reglab/statecodes huggingface dataset:
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-4650 - "Full cost" public hospital certified public expenditure (CPE) payment program

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid
				agency's "full cost" public hospital certified public expenditure (CPE)
				inpatient payment program provides payments to participating
				government-operated hospitals based on the "full cost" of covered medically
				necessary services and requires the expenditure of local funds in lieu of state
				funds to qualify for federal matching funds. The agency's inpatient payments to
				participating hospitals equal the federal matching amount for allowable costs.
				The agency uses the ratio of costs-to-charges (RCC) method described in WAC
				182-550-4500 to determine "full
				cost."
(2) To be eligible for the
				"full cost" public hospital CPE payment program, the hospital must be:
(a) Operated by a public hospital district in
				the state of Washington, not certified by the department of health (DOH) as a
				critical access hospital, and has not chosen to opt-out of the CPE payment
				program as allowed in subsection (6) of this section;
(b) Harborview Medical Center; or
(c) University of Washington Medical
				Center.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-4670 - CPE payment program-"Hold harmless" provision

Current through Register Vol. 24-14, July 15, 2024
To meet legislative requirements, the medicaid agency
				  includes a "hold harmless" provision for eligible hospitals participating in
				  certified public expenditure (CPE) payment programs under WAC
				  182-550-4650 and
				  182-550-5400. Under the provision
				  and subject to legislative directives and appropriations, hospitals eligible
				  for payments under CPE payment programs will receive no less in combined state
				  and federal payments than they would have received under the methodologies
				  otherwise in effect as described in this section. All hospital submissions
				  pertaining to CPE payment programs including, but not limited to, cost report
				  schedules, are subject to audit at any time by the agency or its
				  designee.
(1) The agency:
(a) Uses historical cost and payment data
				trended forward to calculate prospective hold harmless grant payment amounts
				for the current state fiscal year (SFY); and
(b) Reconciles these hold harmless grant
				payment amounts when the actual claims data are available for the current
				fiscal year.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-4690 - Authorization requirements and utilization review for hospitals eligible for CPE payments

Current through Register Vol. 24-14, July 15, 2024
This section does not apply to psychiatric certified public
				  expenditure (CPE) inpatient hospital admissions. See WAC
				  182-550-2600.
(1) CPE inpatient hospital claims submitted
				to the med-icaid agency must meet all authorization and program requirements in
				WAC and current agency-published issuances.
(2) The agency performs utilization reviews
				of inpatient hospital:
(a) Admissions under
				the requirements of 42 C.F.R. 456, subparts A through C; and
(b) Claims for compliance with medical
				necessity, appropriate level of care and the agency's (or an agency
				des-ignee's) established length of stay (LOS) standards.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-4700 - Payment-Non-SCA participating hospitals (Repealed)

Current through Register Vol. 24-14, July 15, 2024
11-14-075, recodified as §
											182-550-4700, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.08.090,
					 74.09.500. 07-12-040, §
					 388-550-4700, filed 5/30/07, effective 7/1/07. Statutory Authority:
					 RCW
					 74.08.090,
					 42 USC
					 1395 x(v),
					 42 C.F.R.
					 447.271, 447.11303, and 447.2652. 99-06-046,
					 § 388-550-4700, filed 2/26/99, effective 3/29/99. Statutory Authority:
					 RCW
					 74.08.090,
					 74.09.730,
					 74.04.050,
					 70.01.010,
					 74.09.200, [74.09.]500,
					 [74.09.]530 and 43.20B.020. 98-01-124, § 388-550-4700, filed 12/18/97,
					 effective 1/18/98.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-4800 - Hospital payment methods- State-administered programs

Current through Register Vol. 24-14, July 15, 2024
This section does not apply to out-of-state hospitals unless
				  they are border hospitals (critical or noncritical).
(1) The medicaid agency:
(a) Pays for services provided to a client
				eligible for a state-administered program (SAP) based on SAP rates;
(b) Establishes SAP rates independently from
				the process used in setting the medicaid payment rates;
(c) Calculates a ratable each year to adjust
				each hospital's SAP rates for their percentage of community-based dollars to
				the total revenues for all hospitals;
(d) Calculates an equivalency factor (EF) to
				keep the SAP payment rates at the same level before and after the medicaid
				rates were rebased.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-4900 - Disproportionate share hospital (DSH) payments-General provisions

Current through Register Vol. 24-14, July 15, 2024
(1) As required by
				Section 1902 (a)(13)(A) of the Social Security Act (42 U.S.C.
				1396(a)(13)(A)) and
				RCW
				74.09.730, the medicaid agency makes payment
				adjustments to eligible hospitals that serve a disproportionate number of
				low-income clients with special needs. These adjustments are also known as
				disproportionate share hospital (DSH) payments.
(2) No hospital has a legal entitlement to
				any DSH payment. A hospital may receive DSH payments only if:
(a) It satisfies the requirements of
				42 U.S.C.
				1396r-4;
(b) It satisfies all the requirements of
				agency rules and policies; and
(c)
				The legislature appropriates sufficient funds.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-4925 - Eligibility for DSH programs-New hospital providers

Current through Register Vol. 24-14, July 15, 2024
To be eligible for disproportionate share hospital (DSH)
				  payments, a new hospital provider must have claims data, audited financial
				  statements, and an "as filed" or finalized medicare cost report for the
				  hospital base year used by the medicaid agency in calculating DSH payments for
				  the state fiscal year (SFY) for which the hospital provider is applying. See
				  WAC 182-550-4900(9).
11-14-075, recodified as §
											182-550-4925, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.08.090,
					 74.09.500. 07-14-090, §
					 388-550-4925, filed 6/29/07, effective
					 8/1/07.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-4935 - DSH eligibility-Change in hospital ownership

Current through Register Vol. 24-14, July 15, 2024
(1) For purposes of eligibility for
				disproportionate share hospital (DSH) payments, a change in hospital ownership
				has occurred if any of the criteria in WAC
				182-550-4200(1)
				is met.
(2)To be considered
				eligible for DSH, a hospital whose ownership has changed must notify the
				medicaid agency in writing no later than thirty days after the change in
				ownership becomes final. The notice must include the new entity's fiscal year
				end.
(3)A hospital that did not
				offer nonemergency obstetric services to the general public as of December 22,
				1987, when section 1923 of the Social Security Act was enacted, and changes
				ownership after that date is not eligible for DSH unless it continues to be
				classified as an acute care hospital serving pediatric and/or adult patients.
				See WAC 182-550-4900(5)
				for the obstetric services and utilization rate requirements for DSH
				eligibility.
(4) If the fiscal year
				reported on a hospital's medicare cost report does not exactly match the fiscal
				year reported on the hospital's DSH application to the agency, and if therefore
				the utilization data reported to the agency do not agree, the agency will use
				as the data source the document that gives the higher number of total inpatient
				hospital days for purposes of calculating the hospital's medicaid inpatient
				utilization rate (MIPUR). See WAC
				182-550-4900(6)(b).
11-14-075, recodified as §
											182-550-4935, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.08.090,
					 74.09.500. 07-14-090, §
					 388-550-4935, filed 6/29/07, effective
					 8/1/07.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-4940 - Disproportionate share hospital independent audit findings and recoupment process

Current through Register Vol. 24-14, July 15, 2024
(1) In order to
				comply with federal law and regulation (
				42 U.S.C.
				1396r - 4(j)(2); 42 C.F.R. Part 455, Subpart
				D), the medicaid agency contracts with an independent auditor to conduct an
				annual, independent, certified audit of the agency's disproportionate share
				hospital (DSH) payments. Chapter 182-502A WAC is not applicable to the
				independent, certified audits described in this section.
(2) Hospitals must comply with the agency's
				or the auditor's requests for documentation. A hospital's failure to provide
				requested documentation may result in a finding that any or all of the DSH
				payments for the audited year are overpayments.
(3) Beginning in state fiscal year 2011, an
				audit finding that demonstrates DSH payments made to a hospital in that year
				exceeded the documented hospital-specific DSH cap (as defined in WAC
				182-550-4900(3) 
				), is considered a discovery of an overpayment under 42 C.F.R. Part 433,
				Subpart F.
(4) Hospitals must
				return overpayments to the agency for redistribution to qualifying hospitals. A
				qualifying hospital is defined as a disproportionate share hospital that has a
				positive hospital-specific DSH cap.
(5) The additional DSH payment to be given to
				each of the other qualifying hospitals from the recouped amount is proportional
				to each hospital's share of the particular DSH program. Only the recouped
				payments are redistributed among those eligible DSH hospitals that have a
				remaining positive hospital-specific DSH cap.
(6) The independent auditor will provide
				preliminary audit results to each hospital that received DSH payments,
				including a statement as to whether the hospital's payments did or did not
				exceed the hospital's DSH cap. Hospitals identified as receiving DSH payments
				exceeding their hospital-specific DSH cap may request additional information on
				the preliminary audit results. The agency must receive the hospital's request
				for the additional information on the preliminary audit results no later than
				the last working day in November of the year in which the audit is
				conducted.
(7) In response to a
				hospital's timely request under subsection (6) of this section, the independent
				auditor will provide the hospital with at least the following information
				specific to the requesting hospital:
(a)
				Calculation of the medicaid inpatient utilization rate (MIUR);
(b) Regular inpatient and outpatient medicaid
				fee for service basic rate payments;
(c) Supplemental/enhanced inpatient and
				outpatient medicaid payments;
(d)
				Total medicaid payments;
(e) Total
				cost of care;
(f) Total cost of
				care of the uninsured; and
(g) A
				provider data summary schedule (PDSS) to compare to the agency's report
				required by 42 C.F.R. Sec. 447.299, Subpart E.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-5000 - Payment method-Low income disproportionate share hospital (LIDSH)

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid
				agency makes low income disproportionate share hospital (LIDSH) payments to
				qualifying hospitals through the disproportionate share hospital (DSH)
				program.
(2) To qualify for an
				LIDSH payment, a hospital must:
(a)Not be a
				hospital eligible for public disproportionate share (PHDSH) payments (see WAC
				182-550-5400 );
(b)Not be designated as an "institution for
				mental diseases (IMD)" as defined in WAC
				182-550-2600(2)(d);
(c)Meet the criteria in WAC
				182-550-4900(4) and
				(5);
(d) Be an in-state hospital. A hospital
				located out-of-state or in a designated bordering city is not eligible to
				receive LIDSH payments; and
(e)Meet
				at least one of the following requirements. The hospital must:
(i) Have a medicaid inpatient utilization
				rate (MIPUR) as defined in WAC
				182-550-4900(3)(h)
				at least one standard deviation above the mean medicaid inpatient utilization
				rate of in-state hospitals that receive medicaid payments; or
(ii) Have a low income utilization rate
				(LIUR) as defined in WAC
				182-550-4900(3)(g)
				that exceeds twenty-five percent.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-5125

Current through Register Vol. 24-14, July 15, 2024
11-14-075, recodified as §
											182-550-5125, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.08.090,
					 74.09.500. 07-14-090, §
					 388-550-5125, filed 6/29/07, effective 8/1/07; 06-08-046, § 388-550-5125,
					 filed 3/30/06, effective 4/30/06.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-5130 - Payment method-Institution for mental diseases disproportionate share hospital (IMDDSH) and institution for mental diseases (IMD) state grants

Current through Register Vol. 24-14, July 15, 2024
(1) A psychiatric
				hospital owned and operated by the state of Washington is eligible to receive
				payments under the institution for mental diseases disproportionate share
				hospital (IMDDSH) program.
(2)For
				the purposes of the IMDDSH program, the following definitions apply:
(a)"Institution for mental diseases (IMD)"
				means a hospital, nursing facility, or other institution of more than sixteen
				beds, that is primarily engaged in providing diagnosis, treatment, or care of
				people with mental diseases, including medical attention, nursing care, and
				related services.
(b)"Psychiatric
				community hospital" means a psychiatric hospital other than a state-owned and
				operated hospital.
(c)"Psychiatric
				hospital" means an institution which is primarily engaged in providing
				psychiatric services for the diagnosis and treatment of mentally ill people.
				The term applies to a medicare-certified distinct psychiatric care unit, a
				medicare-certified psychiatric hospital, or a state-designated pediatric
				distinct psychiatric unit in a medicare-certified acute care
				hospital.
(d) "State-owned and
				operated psychiatric hospital" means eastern state hospital and western state
				hospital.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-5150 - Payment method - Medical care services disproportionate share hospital (MCSDSH)

Current through Register Vol. 24-14, July 15, 2024
(1) A hospital is
				eligible for the medical care services disproportionate share hospital (MCSDSH)
				payment if the hospital:
(a) Meets the
				criteria in WAC
				182-550-4900;
(b) Is an in-state or designated bordering
				city hospital;
(c) Provides
				services to clients eligible under the medical care services program;
				and
(d) Has a medicaid inpatient
				utilization rate (MIPUR) of one percent or more.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-5200 - Payment method-Small rural disproportionate share hospital (SRDSH)

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid
				agency makes small rural disproportionate share hospital (SRDSH) payments to
				qualifying small rural hospitals through the disproportionate share hospital
				(DSH) program.
(2)To qualify for an
				SRDSH payment, a hospital must:
(a)Not be
				participating in the "full cost" public hospital certified public expenditure
				(CPE) payment program as described in WAC
				182-550-4650;
(b)Not be designated as an "institution for
				mental diseases (IMD)" as defined in WAC
				182-550-2600(2)(d);
(c)Meet the criteria in WAC
				182-550-4900(4) and
				(5);
(d)Have fewer than seventy-five acute
				beds;
(e)Be an in-state hospital. A
				hospital located out-of-state or in a designated bordering city is not eligible
				to receive SRDSH payments; and
(f)Be located in a city or town with a
				nonstudent population of no more than seventeen thousand eight hundred six in
				calendar year 2008, as determined by population data reported by the Washington
				state office of financial management population of cities, towns, and counties
				used for the allocation of state revenues. This nonstudent population is used
				for state fiscal year (SFY) 2010, which began July 1, 2009. For each subsequent
				SFY, the nonstudent population is increased by two percent.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-5210 - Payment method-Small rural indigent assistance disproportionate share hospital (SRIADSH)

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid
				agency makes small rural indigent assistance disproportionate share hospital
				(SRIADSH) program payments to qualifying small rural hospitals through the
				disproportionate share hospital (DSH) program.
(2) To qualify for an SRIADSH payment, a
				hospital must:
(a)Not be participating in the
				"full cost" public hospital certified public expenditure (CPE) payment program
				as described in WAC
				182-550-4650;
(b)Not be designated as an "institution for
				mental diseases (IMD)" as defined in WAC
				182-550-2600(2)(d);
(c)Meet the criteria in WAC
				182-550-4900(4) and
				(5);
(d)Have fewer than seventy-five acute
				beds;
(e)Be an in-state hospital
				that provided charity services to clients during the base year. A hospital
				located out-of-state or in a designated bordering city is not eligible to
				receive SRIADSH payments; and
(f)Be
				located in a city or town with a nonstudent population of no more than
				seventeen thousand eight hundred six in calendar year 2008, as determined by
				the Washington State office of financial management population of cities,
				towns, and counties used for the allocation of state revenues. This nonstudent
				population is used for SFY 2010, which begins July 1, 2009. For each subsequent
				SFY, the nonstudent population ceiling is increased by two percent.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-5220 - Payment method-Nonrural indigent assistance disproportionate share hospital (NRIADSH)

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid
				agency makes nonrural indigent assistance disproportionate share hospital
				(NRIADSH) payments to qualifying nonrural hospitals through the
				disproportionate share hospital (DSH) program.
(2) To qualify for an NRIADSH payment, a
				hospital must:
(a)Not be participating in the
				"full cost" public hospital certified public expenditure (CPE) payment program
				as described in WAC
				182-550-4650;
(b) Not be designated as an "institution of
				mental diseases (IMD)" as defined in WAC
				182-550-2600(2)(d);
(c)Meet the criteria in WAC
				182-550-4900(4) and
				(5);
(d)Be a hospital that does not qualify as a
				small rural hospital as defined in WAC
				182-550-4900(3)(n);
				and
(e) Be an in-state or
				designated bordering city hospital that provided charity services to clients
				during the base year. For DSH purposes, the agency considers as nonrural any
				hospital located in a designated bordering city.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-5300 - Payment method - Children's health program disproportionate share hospital (CHPDSH)

Current through Register Vol. 24-14, July 15, 2024
(1) Effective July
				1, 2011, a hospital is eligible for the children's health program
				disproportionate share hospital (CHPDSH) payment if funding is legislatively
				appropriated and if the hospital:
(a) Meets
				the criteria in WAC
				182-550-4900;
(b) Is an in-state or designated bordering
				city hospital; or
(c) Provides
				services to low-income, children's health program (CHP) clients who, because of
				their citizenship status, are not eligible for medicaid nonemergency health
				coverage and who are encountering a nonemergency medical condition.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-5380 - Payment method-Sole community disproportionate share hospital (SCDSH)

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid
				agency's sole community disproportionate share hospital (SCDSH) program is a
				program for in-state hospitals that:
(a) Were
				certified by the Centers for Medicare and Medicaid Services (CMS) as sole
				community hospitals as of January 1, 2013;
(b) Had less than one hundred fifty acute
				care licensed beds in state fiscal year (SFY) 2011;
(c) Qualify under Section 1923(d) of the
				Social Security Act;
(d) Are not
				participating in the certified public expenditure (CPE) program; and
(e) Are rural hospitals in Lewis
				County.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-5400 - Payment method-Public hospital disproportionate share hospital (PHDSH)

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid
				agency's public hospital disproportionate share hospital (PHDSH) program is a
				certified public expenditure program for government-operated hospitals. To be
				eligible for PHDSH, a hospital must qualify for disproportionate share hospital
				(DSH) payments under WAC
				182-550-4900 and be:
(a) Operated by a public hospital district in
				the state of Washington and participating in the "full cost" public hospital
				certified public expenditure (CPE) payment program described in WAC
				182-550-4650;
(b)Harborview Medical Center; or
(c)University of Washington Medical
				Center.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-5410 - CPE medicaid cost report and settlements

Current through Register Vol. 24-14, July 15, 2024
(1) For patients discharged after June 30,
				2005, a certified public expenditure (CPE) hospital must annually submit to the
				medicaid agency federally required medicaid cost report schedules, using
				schedules approved by the centers for medicare and medicaid services (CMS),
				that apportion inpatient and outpatient costs to medicaid clients and uninsured
				patients for the service year, as follows:
(a)
				Title XIX fee-for-service claims;
(b) Medicaid managed care organization (MCO)
				plan claims;
(c) Uninsured
				patients. The cost report schedules for uninsured patients must not include
				services that medicaid would not have covered had the patients been medicaid
				eligible (see WAC
				182-550-1400 and
				182-550-1500 ); and
(d)State-administered program patients.
				State-administered program patients are reported separately and are not to be
				included on the uninsured patient cost report schedule. The agency will provide
				provider statistics and reimbursements (PS&R) reports for the
				state-administered program claims.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-5425 - Upper payment limit (UPL) payments for inpatient hospital services (Repealed)

Current through Register Vol. 24-14, July 15, 2024
11-14-075, recodified as §
											182-550-5425, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.08.090,
					 74.09.500. 07-14-090, §
					 388-550-5425, filed 6/29/07, effective 8/1/07; 06-08-046, § 388-550-5425,
					 filed 3/30/06, effective 4/30/06.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-5450 - Supplemental distributions to approved trauma service centers

Current through Register Vol. 24-14, July 15, 2024
(1) The trauma care
				fund (TCF) is an amount appropriated to the medicaid agency each state fiscal
				year (SFY), at the legislature's sole discretion, for the purpose of
				supplementing the agency's payments to eligible trauma service centers for
				providing qualified trauma services to medicaid clients.
(2) Encounter data, for trauma care provided
				to medicaid clients enrolled in an agency-contracted managed care organization,
				may be included when calculating supplemental distributions from the TCF, so
				long as the beginning dates of service for trauma care are on and after July 1,
				2013.
(3) To qualify for
				supplemental distributions from the TCF, a hospital must:
(a) Be designated or recognized by the
				department of health (DOH) as an approved Level I, Level II, or Level III adult
				or pediatric trauma service center;
(b) Meet the provider requirements in this
				section and other applicable rules;
(c) Meet the billing requirements in this
				section and other applicable rules;
(d) Submit all information the agency
				requires to monitor the program; and
(e) Comply with DOH's Trauma Registry
				reporting requirements.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-5500 - Payment-Hospital-based RHCs

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid
				agency will reimburse hospital-based rural health clinics under the prospective
				payment methods effective July 1, 1994. Under the prospective payment method,
				the agency will not make reconciliation payments to a hospital-based rural
				health clinic to cover its costs for a preceding period.
(2) The agency will shall pay an amount equal
				to the hospital-based rural health clinic's charge multiplied by the hospital's
				specific ratio of costs to charges (RCC), not to exceed one hundred percent of
				the charges.
(3)The agency will
				shall determine the hospital-based rural health clinic's RCC from the
				hospital's annual medicare cost report, according to WAC
				182-550-4500(1).
11-14-075, recodified as §
											182-550-5500, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.08.090,
					 74.09.730,
					 74.04.050,
					 70.01.010,
					 74.09.200, [74.09.]500,[74.09.]530
					 and 43.20B.020. 98-01-124, § 388-550-5500, filed 12/18/97, effective
					 1/18/98.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-5550 - Public notice for changes in medicaid payment rates for hospital services

Current through Register Vol. 24-14, July 15, 2024
(1) The purpose and
				intent of this section is to describe how the medicaid agency, pertaining to
				medicaid hospital rates, will comply with section 4711(a) of the federal
				Balanced Budget Act of 1997,
				Public Law
				105-33, as codified at
				42 U.S.C.
				1396 a (a)(13)(A).
(2)For purposes of this section, the term:
(a)"Stakeholders" means providers,
				beneficiaries, representatives of beneficiaries, and other concerned state
				residents.
(b)"Rate" means the
				medicaid payment amount to a provider for a particular hospital service, except
				for disproportionate share payments not mandated by federal law.
(c) "Methodology" underlying the
				establishment of a medicaid hospital rate means (unless otherwise noted) the
				principles, procedures, limitations, and formulas detailed in WAC
				182-550-2900 through
				182-550-5500.
(d) "Justification" means an explanation of
				why the agency is proposing or implementing a medic-aid rate change based on a
				change in medicaid rate setting methodology.
(e)"Reasonable opportunity to review and
				provide written comments" means a period of fourteen calendar days in which
				stakeholders may provide written comments to the agency.
(f)"Hospital services" means those services
				that are performed in a hospital facility for an inpatient client and which are
				payable only to the hospital entity, not to individual performing
				providers.
(g)"Web site" means the
				agency's internet home page on the worldwide web:
http://www.hca.wa.gov/
is the
				internet address.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-5600 - Dispute resolution process for hospital rate reimbursement

Current through Register Vol. 24-14, July 15, 2024
The dispute resolution process for hospital rate
				  reimbursement follows the procedures as stated in WAC
				  182-502-0220.
11-14-075, recodified as §
											182-550-5600, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.08.090,
					 74.09.500,
					 74.09.035(1), and
					 43.88.290. 03-13-055, §
					 388-550-5600, filed 6/12/03, effective 7/13/03. Statutory Authority:
					 RCW
					 74.08.090 and
					 74.09.730. 99-16-070, §
					 388-550-5600, filed 8/2/99, effective 9/2/99. Statutory Authority:
					 RCW
					 74.08.090,
					 74.09.730,
					 74.04.050,
					 70.01.010,
					 74.09.200, [74.09.]500,
					 [74.09.]530 and 43.20B.020. 98-01-124, § 388-550-5600, filed 12/18/97,
					 effective 1/18/98.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-5700 - Hospital reports and audits

Current through Register Vol. 24-14, July 15, 2024
(1)
				In-state and border area hospitals will complete and submit a copy of their
				annual medicare cost reports (HCFA 2552) to the medicaid agency. These hospital
				providers will:
(a) Maintain adequate records
				for audit and review purposes, and assure the accuracy of their cost
				reports;
(b) Complete their annual
				medicare HCFA 2552 cost report according to the applicable medicare statutes,
				regulations, and instructions; and
(c) Submit a copy to the agency:
(i) Within 150 days from the end of the
				hospital's fiscal year; or
(ii) If
				the hospital provider's contract is terminated, within 150 days of effective
				termination date; or
(d)
				Request up to a 30-day extension of the time for submitting the cost report in
				writing at least 10 days before the due date of the report. Hospital providers
				will include in the extension request the completion date of the report, and
				the circumstances prohibiting compliance with the report due date;
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-5800 - Outpatient and emergency hospital services

Current through Register Vol. 24-14, July 15, 2024
The medicaid agency will cover outpatient services, emergent
				  outpatient surgical care, and other emergency care performed on an outpatient
				  basis in a hospital for categorically needy or limited casualty
				  program-medically needy clients.
11-14-075, recodified as §
											182-550-5800, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.08.090,
					 74.09.730,
					 74.04.050,
					 70.01.010,
					 74.09.200, [74.09.]500,[74.09.]530
					 and 43.20B.020. 98-01-124, § 388-550-5800, filed 12/18/97, effective
					 1/18/98.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-6000 - Outpatient hospital services-Conditions of payment and payment methods

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid
				agency pays hospitals for covered outpatient hospital services provided to
				eligible clients when the services meet the provisions in WAC
				182-550-1700.
				All professional medical services must be billed according to chapter 182-531
				WAC.
(2) To be paid for covered
				outpatient hospital services, a hospital provider must:
(a) Have a current core provider agreement
				with the agency;
(b) Bill the
				agency according to the conditions of payment under WAC
				182-502-0100;
(c) Bill the agency according to the time
				limits under WAC
				182-502-0150;
				and
(d) Meet program requirements
				in other applicable WAC and the agency's published issuances.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-6100 - Outpatient hospital physical therapy

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid agency pays for physical
				therapy provided to eligible clients as an outpatient hospital service
				according to WAC
				182-545-200 and
				182-550-6000.
(2) A hospital must bill outpatient hospital
				physical therapy services using appropriate billing codes listed in the
				agency's current published billing instructions. The agency does not pay
				outpatient hospitals a facility fee for these services.
11-14-075, recodified as §
											182-550-6100, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.04.050,
					 74.04.057,
					 74.08.090, and
					 Public Law
					 104-191. 03-19-043, § 388-550-6100, filed
					 9/10/03, effective 10/11/03. Statutory Authority:
					 RCW
					 74.08.090,
					 74.09.730,
					 74.04.050,
					 70.01.010,
					 74.09.200, [74.09.]500,
					 [74.09.]530 and 43.20B.020. 98-01-124, § 388-550-6100, filed 12/18/97,
					 effective 1/18/98.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-6150 - Outpatient hospital occupational therapy

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid agency pays for occupational
				therapy provided as an outpatient hospital service to eligible clients
				according to WAC
				182-545-200 and
				182-550-6000.
(2) The hospital must bill outpatient
				hospital occupational therapy services using appropriate billing codes listed
				in the agency's current published billing instructions. The agency does not pay
				outpatient hospitals a facility fee for these services.
11-14-075, recodified as §
											182-550-6150, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.04.050,
					 74.04.057,
					 74.08.090, and
					 Public Law
					 104-191. 03-19-043, § 388-550-6150, filed
					 9/10/03, effective 10/11/03. Statutory Authority:
					 RCW
					 74.08.090,
					 74.09.730,
					 74.04.050,
					 70.01.010,
					 74.09.200, [74.09.]500,
					 [74.09.]530 and 43.20B.020. 98-01-124, § 388-550-6150, filed 12/18/97,
					 effective 1/18/98.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-6200 - Outpatient hospital speech therapy services

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid agency pays for speech
				therapy services provided to eligible clients as an outpatient hospital service
				according to this section and WAC
				182-545-200 and
				182-550-6000.
(2)The agency requires swallowing
				(dys-phagia) evaluations to be performed by a speech/language pathologist who
				holds a master's degree in speech pathology and who has received extensive
				training in the anatomy and physiology of the swallowing mechanism, with
				additional training in the evaluation and treatment of dysphagia.
(3) The agency requires a swallowing
				evaluation to include:
(a)An oral-peripheral
				exam to evaluate the anatomy and function of the structures used in
				swallowing;
(b) Dietary
				recommendations for oral food and liquid intake therapeutic or management
				techniques;
(c)Therapeutic or
				management techniques; and
(d)Video
				fluoroscopy, when necessary, for further evaluation of swallowing status and
				aspiration risks.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-6250 - Pregnancy-Enhanced outpatient benefits

Current through Register Vol. 24-14, July 15, 2024
The medicaid agency will provide outpatient substance use
				  disorder treatment in programs qualified under WAC
				  182-538C-230
				  and certified under chapter 246-341 WAC or its successor. See RCW
				  71.24.-385.
11-14-075, recodified as §
											182-550-6250, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.08.090,
					 74.09.730,
					 74.04.050,
					 70.01.010,
					 74.09.200, [74.09.]500,[74.09.]530
					 and 43.20B.020. 98-01-124, § 388-550-6250, filed 12/18/97, effective
					 1/18/98.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-6300 - Outpatient nutritional counseling

Current through Register Vol. 24-14, July 15, 2024
See chapter 182-555 WAC for medical nutrition
				  therapy.
11-14-075, recodified as §
											182-550-6300, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.08.090,
					 74.09.730,
					 74.04.050,
					 70.01.010,
					 74.09.200, [74.09.]500,[74.09.]530
					 and 43.20B.020. 98-01-124, § 388-550-6300, filed 12/18/97, effective
					 1/18/98.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-6400 - Outpatient hospital diabetes education

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid agency pays for outpatient
				hospital-based diabetes education for an eligible client when:
(a) The facility where the services are
				provided is approved by the department of health (DOH) as a diabetes education
				center, and
(b)The client is
				referred by a licensed health care provider.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-6450 - Outpatient hospital weight loss program

Current through Register Vol. 24-14, July 15, 2024
The medicaid agency may pay for an outpatient weight loss
				  program only when provided through an outpatient weight loss facility approved
				  by the agency. The agency will deny payment for services provided by
				  nonapproved providers.
11-14-075, recodified as §
											182-550-6450, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.08.090,
					 74.09.730,
					 74.04.050,
					 70.01.010,
					 74.09.200, [74.09.]500,[74.09.]530
					 and 43.20B.020. 98-01-124, § 388-550-6450, filed 12/18/97, effective
					 1/18/98.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-6500 - Blood and blood components

Current through Register Vol. 24-14, July 15, 2024
(1) The
				medicaid agency pays a hospital only for:
(a)Blood bank service charges for processing
				and storage of blood and blood components; and
(b)Blood administration charges.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-6600 - Hospital-based physician services

Current through Register Vol. 24-14, July 15, 2024
See chapter 182-531 WAC regarding rules for inpatient and
				  outpatient physician services.
11-14-075, recodified as §
											182-550-6600, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.08.090,
					 74.09.730,
					 74.04.050,
					 70.01.010,
					 74.09.200, [74.09.]500,[74.09.]530
					 and 43.20B.020. 98-01-124, § 388-550-6600, filed 12/18/97, effective
					 1/18/98.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-6700 - Hospital services provided out-of-state

Current through Register Vol. 24-14, July 15, 2024
(1) The agency pays:
(a) For dates of admission before August 1,
				2007, for only emergency care for an eligible medicaid and CHIP client who goes
				to another state, except specified border cities, specifically for the purpose
				of obtaining medical care that is available in the state of Washington. See WAC
				182-501-0175 for a list of border
				cities.
(b) For dates of admission
				on and after August 1, 2007, for both emergency and nonemergency out-of-state
				hospital services, including those provided in bordering city hospitals and
				critical border hospitals, for eligible medicaid and CHIP clients based on the
				medical necessity and utilization review standards and limits established by
				the agency.
(i) Prior authorization by the
				agency is required for the nonemergency out-of-state hospital medical care
				provided to medicaid and CHIP clients.
(ii) Bordering city hospitals are considered
				the same:
(A) As instate hospitals for
				coverage of hospital services; and
(B) As out-of-state hospitals for payment
				methodology. Agency designated critical border hospitals are paid as instate
				hospitals. See WAC
				182-550-3900 and
				182-550-4000.
(c) For out-of-state
				voluntary psychiatric inpatient hospital services for eligible medicaid and
				CHIP clients based on authorization by a division of behavioral health
				designee.
(d) Based on the agency's
				limitations on hospital coverage under WAC
				182-550-1100 and
				182-550-1200 and other applicable
				rules.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-7000 - Outpatient prospective payment system (OPPS) - General

Current through Register Vol. 24-14, July 15, 2024
(1) The medic-aid agency pays for outpatient
				services using an outpatient prospective payment system (OPPS) for all
				hospitals that do not qualify as in-state critical access hospitals per WAC
				182-550-2598.
(2) The agency uses the enhanced ambulatory
				payment group (EAPG) software provided by 3MTM
				Health Information Systems to group OPPS claims based on services performed and
				resource intensity.
(3) The agency
				uses the group established in subsection (2) of this section to determine
				payment for OPPS claims.
11-14-075, recodified as §
											182-550-7000, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.08.090,
					 74.09.500. 07-13-100, §
					 388-550-7000, filed 6/20/07, effective 8/1/07; 04-20-061, § 388-550-7000,
					 filed 10/1/04, effective 11/1/04.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-7050

Current through Register Vol. 24-14, July 15, 2024
11-14-075, recodified as §
											182-550-7050, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.04.050,
					 74.04.057,
					 74.09.500, and
					 74.09.530. 10-08-023, §
					 388-550-7050, filed 3/30/10, effective 4/30/10. Statutory Authority:
					 RCW
					 74.04.050,
					 74.04.057,
					 74.08.090,
					 74.09.500, and 2009-11 Omnibus
					 Operating Budget (ESHB 1244). 09-12-062, § 388-550-7050, filed 5/28/09,
					 effective 7/1/09. Statutory Authority:
					 RCW
					 74.08.090,
					 74.09.500. 07-13-100, §
					 388-550-7050, filed 6/20/07, effective 8/1/07; 04-20-061, § 388-550-7050,
					 filed 10/1/04, effective 11/1/04.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-7200 - OPPS-Billing requirements and payment method

Current through Register Vol. 24-14, July 15, 2024
This section describes hospital provider billing requirements
				  and the payment methods the medicaid agency uses to pay for covered outpatient
				  hospital services provided by hospitals included in the outpatient prospective
				  payment system (OPPS).
(1) Providers
				must bill according to national correct coding initiative (NCCI) standards
				maintained by the Centers for Medicare and Medicaid Services (CMS).
ENHANCED AMBULATORY PATIENT GROUP (EAPG)
				  METHOD
(2) The agency uses the
				enhanced ambulatory patient group (EAPG) method as the primary payment method
				for OPPS. Examples of services paid by the EAPG method include:
(a) Surgeries;
(b) Significant procedures;
(c) Observation services;
(d) Medical visits;
(e) Dental procedures; and
(f) Ancillary services.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-7300 - OPPS-Payment limitations

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid
				agency limits payment for covered outpatient hospital services to the current
				published maximum allowable units of services listed in the outpatient fee
				schedule published on the agency's web site, subject to the following
				limitations:
(a) To receive payment for
				services, providers must bill claims according to national correct coding
				initiative (NCCI) standards. When a unit limit for services is not stated in
				the outpatient fee schedule, the agency pays for services according to the
				program's unit limits stated in applicable WAC and published provider
				guides.
(b) The average resource,
				including units of service, are factored into the enhanced ambulatory patient
				group (EAPG) weight determination, and the allowable units of service for EAPGs
				is equal to one.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-7400 - OPPS APC relative weights

Current through Register Vol. 24-14, July 15, 2024
(1) The
				medicaid agency uses national relative weights established by
				3MTM as part of its enhanced ambulatory patient
				group (EAPG) payment system.
(2)
				The agency may update the relative weights used for calculating OPPS payments
				on July 1st of each year, beginning on July 1, 2015.
(3) The agency may update relative weights
				more frequently for newly added EAPGs in order to maintain current EAPG grouper
				system functionality.
(4) The
				agency will post all relative weights used on the agency's web site.
11-14-075, recodified as §
											182-550-7400, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.08.090,
					 74.09.500. 07-13-100, §
					 388-550-7400, filed 6/20/07, effective 8/1/07; 04-20-061, § 388-550-7400,
					 filed 10/1/04, effective 11/1/04.