00465: Mismatch between Claim header amount and Line sum (multiple t1015 lines)
Discovery log number
00465
Discovery description

For claims containing multiple T1015 lines, the system does not currently aggregate the line amounts correctly, leading to a mismatch between the header amount and the sum of the associated claim lines. A fix has been identified to ensure correct process.

Date reported
ETA
Provider impact
Phase 1
Workaround
N/A
Description
The agency is amending these rules to remove short-term post-hospitalization housing from the medical respite program definition as this housing is separate from medical respite. Medical respite is short-term recovery/rehabilitation for a client’s acute medical condition. The housing applies to other health-related social needs (HRSN) services that only provide room and board such as rent/temporary housing that is included per demonstration period. Additionally, the cap of 6 months of utilization will be per rolling 12-month period for the medical respite program as this aligns with CMS guidance.

Agency contacts

Rulemaking contact

Valerie Freudenstein

Program contact

Rob McDonough

Rulemaking status history

Preproposal (CR101)

Simon Borumand

Description
To implement the Prescription Drug Affordability Board methodology for setting upper payment limits for prescription drugs the board has determined have led or will lead to excess costs based on its affordability review as required in RCW 70.405.050.

Agency contacts

Rulemaking contact

Valerie Freudenstein

Program contact

Simon Borumand

Rulemaking status history

Preproposal (CR101)

Katherine Ruiz

00464: ProviderOne Deducting Incorrect Client Responsibility Amount
Discovery log number
00464
Discovery description

ProviderOne is receiving reports from Social Service providers that the amount of client responsibility deducted from their January 2026 claims do not match the amount applied to the Social Service Authorization line. Our system vendor is working to resolve the issue. ProviderOne will provide more information and steps to correct the claims as soon as we have a path forward.

Impact to clients, provider or staff: The incorrect amount of client responsibility is being deducted from the claim.

Date reported
ETA
Provider impact
Phase 2
Workaround
None
Description
The agency is planning to move urological and incontinence supplies from WAC 182-543-5500 into a new section under WAC 182-543-6100. This change aligns with the agency’s move to contracted provider reimbursement for these supplies.

Agency contacts

Rulemaking contact

Valerie Freudenstein

Rulemaking status history

Preproposal (CR101)

Description
Engrossed Substitute Senate Bill 5291 (Chapter 380, Laws of 2025) was signed into law on May 20, 2025. The bill created a new chapter 212 under Title 48 RCW concerning supplemental long-term care insurance. Supplemental long-term care insurance is a new product designed to provide coverage once WA Cares benefits under chapter 50B.04 RCW have been exhausted. The Office of the Insurance Commissioner (OIC) added a new chapter 212 to Title 284 WAC (WSR 26-05-001) to implement the new law and to ensure all affected parties understand their rights and obligations. The Health Care Authority is amending its long-term care partnership rules to add a cross-reference to the new OIC rules.

Agency contacts

Rulemaking contact

Brian Jensen

Program contact

Paige Lewis

Rulemaking status history

Expedited Adoption (CR105)

00464: ProviderOne Deducting Incorrect Client Responsibility Amount
Discovery log number
00464
Discovery description

ProviderOne is receiving reports from Social Service providers that the amount of client responsibility deducted from their January 2026 claims do not match the amount applied to the Social Service Authorization line. Our system vendor is working to resolve the issue. ProviderOne will provide more information and steps to correct the claims as soon as we have a path forward.

Impact to clients, provider or staff: The incorrect amount of client responsibility is being deducted from the claim.

 

Date reported
Provider impact
Phase 2
Workaround
None
Can being approved for PFML or FMLA impact an employee's eligibility for PEBB benefits?

Employers need to determine eligibility for PEBB benefits without considering whether an employee will or will not take leave that is protected under state and/or federal laws. Working hours that contribute to the minimum necessary for eligibility are not “reduced” by anticipated OR taken PFML or FMLA time. If an employee is already determined to be benefits eligible when they go on PFML or FMLA, those benefits must be maintained during PFML or FMLA.

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