WSR 17-06-063 PERMANENT RULES HEALTH CARE AUTHORITY (Washington Apple Health) [Filed February 28, 2017, 3:20 p.m., effective March 31, 2017] Effective Date of Rule: Thirty-one days after filing.
Purpose: The agency is amending WAC 182-502-0110 to clarify prior authorization requirements for dual-eligible clients when their medicare benefits exhaust. The amendments also add language to clarify that timely billing requirements must be met and that the agency may do postpayment review on claims. The revisions do not change current policy. The WAC section caption is being changed to better reflect the information in the section.
Citation of Existing Rules Affected by this Order: Amending WAC 182-502-0110.
Adopted under notice filed as WSR 17-03-113 on January 17, 2017.
Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.
Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.
Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 1, Repealed 0.
Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 0, Repealed 0.
Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 1, Repealed 0.
Date Adopted: February 28, 2017.
Wendy Barcus
Rules Coordinator
AMENDATORY SECTION (Amending WSR 16-13-157, filed 6/22/16, effective 7/23/16)
WAC 182-502-0110 Conditions of payment and prior authorization requirements—Medicare coinsurance, copayments, and deductibles.
(1) The following people are eligible for benefits under this section:
(a) Dual-eligible clients enrolled in categorically needy Washington apple health programs;
(b) Dual-eligible clients enrolled in medically needy Washington apple health programs; or
(c) Clients enrolled in the qualified medicare beneficiary (QMB) program.
(2) The agency pays the medicare coinsurance, copayments, and deductibles for Part A, Part B, and medicare advantage Part C for an eligible person under subsection (1) of this section:
(a) Up to the published or calculated medicaid-only rate; and
(b) If the provider accepts assignment for medicare payment.
(3) If a medicare Part A recipient has remaining lifetime reserve days, the agency pays the deductible and coinsurance amounts up to the allowed amount as calculated by the agency.
(4) If a medicare Part A recipient has exhausted lifetime reserve days during an inpatient hospital stay, the agency pays the deductible and coinsurance amounts up to the agency-calculated allowed amount minus any payment made by medicare, and any payment made by the agency, up to the outlier threshold. Once the outlier threshold is reached, the agency pays according to WAC 182-550-3700.
(5) If medicare and medicaid cover the service, the agency pays the deductible and coinsurance up to medicare or medicaid's allowed amount, whichever is less.
(6) If only medicare covers the service, the agency pays the deductible and coinsurance up to the agency's allowed amount established for a QMB client, and at zero for a non-QMB client.
(7) If a client exhausts medicare benefits, the agency pays for medicaid-covered services under Title 182 WAC and the agency's billing instructions.
(8) When medicaid requires prior authorization for a service covered by both medicare and medicaid:
(a) Medicaid does not require prior authorization when the client's medicare benefit is not exhausted.
(b) Medicaid does require prior authorization when the client's medicare benefit is exhausted. See also WAC 182-501-0050(5).
(9) Providers must meet the timely billing requirements under WAC 182-502-0150 in order to be paid for services.
(10) Payment for services is subject to postpayment review.
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