Original Notice.

Preproposal statement of inquiry was filed as WSR 99-13-191 and 98-22-058.

Title of Rule: New WAC 388-546-5000, 388-546-5100, 388-546-5200, 388-546-5300, 388-546-5400 and 388-546-5500, transportation service (nonambulance transportation); repealing WAC 388-86-085 Transportation (other than ambulance) and 388-87-035 Payment -- Transportation (other than ambulance); and amending WAC 388-86-100 Durable medical equipment.

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 WAC 388-86-085 and 388-87-035 are being repealed and WAC 388-86-100 is being amended in order to avoid duplication.

Statutory Authority for Adoption: RCW 74.08.090.

Statute Being Implemented: RCW 74.04.050, [74.]04.055, and [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: Diane Kessel, MAA/DCS, P.O. Box 45535, Olympia, WA 98504, (360) 725-1318.

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 transportation 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 transportation services. The proposed rules reflect the program'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 Diane Kessel, MAA/DCS, P.O. Box 45535, Olympia, WA 98504, (360) 725-1318.

Hearing Location: Blake Office Building East, 4500 10th Avenue S.E., Rose Room, Lacey, WA 98503, on October 3, 2000, at 10:00.

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 11, 2000

Marie Myerchin-Redifer, Manager

Rules and Policies Assistance Unit

The following terms apply to WAC 388-546-5000, 388-546-5100, 388-546-5200, 388-546-5300, 388-546-5400, and 388-546-5500:

     "Broker" means an organization or entity contracted with the department of social and health services (DSHS)/medical assistance administration (MAA) to arrange nonemergency transportation services for MAA's clients.

     "Drop-off point" means the place authorized by the transportation broker for the client's trip to end.

     "Escort" means a person authorized by the broker to be transported with a client to a medical service. An escort may be authorized depending on the client's age, mental state or capacity, safety requirements, mobility requirements, communication or translation requirements, or cultural issues.

     "Guardian" means a person who is legally responsible for a client and who may be required to be present when a client is receiving medical services.

     "Local provider of type" means the medical provider who is closest to the client's residence and who fulfills the requirements of the medical appointment. The provider may vary by medical specialty, the provider's acceptance of MAA's clients, and whether managed care, primary care case management or third party participation is involved.

     "Pick-up point" means the place authorized by MAA's transportation broker for the client's trip to begin.

     "Service mode" means the method of transportation the transportation broker selects to use for an MAA client.

     "Stretcher trip" means a transportation service that requires a client to be transported in a prone or supine position. This may be by stretcher, board or gurney (reclined and with feet elevated). Medical or safety requirements must be the basis for transporting a client in the prone or supine position.

     "Trip" means transportation one-way from the pick-up point by an authorized transportation provider to the drop-off point.

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(1) MAA covers transportation that is necessary for its clients to receive medically necessary MAA covered services. See WAC 388-546-0100 through 388-546-1000 for Ambulance transportation that covers emergency ambulance transportation and limited nonemergency ground ambulance transportation as medical services.

     (2) Licensed ambulance companies, who contract with MAA's transportation brokers, may be reimbursed for nonemergency transportation services under WAC 388-546-5200 as administrative services.

     (3) MAA covers nonemergency transportation under WAC 388-546-5000 through 388-546-5500 as an administrative service as provided by the Code of Federal Regulations (42 CFR 431.53 and 42 CFR 440.170 (a)(2). As a result, clients may not select the transportation provider(s) or the mode of transportation (service mode).

     (4) Prior authorization by MAA is required for all out-of-state nonemergency medical transportation. Border areas as defined by WAC 388-501-0175 are considered in-state under this section and subsequent sections.

     (5) MAA requires all medical transportation to and from eligible medical services to meet the following:

     (a) Be medically necessary as defined in WAC 388-500-0005;

     (b) Be the lowest cost available alternative that is appropriate to the client's medical need; and

     (c) Be limited to the local provider of type as follows:

     (i) Clients who are served under MAA's fee-for-service program may be transported only to the local provider of type. MAA's transportation broker is responsible for considering and authorizing exceptions.

     (ii) Clients under MAA's managed care (healthy options) program may be transported to a provider as determined necessary by the client's managed care plan.

     (6) MAA does not cover any nonemergency transportation service that is not addressed in WAC 388-546-1000 or in 388-546-5000 through 388-546-5500. See WAC 388-501-0160 for information about obtaining approval for noncovered transportation services, known as exception to rule (ETR).

     (7) If a medical service is approved by ETR, both the broker and MAA must separately prior approve transportation to that service.

     (8) MAA may exempt members of federally recognized Indian tribes from the brokered transportation program. Where MAA approves the request of a tribe or a tribal agency to administer or provide transportation services under WAC 388-546-5000 through 388-546-5400, tribal members obtain their transportation services as provided by the tribe or tribal agency.

     (9) A client who is denied service under this chapter may request a fair hearing per chapter 388-02 WAC.

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(1) MAA requires that all nonambulance transportation providers serving MAA clients be subcontracted with the department's primary transportation broker contractors. In addition, MAA's transportation brokers may choose to subcontract with willing ambulance providers in order to provide nonemergency trips in licensed ground ambulance vehicles as an administrative service rather than a medical service - see WAC 388-546-5100(2).

     (2) MAA requires all contracted and subcontracted transportation providers under this chapter to be licensed, equipped, and operated in accordance with applicable federal, state, and local statutes, regulations, and ordinances.

     (3) MAA's contracted brokers determine the level of transportation service needed by the client and the mode of transportation to be used for each authorized trip.

     (4) MAA's contracted brokers must comply with the terms specified in their contracts.

     (5) MAA's transportation brokers may require up to forty-eight hours advance notice of a requested trip (see WAC 388-546-5300(2)). MAA allows its transportation brokers to accommodate requests that provide less than forty-eight hours advance notice, within the limits of the resources available to a broker at the time of the request.

     (6) If MAA's broker is not open for business and unavailable to give advance approval as described in subsection (5), the sub-contracted transportation provider must either:

     (a) Provide the transportation in accordance with the broker's instructions and request an after-the-fact authorization from the transportation broker within seventy-two hours of the transport; or

     (b) Deny the transportation, if the requirements of this section cannot be met.

     (7) If the sub-contracted transportation provider provides transportation as described in subsection (6), the broker may agree to grant retroactive authorization as provided in WAC 388-546-5300(3). Such retroactive authorization must be:

     (a) Documented as to the reasons retroactive authorization is needed; and

     (b) Agreed to by the broker within seventy-two hours after the transportation to a medical appointment.

     (8) MAA, through its contracted brokers, limits its payment for transportation according to the following conditions:

     (a) Clients are not eligible for transportation services when medical services are within reasonable walking distance (normally three-quarters of a mile actual traveling distance), taking into account the client's documented medical condition;

     (b) Clients must use personal or informal transportation alternatives if they are available and appropriate to the clients' needs;

     (c) If a fixed-route public transportation service is available to the client within three-quarters of a mile walking distance, the broker may require the client to use the fixed route public transportation system unless a higher need is both present and documented (e.g., portable ventilator, use of a walker or quad cane);

     (d) MAA or MAA's contracted broker may deny transportation services requested if the request is not necessary, suitable, or appropriate to the client's medical condition;

     (e) The medical services requiring transportation must be services that are covered by the client's medical program; and

     (f) The transportation selected by the broker for the client must be the lowest cost alternative, considering all cost factors (e.g., the impact on MAA of third party coverage, the costs of meals and lodging).

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(1) Clients must cooperate with MAA's contracted brokers, the brokers' subcontracted transportation providers, and MAA's medical services providers. A client who refuses to cooperate may be suspended or terminated from access to nonemergency transportation services.

     (2) Clients must request, arrange and obtain authorization for medical transportation forty-eight hours in advance of a medical appointment. Exceptions to the forty-eight-hour advance arrangements are described in subsection (3) of this section and in WAC 388-546-5200(6).

     (3) If MAA's contracted broker is not open for business at the time nonemergency transportation is needed, the client must follow the transportation broker's instructions to obtain a medically necessary transportation service.

     (4) Clients must use the closest available medical care provider that can meet the client's medical needs. Exceptions are:

     (a) The client is enrolled in a healthy options managed health care plan and the client's primary care provider (PCP) or a PCP referred provider is not the closest available provider;

     (b) The client's service is covered by a third party payer and the payer requires or refers the client to a specific provider;

     (c) A charitable or other voluntary program (e.g., Shriners) is paying for the client's medical service;

     (d) The medical service required by the client is not available within the local healthcare service area;

     (e) The total cost to MAA is lower when the services are obtained outside of the local healthcare service area; or

     (f) The out-of-area service is required to provide continuity of care for the client's ongoing care as:

     (i) Documented by the client's primary care provider; and

     (ii) Agreed to by MAA's contracted transportation broker.

     (5) MAA may require transportation brokers to refer any of the exception categories listed in subsection (4) to MAA's medical director or the medical director's designee for review and/or prior authorization of the medical service.

     (6) If local medical services are not available to a client because of the client's behavior or the client's lack of cooperation, MAA does not cover nonemergency transportation to out-of-area medical services for the client. MAA's contracted broker must notify a client, in writing, if the broker determines that the client's documented behavior results in a denial to out-of-area transportation services.

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(1) To be reimbursed, MAA requires that a trip be a minimum of three-quarters of a mile from pick-up point to drop off point. MAA's transportation broker may grant exceptions to the minimum distance requirement for any of the following conditions:

     (a) When there is medical justification for a shorter trip;

     (b) When the trip involves an area that MAA's contracted broker considers to be unsafe for the client, other riders, or the driver; or

     (c) When the trip involves an area that the broker determines is not physically accessible to the client.

     (2) MAA reimburses for return trips from eligible medical services if the return trips are directly related to the original trips. MAA may deny coverage of a return trip if any delays in the return trip are for reasons not directly related to the original trip.

     (3) MAA does not reimburse any costs related to intermediate stops that are not directly related to the original approved trip.

     (4) The broker may authorize intermediate stops that are directly related to the original approved trip if the broker determines that the intermediate stop is likely to limit or eliminate the need for supplemental covered trips. MAA considers the following reasons to be related to the original trip:

     (a) Transportation to and from an immediate subsequent medical referral; and

     (b) Transportation to a pharmacy to obtain one or more prescriptions when the pharmacy is within a reasonable distance of the original medical appointment route.

     (5) MAA may pay the costs of meals and lodging for clients who must be transported to out-of-area medical services. MAA's contracted brokers make the determination that meals and lodging are necessary based on client need and the reasonableness of costs (as measured against state per diem rates).

     (6) MAA may pay transportation costs, including meals and lodging, for authorized escorts. MAA's contracted brokers make the determination that the costs of escorts are necessary based on client need and reasonableness of costs (as measured against state per diem rates).

     (7) MAA does not provide escorts or pay the wages of escorts. MAA does not pay for the transportation of an escort when the client is not present unless the broker documents exceptional circumstances causing the broker to determine that the service is necessary to ensure that the client has access to medically necessary care.

     (8) MAA may reimburse for the transportation of a guardian with or without the presence of the client if the broker documents its determination that such a service is necessary to ensure that the client has access to medically necessary care.

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(1) MAA may cover and reimburse the purchase of vehicle driving controls, a vehicle wheelchair lift conversion, or the purchase or repair of a vehicle wheelchair lift, when:

     (a) The requested item is medically necessary as defined under WAC 388-500-0005; and

     (b) The client owns a vehicle that MAA determines is suitable for modification; and

     (c) Medical transportation provided under WAC 388-546-5000 through 388-546-5400 cannot meet the client's need for transportation to and from medically necessary covered services at a lower total cost to the department (including anticipated costs); and

     (d) Prior approval from MAA is obtained.

     (2) Any vehicle driving controls, vehicle wheelchair lift conversion or vehicle wheelchair lift purchased by MAA under this section becomes the property of the client on whose behalf the purchase is made. MAA assumes no continuing liability associated with the ownership or use of the device.

     (3) MAA limits the purchase of vehicle driving control(s), vehicle wheelchair lift conversion or vehicle wheelchair lift to one purchase per client. If a device purchased under this section becomes inoperable due to wear or breakage and the cost of repair is more than the cost of replacement, MAA will consider an additional purchase under this section as long as the criteria in subsection (1) of this section are met.

     (4) MAA must remain the payer of last resort under this section.

     (5) MAA does not cover the purchase of any new or used vehicle under this section or under this chapter.

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(1) The division of medical assistance shall purchase and/or rent medically necessary medical equipment, prosthetic devices, and other disposable/nonreuseable medical supplies when:

     (a) The division is the payor of last resort; and

     (b) The item requested is not included with other reimbursement methodologies, such as, but not limited to, diagnosis related group (DRG) for hospital inpatients, or a nursing home's per diem reimbursement.

     (2) The division of medical assistance shall authorize payment for a requested item only when the item is medically necessary as defined under WAC ((388-80-005(45))) 388-500-0005 and is covered by the medical assistance program.

     (3) The division of medical assistance shall purchase and/or rent a wheelchair for a permanently disabled nursing home recipient when the chair is for the exclusive full-time use of the recipient and is not included in the nursing home's per diem reimbursement.

     (4) Medical equipment and supplies purchased or reissued by the division of medical assistance become the property of the recipient for whom they are purchased/reissued.

     (5) The division of medical assistance shall normally authorize the purchase and/or repair of only one wheelchair, manual or power-drive, per recipient.      However, another wheelchair shall be provided and/or repaired when medically necessary.

     (6) Durable medical equipment, prosthetic devices, and disposable/nonreuseable supplies that require approval by the division of medical assistance prior to delivery of service include:

     (a) Prosthetic limbs;

     (b) Orthopedic shoes;

     (c) Osteogenic stimulator, noninvasive;

     (d) Communication devices;

     (e) Transcutaneous nerve stimulators;

     (f) Wheeled shower chairs;

     (g) Blood pressure kits;

     (h) Blood glucose monitors;

     (i) Air and gel cushions;

     (j) Fluidized air flotation system;

     (k) Decubitus care mattress, including flotation or gel mattress;

     (l) Complete patient lift, except for sling or wall mount;

     (m) Wheelchairs:

     (i) Accessories;

     (ii) Fitting fees; and

     (iii) Freight charges.

     (n) Hospital bed and replacement mattress;

     (o) Replacement parts, repairs, and labor charges;

     (p) Bath accessories, decubitus care products (nonformulary), and patient equipment not listed in the division of medical assistance "durable medical equipment and supplies" billing instructions; and

     (q) All rentals.

     (((7) The division of medical assistance shall not authorize the purchase of vehicle driving controls, a vehicle wheelchair lift conversion, or purchase or repair of a vehicle wheelchair lift, unless:

     (a) Medical transportation provided under WAC 388-86-085 cannot meet the recipient's need for transportation to and from medically necessary covered services at a lower cost to the department; and

     (b) Prior approval is obtained.))

[Statutory Authority: RCW 74.08.090.      89-08-052 (Order 2783), § 388-86-100, filed 3/31/89; 86-03-047 (Order 2329), § 388-86-100, filed 1/15/86; 82-17-072 (Order 1868), § 388-86-100, filed 8/18/82; 81-16-033 (Order 1685), § 388-86-100, filed 7/29/81; 81-06-003 (Order 1610), § 388-86-100, filed 2/19/81; 78-10-077 (Order 1346), § 388-86-100, filed 9/27/78; 78-02-024 (Order 1265), § 388-86-100, filed 1/13/78; Order 1233, § 388-86-100, filed 8/31/77; Order 1019, § 388-86-100, filed 4/30/75; Order 938, § 388-86-100, filed 5/23/74; Order 499, § 388-86-100, filed 12/2/70; Order 480, § 388-86-100, filed 9/22/70; Order 463, § 388-86-100, filed 6/23/70; Order 419, § 388-86-100, filed 12/31/69; Order 385, § 388-86-100, filed 8/27/69; Order 264 (part), § 388-86-100, filed 11/24/67.]

Reviser's note: RCW 34.05.395 requires the use of underlining and deletion marks to indicate amendments to existing rules. The rule published above varies from its predecessor in certain respects not indicated by the use of these markings.2820.1
REPEALER

     The following sections of the Washington Administrative Code are repealed:

WAC 388-86-085	Transportation (other than ambulance).
WAC 388-87-035	Payment -- Transportation (other than ambulance).

© Washington State Code Reviser's Office