hospitalization charges as specified under WAC ((275-16-030)) 388-855-0030, the department shall:

     (a) Inform the financially responsible person of the current charges; and

     (b) Periodically recompute the financially responsible person's charges.

     (3) When the NFR is for adjusted charges, the department shall:

     (a) Express the charges in a daily or monthly rate; and

     (b) Set aside charges for ancillary services.

     (4) The right to an adjudicative proceeding to contest the NFR is contained in RCW 43.20B.340.

     (a) A financially responsible person wishing to contest the NFR shall, within twenty-eight days of receipt of the NFR:

     (i) File a written application for an adjudicative proceeding showing proof of receipt with the Secretary, DSHS, Attn: Determination Officer, P.O. Box 9768, Olympia, WA 98504; and

     (ii) Include in or with the application:

     (A) A specific statement of the issues and law involved;

     (B) The grounds for contesting the department decision; and

     (C) A copy of the contested NFR.

     (b) The proceeding shall be governed by the Administrative Procedure Act (chapter 34.05 RCW), RCW 43.20B.340, this chapter, and chapter ((388-08)) 388-02 WAC.      If any provision in this chapter conflicts with chapter ((388-08)) 388-02 WAC, the provision in this chapter governs.

[Statutory Authority: RCW 71.05.560.      90-21-030 (Order 3083), § 275-16-055, filed 10/9/90, effective 11/9/90.      Statutory Authority: RCW 34.05.220 (1)(a) and 43.20B.335.      90-04-075 (Order 3001), § 275-16-055, filed 2/5/90, effective 3/1/90.      Statutory Authority: RCW 81.02.412 [71.02.412].      81-08-020 (Order 1627), § 275-16-055, filed 3/25/81.]


AMENDATORY SECTION(Amending Order 1627, filed 3/25/81)

WAC 275-16-065
Determination of liability.

(1) In determining the ability of the estate of the patient and responsible relative to pay hospitalization charges, first priority shall be given to any third party benefits which might be available.      The availability of third party benefits, such as medical insurance, health insurance, Medicare, Medicaid, CHAMPUS, CHAMPVA, shall be considered as an available asset of the estate and shall justify a finding for actual costs of hospitalization during such period as the coverage is in effect.

     (2) In the absence of third party benefits, charges shall be based upon the available assets of the estate giving consideration to any unusual and exceptional circumstances and other pertinent factors.      No financial determination of the ability of the estate to pay hospitalization charges shall conflict with the eligibility requirements for Medicaid for those patients who are eligible or potentially eligible for such benefits.

     (3) The ability of the estate to pay adjusted charges will be determined by applying the following formula:


X = (Z-E)F
Where Z = (A-Y-N-R)÷D
Z = available income per family member
X = adjusted charges (daily)
A = gross income
Y = mandatory deductions
N = allowance for unusual and exceptional circumstances
R = allowance for other pertinent factors
D = number of dependents
E = exempt income
F = a factor which converts the monthly figures to a daily rate (.0328767).

     All calculations are expressed in monthly terms except the final adjusted charge which is converted to a daily rate.      All final figures are rounded out to the nearest cent.

     (4) The adjusted gross income (A-Y) is determined by first developing the gross income of the estate of the patient and the responsible relative.      Gross income (A) includes not only gross wages for services rendered, and/or net earnings from self-employment, but all other available assets ((converted to some reasonable)) which have been divided by twelve months to convert them to a monthly cash equivalent figure.      All mandatory deductions (Y), such as income tax and social security, are deducted from the gross income to arrive at the adjusted gross income.

     (5) Approved allowances for unusual and exceptional circumstances (N) and for other pertinent factors (R) are then subtracted from the adjusted gross income.

     (6) The available income (A-Y-N-R) is then divided by the number of dependents in the household of the patient (D) to determine the available income per family member.

     (7) Exempt income (E) as defined in WAC ((275-16-045)) 388-855-0045 is then subtracted from the available income per family member to arrive at the monthly adjusted charges.

     (8) The monthly adjusted charges are multiplied by the factor of .0328767 which converts the monthly figure to a daily rate.

[Statutory Authority: RCW 81.02.412 [71.02.412].      81-08-020 (Order 1627), § 275-16-065, filed 3/25/81.]


AMENDATORY SECTION(Amending WSR 96-18-090, filed 9/4/96, effective 10/5/96)

WAC 275-16-085
Other pertinent factors.

The determination officer may consider the following other pertinent factors in determining the ability of the estate of the patient and responsible relatives to pay.

     (1) The determination officer may consider those factors related to the well-being, education and training, child support obligations set by court order or by administrative finding under chapter 74.20A RCW, and/or rehabilitation of the patient and the patient's immediate family, to whom the patient owes a duty of support.      The patient and/or responsible relatives shall show the existence and the necessity for the pertinent factors as defined.      Upon such a showing, the determination officer may consider such resources necessary to reasonably provide for such pertinent factors as assets not available to the estate of the patient and responsible relatives.

     (2) Consistent with RCW 43.20B.335, the determination officer shall consider a judgment owed by the patient to any victim of an act that would have resulted in criminal conviction of the patient but for a finding of the patient's criminal insanity.      A victim shall include an estate's personal representative who has obtained judgment for wrongful death against the criminally insane patient((.

     (3) The department shall ensure that any allowance for other pertinent factors does not conflict with Medicaid eligibility requirements for those patients who are eligible or potentially eligible for such benefits)).

[Statutory Authority: RCW 43.20B.335.      96-18-090, § 275-16-085, filed 9/4/96, effective 10/5/96.      81.02.412 [71.02.412].      Statutory Authority: RCW 81-08-020 (Order 1627), § 275-16-085, filed 3/25/81.]


NEW SECTION


     The following sections of the Washington Administrative Code, as amended, are recodified as follows:

    
Old WAC Number New WAC Number
275-16-015 388-855-0015
275-16-035 388-855-0035
275-16-045 388-855-0045
275-16-055 388-855-0055
275-16-065 388-855-0065
275-16-085 388-855-0085

NEW SECTION


     The following sections of the Washington Administrative Code are recodified as follows:

    
Old WAC Number New WAC Number
275-16-010 388-855-0010
275-16-030 388-855-0030
275-16-075 388-855-0075
275-16-095 388-855-0095
275-16-105 388-855-0105

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