Current through Register Vol. 24-18, September 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.
(4) Supplemental distributions from the TCF
are:
(a) Allocated into five payment pools.
Timing of payments is described in subsection (5) of this section.
Distributions from the payment pools to the individual hospitals are determined
by first summing the agency's qualifying payments to each eligible hospital
since the beginning of the service year. This amount is then expressed as a
percentage of the agency's total payments to all eligible hospitals for
qualifying services provided during the service year-to-date. For TCF purposes,
service year is defined as the SFY. Each hospital's qualifying payment
percentage for the service year-to-date is multiplied by the available amount
for the service year-to-date, and then the agency subtracts what has been
allocated to each hospital for the service year-to-date to determine the
portion of the current payment pool to be paid to each qualifying hospital.
Eligible hospitals and qualifying payments are described in (a)(i) through
(iii) of this subsection. Qualifying payments are the agency's payments to:
(i) Level I, Level II, and Level III trauma
service centers for qualified medicaid trauma cases since the beginning of the
service year. The agency determines the countable payment for trauma care
provided to medicaid clients based on date of service, not date of
payment;
(ii) The Level I, Level
II, and Level III hospitals for trauma cases transferred to these facilities
since the beginning of the service year. A Level I, Level II, or Level III
hospital that receives a transferred trauma case from any lower level hospital
is eligible for an enhanced payment, regardless of the client's injury severity
score (ISS); and
(iii) Level II and
Level III hospitals for qualified trauma cases (those that meet or exceed the
ISS criteria in (b) of this subsection) transferred by these hospitals since
the beginning of the service year to a trauma service center with a higher
designation level.
(b)
Paid only for a medicaid trauma case that meets:
(i) The ISS of thirteen or greater for an
adult trauma patient (a client age fifteen or older);
(ii) The ISS of nine or greater for a
pediatric trauma patient (a client younger than age fifteen); or
(iii) The conditions of (c) of this
subsection.
(c) Made to
hospitals, as follows, for a trauma case that is transferred:
(i) A hospital that receives the transferred
trauma case qualifies for payment regardless of the ISS if the hospital is
designated or recognized by DOH as an approved Level I, Level II, or Level III
adult or pediatric trauma service center;
(ii) A hospital that transfers the trauma
case qualifies for payment only if:
(A) The
hospital is designated or recognized by DOH as an approved Level II or Level
III adult or pediatric trauma service center; and
(B) The ISS requirements in (b)(i) or (ii) of
this subsection are met.
(iii) A hospital that DOH designates or
recognizes as an approved Level IV or Level V trauma service center does not
qualify for supplemental distributions for trauma cases that are transferred in
or transferred out, even when the transferred cases meet the ISS criteria in
(b) of this subsection.
(d) Not funded by disproportionate share
hospital (DSH) funds; and
(e) Not
distributed by the agency to:
(i) Trauma
service centers designated or recognized as Level IV or Level V;
(ii) Critical access hospitals (CAHs), except
when the CAH is also a Level III trauma service center; or
(iii) Any facility for follow-up services
related to the qualifying trauma incident but provided to the client after the
client has been discharged from the initial hospitalization for the qualifying
injury.
(5)
Distributions for an SFY are paid as follows:
(a) The first supplemental distribution from
the TCF is made three to six months after the SFY begins;
(b) Subsequent distributions are made
approximately every two to four months after the first distribution is made,
except as described in (c) of this subsection;
(c) The final distribution from the TCF for
an SFY is:
(i) Made one year after the end of
the SFY;
(ii) Limited to the
remaining balance of the agency's TCF appropriation for that SFY; and
(iii) Distributed based on each eligible
hospital's percentage share of the total payments made by the agency to all
designated trauma service centers for qualified trauma services provided during
the relevant SFY.
(6) For purposes of the supplemental
distributions from the TCF, all of the following apply:
(a) At its discretion, and with sufficient
public notice, the agency may adjust the deadline for submission and/or
adjustment of trauma claims in response to budgetary program needs;
(b) The agency considers a provider's request
for a trauma claim adjustment only if the adjustment request is received by the
agency within three hundred sixty-five calendar days from the date of the
initial trauma service;
(c) Except
as provided in (a) of this subsection, the deadline for making adjustments to a
trauma claim is the same as the deadline for submitting the initial claim to
the agency as specified in WAC
182-502-0150(3).
See WAC 182-502-0150(11) and
(12) for other time limits applicable to TCF
claims;
(d) All claims and claim
adjustments are subject to federal and state audit and review requirements;
and
(e) The total amount of
supplemental distributions from the TCF disbursed to eligible hospitals by the
agency in any SFY cannot exceed the amount appropriated by the legislature for
that SFY. The agency has the authority to take whatever actions necessary to
ensure the department stays within the TCF appropriation.
Statutory Authority:
RCW
41.05.021. WSR 12-14-041, §182-550-5450,
filed 6/27/12, effective 7/28/12. WSR 11-14-075, recodified as
§182-550-5450, filed 6/30/11, effective 7/1/11. Statutory Authority:
RCW
70.168.040,
74.08.090, and
74.09.500. WSR 10-12-013, §
388-550-5450, filed 5/21/10, effective 6/21/10. Statutory Authority:
RCW
74.08.090,
74.09.160,
74.09.500, and
70.168.040. WSR 08-08-065, §
388-550-5450, filed 3/31/08, effective 5/1/08. Statutory Authority:
RCW
74.08.090,
74.09.500. WSR 07-14-090, §
388-550-5450, filed 6/29/07, effective 8/1/07; WSR 06-08-046, §
388-550-5450, filed 3/30/06, effective 4/30/06; WSR 04-19-113, §
388-550-5450, filed 9/21/04, effective
10/22/04.
