Current through Register Vol. 24-18, September 15, 2024
(1) Effective for dates of admission from
July 1, 2005, through June 30, 2007, and in accordance with legislative
directive, the agency implemented two separate base community psychiatric
hospitalization payment rates, one for medicaid and children's health insurance
program (CHIP) clients and one for nonmedicaid and non-CHIP clients. Effective
for dates of admission on and after July 1, 2007, the base community
psychiatric hospitalization payment method for medicaid and CHIP clients and
nonmedicaid and non-CHIP clients is no longer used. (For the purpose of this
section, a "nonmedicaid or non-CHIP client" is defined as a client eligible
under the medical care services (MCS) program, as determined by the agency.)
(a) The medicaid base community psychiatric
hospital payment rate is a minimum per diem for claims for psychiatric services
provided to medicaid and CHIP covered patients, paid to hospitals that accept
commitments under the Involuntary Treatment Act (ITA).
(b) The nonmedicaid base community
psychiatric hospital payment rate is a minimum allowable per diem for claims
for psychiatric services provided to indigent patients paid to hospitals that
accept commitments under the ITA.
(2) For the purposes of this section,
"allowable" means the calculated allowed amount for payment based on the
payment method before adjustments, deductions, or add-ons.
(3) To be eligible for payment under the base
community psychiatric hospitalization payment method:
(a) A client's inpatient psychiatric
voluntary hospitalization must:
(i) Be
medically necessary as defined in WAC 182-5000070. In addition, the agency
considers medical necessity to be met when:
(A) Ambulatory care resources available in
the community do not meet the treatment needs of the client;
(B) Proper treatment of the client's
psychiatric condition requires services on an inpatient basis under the
direction of a physician;
(C) The
inpatient services can be reasonably expected to improve the client's condition
or prevent further regression so that the services will no longer be needed;
and
(D) The client, at the time of
admission, is diagnosed as having an emotional/behavioral disturbance as a
result of a mental disorder as defined in the current published Diagnostic and
Statistical Manual of the American Psychiatric Association. The agency does not
consider withdrawal management to be psychiatric in nature.
(ii) Be approved by the
professional in charge of the hospital or hospital unit.
(iii) Be authorized by the appropriate
division of behavioral health and recovery (DBHR) designee prior to admission
for covered diagnoses.
(iv) Meet
the criteria in WAC
182-550-2600.
(b) A client's inpatient
psychiatric involuntary hospitalization must:
(i) Be in accordance with the admission
criteria in chapters 71.05 and 71.34 RCW.
(ii) Be certified by a DBHR
designee.
(iii) Be approved by the
professional in charge of the hospital or hospital unit.
(iv) Be prior authorized by the agency or the
agency's designee.
(v) Meet the
criteria in WAC
182-550-2600.
(4) Payment for all
claims is based on covered days within a client's approved length of stay
(LOS), subject to client eligibility and agency-covered services.
(5) The medicaid base community psychiatric
hospitalization payment rate applies only to a medicaid or CHIP client admitted
to a nonstate-owned free-standing psychiatric hospital located in Washington
state.
(6) The nonmedicaid base
community psychiatric hospitalization payment rate applies only to a
nonmedicaid or CHIP client admitted to a hospital:
(a) Designated by the agency as an
ITA-certified hospital; or
(b) That
has an agency-certified ITA bed that was used to provide ITA services at the
time of the nonmedicaid or non-CHIP admission.
(7) For inpatient hospital psychiatric
services provided to eligible clients for dates of admission on and after July
1, 2005, through June 30, 2007, the agency pays:
(a) A hospital's department of health
(DOH)-certified distinct psychiatric unit as follows:
(i) For medicaid and CHIP clients, inpatient
hospital psychiatric services are paid using the agency-specific nondiagnosis
related group (DRG) payment method.
(ii) For nonmedicaid and non-CHIP clients,
the allowable for inpatient hospital psychiatric services is the greater of:
(A) The state-administered program DRG
allowable (including the high cost outlier allowable, if applicable), or the
agency-specified non-DRG payment method if no relative weight exists for the
DRG in the agency's payment system; or
(B) The nonmedicaid base community
psychiatric hospitalization payment rate multiplied by the covered
days.
(b) A
hospital without a DOH-certified distinct psychiatric unit as follows:
(i) For medicaid and CHIP clients, inpatient
hospital psychiatric services are paid using:
(A) The DRG payment method; or
(B) The agency-specified non-DRG payment
method if no relative weight exists for the DRG in the agency's payment
system.
(ii) For
nonmedicaid and CHIP clients, the allowable for inpatient hospital psychiatric
services is the greater of:
(A) The
state-administered program DRG allowable (including the high cost outlier
allowable, if applicable), or the agency-specified non-DRG payment method if no
relative weight exists for the DRG in the agency's payment system; or
(B) The nonmedicaid base community
psychiatric hospitalization payment rate multiplied by the covered
days.
(c) A
nonstate-owned free-standing psychiatric hospital as follows:
(i) For medicaid and CHIP clients, inpatient
hospital psychiatric services are paid using as the allowable, the greater of:
(A) The ratio of costs-to-charges (RCC)
allowable; or
(B) The medicaid base
community psychiatric hospitalization payment rate multiplied by covered
days.
(ii) For
nonmedicaid and non-CHIP clients, inpatient hospital psychiatric services are
paid the same as for medicaid and CHIP clients, except the base community
inpatient psychiatric hospital payment rate is the nonmedicaid rate, and the
RCC allowable is the state-administered program RCC allowable.
(d) A hospital, or a distinct
psychiatric unit of a hospital, that is participating in the certified public
expenditure (CPE) payment program, as follows:
(i) For medicaid and CHIP clients, inpatient
hospital psychiatric services are paid using the methods identified in WAC
182-550-4650.
(ii) For nonmedicaid and non-CHIP clients,
inpatient hospital psychiatric services are paid using the methods identified
in WAC
182-550-4650
in conjunction with the nonmedicaid base community psychiatric hospitalization
payment rate multiplied by covered days.
(e) A hospital, or a distinct psychiatric
unit of a hospital, that is participating in the critical access hospital (CAH)
program, as follows:
(i) For medicaid and
CHIP clients, inpatient hospital psychiatric services are paid using the
agency-specified non-DRG payment method.
(ii) For nonmedicaid and non-CHIP clients,
inpatient hospital psychiatric services are paid using the agency-specified
non-DRG payment method.
11-14-075, recodified as §182-550-2650, filed 6/30/11,
effective 7/1/11. Statutory Authority:
RCW
74.08.090,
74.09.500. 07-14-053, §
388-550-2650, filed 6/28/07, effective 8/1/07. Statutory Authority:
RCW
74.08.090,
74.09.500, and 2005 c 518, §
204, Part II. 07-06-043, § 388-550-2650, filed 3/1/07, effective
4/1/07.
