WSR 17-22-029 PROPOSED RULES HEALTH CARE AUTHORITY (Washington Apple Health) [Filed October 24, 2017, 8:17 a.m.] Original Notice. Preproposal statement of inquiry was filed as WSR 17-18-010. Title of Rule and Other Identifying Information: Amends WAC 182-550-2301 Hospital and medical criteria requirements for bariatric surgery. Hearing Location(s): On December 5, 2017, at 10:00 a.m., at the Health Care Authority (HCA), Cherry Street Plaza Building, Pear Room 107, 626 8th Avenue, Olympia, WA 98504. Metered public parking is available street side around building. A map is available at www.hca.wa.gov/documents/directions_to_csp.pdf or directions can be obtained by calling 360-725-1000. Date of Intended Adoption: Not sooner than December 6, 2017. Submit Written Comments to: HCA Rules Coordinator, P.O. Box 42716, Olympia, WA 98504-2716, email arc@hca.wa.gov, fax 360-586-9727, by December 5, 2017, 5:00 p.m. Assistance for Persons with Disabilities: Contact Amber Lougheed, phone 360-725-1349, fax 360-586-9727, TTY 800-848-5429 or 711, email amber.lougheed@hca.wa.gov, by December 1, 2017. Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: The agency has revised the requirements a hospital must meet to perform and be paid for bariatric surgery provided to eligible apple health clients. To qualify, a hospital must be accredited by the metabolic and bariatric surgery accreditation and quality improvement program. Reasons Supporting Proposal: See purpose. Rule is not necessitated by federal law, federal or state court decision. Name of Proponent: HCA, governmental. Name of Agency Personnel Responsible for Drafting: Vance Taylor, P.O. Box 42716, Olympia, WA 98504-2716, 360-725-1344; Implementation and Enforcement: Tonja Nichols, P.O. Box 42716, Olympia, WA 98504-2716, 360-725-1658. A school district fiscal impact statement is not required under RCW 28A.305.135. A cost-benefit analysis is not required under RCW 34.05.328. RCW 34.05.328 does not apply to HCA rules unless requested by the joint administrative rules [review] committee or applied voluntarily. This rule proposal, or portions of the proposal, is exempt from requirements of the Regulatory Fairness Act because the proposal: Is exempt under RCW 19.85.025(4). Explanation of exemptions: This rule does not affect small businesses. The businesses affected by this amendment are hospitals. Hospitals do not meet the definition of a small business. October 24, 2017 Wendy Barcus Rules Coordinator
AMENDATORY SECTION (Amending WSR 15-18-065, filed 8/27/15, effective 9/27/15)
WAC 182-550-2301 Hospital and medical criteria requirements for bariatric surgery.
(1) The medicaid agency pays a hospital for bariatric surgery and bariatric surgery-related services only when the surgery is provided in an inpatient hospital setting and only when:
(a) The client:
(i) Qualifies for bariatric surgery by successfully completing all requirements under WAC 182-531-1600; and
(((b) The client)) (ii) Continues to meet the criteria to qualify for bariatric surgery under WAC 182-531-1600 up to the actual surgery date((;
(c) The hospital providing the bariatric surgery and bariatric surgery-related services meets the requirements in this section and other applicable WAC; and
(d))).
(b) The hospital:
(i) Is accredited by the metabolic and bariatric surgery accreditation and quality improvement program (MBSAQIP); and
(ii) Receives prior authorization from the agency before performing a bariatric surgery for a Washington apple health client.
(2) ((A hospital must meet the following requirements to be paid for bariatric surgery and bariatric surgery-related services provided to an eligible Washington apple health client. The hospital must:
(a) Be approved by the agency to provide bariatric surgery and bariatric surgery-related services and:
(i) For dates of admission after June 30, 2007, be located in Washington state or approved bordering cities (see WAC 182-501-0175).
(ii) For dates of admission after June 30, 2007, be located in Washington state, or be an agency-designated critical border hospital.
(b) Have an established bariatric surgery program in operation under which at least one hundred bariatric surgery procedures have been performed. The program must have been in operation for at least five years and be under the direction of an experienced board-certified surgeon. In addition, the agency requires the bariatric surgery program to:
(i) Have a mortality rate of two percent or less;
(ii) Have a morbidity rate of fifteen percent or less;
(iii) Document patient follow-up for at least five years postsurgery;
(iv) Have an average loss of at least fifty percent of excess body weight achieved by patients at five years postsurgery; and
(v) Have a reoperation or revision rate of five percent or less.
(c) Submit documents to the agency's division of health care services that verify the performance requirements listed in this section.
(3) The agency waives the program requirements listed in subsection (2)(b) of this section if the hospital participates in a statewide bariatric surgery quality assurance program such as the surgical Clinical Outcomes Assessment Program (COAP).
(4))) See WAC 182-531-1600(13) for requirements for surgeons who perform bariatric surgery.
(((5))) (3) Authorization does not guarantee payment. Authorization for bariatric surgery and bariatric surgery-related services is valid only if:
(a) The client is eligible on the date of admission and date of service; and
(b) The hospital and professional providers meet the criteria in this section and other applicable WAC to perform bariatric surgery or to provide bariatric surgery-related services.
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