(1) The department pays the deductible and coinsurance amounts for a client participating in Parts A and/or B of medicare (Title XVIII of the Social Security Act) when the:
(a) Total reimbursement to the provider from medicare and the department does not exceed the rate in the department's fee schedule; and
(b) Provider accepts assignment for medicare payment.
(2) The department pays the deductible and coinsurance amounts for a client who has Part A of medicare. If the client:
(a) Has not exhausted lifetime reserve days, the department considers the medicare diagnostic related group (DRG) as payment in full; or
(b) Has exhausted lifetime reserve days during an inpatient hospital stay, the department considers the medicare DRG as payment in full until the medicaid outlier threshold is reached. After the medicaid outlier threshold is reached, the department pays an amount based on the policy described in the Title XIX state plan.
(3) If medicare and medicaid cover the service, the department pays only the deductible and/or coinsurance up to medicare or medicaid's allowed amount, whichever is less. If only medicare and not medicaid covers the service, the department pays only the deductible and/or coinsurance up to medicare's allowed amount.
(4) The department bases its outlier policy on the methodology described in the department's Title XIX state plan, methods, and standards used for establishing payment rates for hospital inpatient services.
(5) The department pays, according to department rules and billing instructions, for medicaid covered services when the client exhausts medicare benefits.
[11-14-075, recodified as § 182-502-0110, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500, 74.09.530. 00-15-050, § 388-502-0110, filed 7/17/00, effective 8/17/00.]