Apple Health (Medicaid) rulemaking

The agency is amending these rules to provide more general language due to frequent changes of percentages and dollar amounts.

The agency is amending this rule to add gender affirming surgery services to being exempt from DRG payment.

The agency is amending WAC 182-550-1500 to allow for the payment of outpatient services in the following revenue code categories: “Partial hospitalization – Less intensive,” “Partial hospitalization – Intensive,” and “Intensive outpatient services – Psychiatric.

The agency amended this rule to add clarifying language to subsection (5)(c). The agency added that if the state’s
applicable federal medical assistance percentage (FMAP) is 0%, the amount derived in subsection (5)(b) is multiplied by the
lowest Washington state specific medicaid FMAP in effect at the time of claim payment.

HCA is removing references to the hospital outpatient ratio of costs-to-charges (RCC) payment method due to the discontinuation of this payment method.

The agency is amending this section to replace outdated terms such as “Residential Support Network (RSN)” and “mental health designee,” to delete references to the department of mental health, and to update language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 existing rules related to diabetes education. The agency is proposing to move the current diabetes education rule out of chapter 182-550 WAC and into a new chapter 182-564 because the diabetes education program is not restricted to outpatient hospitals. The agency is updating curriculum requirements to align them with Washington State Department of Health requirements for this program. The agency is also removing outdated billing requirements.

The agency is correcting Washington Administrative Code cross citations. The proposed rule corrects typographical errors without changing the rule’s effect.

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.