Apple Health (Medicaid) rulemaking

The agency is amending this section to replace outdated terms such as “Residential Support Network (RSN)” and “mental health designee,” to delete references to the department of mental health, and to update language regarding authorization and certification for inpatient psychiatric care consistent with the current managed care and administrative services organization (ASO) structure. The agency is also making changes to align with 2SSB 5103, 68th Legislature, 2023 Regular Session. This legislation requires the agency to provide a hospital payment for Apple Health clients who meet the criteria for discharge from a hospital stay to certain facilities but who cannot be discharged because placement is unavailable. This revision provides for the payment of medically necessary ancillary services to be billed by and paid to the hospital separately.

The agency is amending WAC 182-550-2750 to correct a typographical error in a WAC reference. The rule references chapter 246-318 WAC; the correct citation is chapter 246-320 WAC. The agency is repealing WAC 182-550-4700 because the hospital selective contracting program to which it applies ended June 30, 2007. The agency is repealing WAC 182-550-5425 because the upper payment limit program to which it applies ended July 1, 2007. The agency is amending WAC 182-550-1100 by deleting subsection (3)(b) because it applies only to the agency’s selective contracting program that ended June 30, 2007

The agency is revising these rules to align with 2SSB 5103, 68th Legislature, 2023 Regular Session. This legislation requires the agency to provide a hospital payment for Apple Health clients who meet the criteria for discharge from a hospital stay to one of several types of facilities but who cannot be discharged because placement is unavailable. This rulemaking will address the services to be included in the payment for the client’s hospital stay, as well as the services to be billed by and paid to the hospital separately.

The agency is amending these rules to update terminology, revise rates approved by the Legislature, remove outdated information, and to make other general policy changes.

The agency is amending WAC 182-550-6400 to apply it to all eligible providers and update diabetes education provider criteria and billing requirements.

The agency is amending this rule to remove the website link referencing where QMB resource standards for an individual and a couple are listed. Under recent legislation, ESSB 5693, Chapter 297, Laws of 2022, Sec. 205 (26), countable resources are no longer required for other eligibility programs. As a result, HCA removed the QMB resource standards chart from its website. The kidney disease program, however, still requires these resource standards which can be found on Medicare’s website.

The agency is amending this rule to align it with applicable federal government regulations and simplify the managed care organization (MCO) appeal process
by removing the requirement that the MCO confirm an oral appeal in writing and removing the requirement that the MCO acknowledge receipt of each appeal in writing.

HCA deleted subsections (9) and (10) within WAC 182-538-070 to be consistent with the integrated managed care contract standards for delivery case rate payments.

The agency is adopting
this new rule to establish eligibility criteria for the Civil Transition Program, which is a state-funded, fee-for-service program
that requires the Department of Social and Health Services (DSHS) to provide wraparound services and supports in
community-based settings, which may include residential supports, to persons who have been found not competent to stand
trial due to an intellectual or developmental disability, dementia, or traumatic brain injury. This Apple Health program is for
persons who are not eligible for any other Apple Health program and will provide state-funded categorically needy coverage.
This program implements a portion of RCW 10.77.202, which became effective December 1, 2023. The agency established
WAC 182-538B-180 through an emergency rule filed under WSR 23-24-052 and refiled under WSR 24-08-051. The purpose
of this rulemaking is to make that rule permanent and to renumber it as WAC 182-508-0200. DSHS is engaged in rulemaking
on this subject. DSHS filed a preproposal statement of inquiry under WSR 23-24-046 and established emergency rules under
WSR 24-05-046.

The agency is amending WAC 182-543-3300. Rule updates will include updated medical necessity criteria based on evidence review(s).