Date of Adoption: June 27, 2002.

     Purpose: To incorporate into rule the long term acute care (LTAC) program. Adopting new WAC 388-550-2565, 388-550-2570, 388-550-2575, 388-550-2580, 388-550-2585, 388-550-2590, 388-550-2595, and 388-550-2596.

     Statutory Authority for Adoption: RCW 74.08.090.

      Adopted under notice filed as WSR 02-10-113 on April 30, 2002.

     Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 8, Amended 0, Repealed 0.

     Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0;      Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 8, Amended 0, Repealed 0.
     Effective Date of Rule: Thirty-one days after filing.

June 27, 2002

Brian H. Lindgren, Manager

Rules and Policies Assistance Unit

     (1) A facility's multidisciplinary team coordinates individualized LTAC services at an MAA-approved LTAC facility.

     (2) MAA determines the authorized length of stay for LTAC services based on the client's need as documented in the client's medical records and the criteria described in WAC 388-550-2590.

     (3) When the MAA-authorized length of stay ends, the provider transfers the client to a more appropriate level of care or, if appropriate, discharges the client to the client's residence.

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     "Level 1 services" means long term acute care (LTAC) services provided to clients who require more than eight hours of direct skilled nursing care per day. Level 1 services include one or both of the following:

     (1) Active ventilator weaning care and any specialized therapy services, such as physical, occupational, and speech therapies; or

     (2) Complex medical care that may include: Care for complex draining wounds, care for central lines, multiple medications, frequent assessments and close monitoring, third degree burns that may involve grafts and/or frequent transfusions, and specialized therapy services, such as physical, occupational, and speech therapies.

     "Level 2 services" means long term acute care (LTAC) services provided to clients who require four to eight hours of direct skilled nursing care per day. Level 2 services include at least two of the following:

     (1) Ventilator care for clients who are stable, dependent on a ventilator, and have complex medical needs;

     (2) Care for clients who have tracheostomies, complex airway management and medical needs, and the potential for decannulation; and

     (3) Specialized therapy services, such as physical, occupational, and speech therapies.

     "Long term acute care" means inpatient intensive long term care services provided in MAA-approved LTAC facilities to eligible medical assistance clients who require Level 1 or Level 2 services.

     "Survey" or "review" means an inspection conducted by a federal, state, or private agency to evaluate and monitor a facility's compliance with LTAC program requirements.

     "Transportation company" means either an MAA-approved transportation broker or a transportation company doing business with MAA.

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     (1) Categorically needy program (CNP);

     (2) CNP - Children's health insurance program (CNP-CHIP);

     (3) Limited casualty program - medically needy program (LCP-MNP);

     (4) CNP - Emergency medical only; or

     (5) LCP-MNP - Emergency medical only.

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     (a) Submit a letter of request to:

     LTAC Program Manager

     Division of Medical Management

     Medical Assistance Administration

     PO Box 45506

     Olympia WA 98504-5506; and

     (b) Include documentation that confirms the facility is:

     (i) Medicare certified for LTAC;

     (ii) Accredited by the joint commission on accreditation of hospital organizations (JCAHO);

     (iii) Licensed by the department of health (DOH) as an acute care hospital as defined under WAC 246-310-010; and

     (iv) Contracted under MAA's selective contracting program, if in a selective contracting area, unless exempted from the requirements by MAA.

     (2) The hospital facility qualifies as an MAA-approved LTAC facility when:

     (a) The facility meets all the requirements in this section;

     (b) MAA's clinical staff has conducted a facility site visit; and

     (c) MAA provides written notification that the facility qualifies to be reimbursed for providing LTAC services to eligible medical assistance clients.

     (3) MAA-approved LTAC facilities must meet the general requirements in chapter 388-502 WAC, Administration of medical programs Providers.

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     (2) A provider of LTAC services must act on any reports of substandard care or violations of the facility's medical staff bylaws. The provider must have and follow written procedures that provide a resolution to either a complaint or grievance or both.

     (3) A complaint or grievance regarding substandard conditions or care may be investigated by any one or more of the following:

     (a) The department of health (DOH);

     (b) The Joint Commission on Accreditation of Hospital Organizations (JCAHO);

     (c) MAA; or

     (d) Other agencies with review authority for MAA programs.

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     (a) For an initial thirty-day stay:

     (i) The client must:

     (A) Be eligible under one of the programs listed in WAC 388-550-2575;

     (B) Meet the high cost outlier status at the transferring hospital as described in WAC 388-550-3700; and

     (C) Require Level 1 or Level 2 services as defined in WAC 388-550-2570.

     (ii) The LTAC provider of services must:

     (A) Before admitting the client to the LTAC facility, submit a request for prior authorization to the MAA clinical consultation team by fax, electronic mail, or telephone, as published in MAA's LTAC billing instructions; and

     (B) Include sufficient medical information to justify the requested initial stay.

     (b) For extensions of stay:

     (i) The client must:

     (A) Be eligible under one of the programs listed in WAC 388-550-2575; and

     (B) Require Level 1 or Level 2 services as defined in WAC 388-550-2570.

     (ii) The LTAC provider of services must:

     (A) Before the client's current authorized period of stay expires, submit a request for the extension of stay to the MAA clinical consultation team by fax, electronic mail, or telephone; and

     (B) Include sufficient medical information to justify the requested extension of stay.

     (2) The MAA clinical consultation team authorizes, in writing, Level 1 or Level 2 services for initial stays or extensions of stay based on the client's circumstances and the medical justification received. A client who does not agree with a decision regarding a length of stay has a right to a fair hearing under chapter 388-02 WAC. After receiving a request for a fair hearing, MAA may request additional information from the client and the facility, or both. After MAA reviews the available information, the result may be:

     (a) A reversal of the initial MAA decision;

     (b) Resolution of the client's issue(s); or

     (c) A fair hearing conducted per chapter 388-02 WAC.

     (3) MAA may authorize administrative day rate reimbursement for a client who:

     (a) Does not meet the requirements described in this section;

     (b) Is waiting for placement in another facility; or

     (c) If appropriate, is waiting to be discharged to the client's residence.

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     (a) Room and board - Rehabilitation;

     (b) Room and board - Intensive care;

     (c) Medical/surgical supplies and devices;

     (d) Laboratory - General;

     (e) Laboratory - Chemistry;

     (f) Laboratory - Immunology;

     (g) Laboratory - Hematology;

     (h) Laboratory - Bacteriology and microbiology;

     (i) Laboratory - Urology;

     (j) Laboratory - Other laboratory services;

     (k) Respiratory services;

     (l) Physical therapy;

     (m) Occupational therapy; and

     (n) Speech-language therapy.

     (2) MAA pays the LTAC facility the LTAC fixed per diem rate in effect at the time the LTAC services are provided, minus the sum of:

     (a) Client liability, whether or not collected by the provider; and

     (b) Any amount of coverage from third parties, whether or not collected by the provider, including, but not limited to, coverage from:

     (i) Insurers and indemnitors;

     (ii) Other federal or state medical care programs;

     (iii) Payments made to the provider on behalf of the client by individuals or organizations not liable for the client's financial obligations; and

     (iv) Any other contractual or legal entitlement of the client, including, but not limited to:

     (A) Crime victims' compensation;

     (B) Workers' compensation;

     (C) Individual or group insurance;

     (D) Court-ordered dependent support arrangements; and

     (E) The tort liability of any third party.

     (3) MAA may make annual rate increases to the LTAC fixed per diem rate by using the same inflation factor and date of rate increase that MAA uses for acute care hospital diagnostic-related group (DRG) rates. This DRG rate adjustment method is described in WAC 388-550-3450(5).

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     (a) Prescription drugs;

     (b) Total parenteral nutrition (TPN) therapy;

     (c) Epogen/neupogen therapy;

     (d) Radiology services;

     (e) Nuclear medicine services;

     (f) Computerized tomographic (CT) scan;

     (g) Operating room services;

     (h) Anesthesia services;

     (i) Blood storage and processing;

     (j) Blood administration;

     (k) Other imaging services - Ultrasound;

     (l) Pulmonary function services;

     (m) Cardiology services;

     (n) Recovery room services;

     (o) EKG/ECG services;

     (p) Gastro-intestinal services;

     (q) Inpatient hemodialysis; and

     (r) Peripheral vascular laboratory services.

     (2) MAA uses the appropriate inpatient or outpatient payment method described in other published WAC to reimburse providers other than LTAC facilities for services and equipment that are covered by MAA but not included in the LTAC fixed per diem rate. The provider must bill MAA directly and MAA reimburses the provider directly.

     (3) Transportation services that are related to transporting a client to and from another facility for the provision of outpatient medical services while the client is still an inpatient at the LTAC facility, or related to transporting a client to another facility after discharge from the LTAC facility:

     (a) Are not covered or reimbursed through the LTAC fixed per diem rate;

     (b) Are not reimbursable directly to the LTAC facility;

     (c) Are subject to the provisions in chapter 388-546 WAC; and

     (d) Must be billed directly to the:

     (i) Department by the transportation company to be reimbursed if the client required ambulance transportation; or

     (ii) Department's contracted transportation broker, subject to the prior authorization requirements and provisions described in chapter 388-546 WAC, if the client:

     (A) Required nonemergent transportation; or

     (B) Did not have a medical condition that required transportation in a prone or supine position.

     (4) MAA evaluates requests for covered transportation services that are subject to limitations or other restrictions, and approves such services beyond those limitations or restrictions when medically necessary, under the standards of WAC 388-501-0165.

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