Current through Register Vol. 24-18, September 15, 2024
(1)
The purpose and intent of this section is to describe how the medicaid agency,
pertaining to medicaid hospital rates, will comply with section 4711(a) of the
federal Balanced Budget Act of 1997,
Public Law
105-33, as codified at
42 U.S.C.
1396 a (a)(13)(A).
(2)For purposes of this section, the term:
(a)"Stakeholders" means providers,
beneficiaries, representatives of beneficiaries, and other concerned state
residents.
(b)"Rate" means the
medicaid payment amount to a provider for a particular hospital service, except
for disproportionate share payments not mandated by federal law.
(c) "Methodology" underlying the
establishment of a medicaid hospital rate means (unless otherwise noted) the
principles, procedures, limitations, and formulas detailed in WAC
182-550-2900 through
182-550-5500.
(d) "Justification" means an explanation of
why the agency is proposing or implementing a medic-aid rate change based on a
change in medicaid rate setting methodology.
(e)"Reasonable opportunity to review and
provide written comments" means a period of fourteen calendar days in which
stakeholders may provide written comments to the agency.
(f)"Hospital services" means those services
that are performed in a hospital facility for an inpatient client and which are
payable only to the hospital entity, not to individual performing
providers.
(g)"Web site" means the
agency's internet home page on the worldwide web:
http://www.hca.wa.gov/ is the
internet address.
(3)
The agency will notify stakeholders of proposed and final changes in individual
medicaid hospital rates for hospital services, as follows:
(a) Publish the proposed medicaid hospital
rates, the methodologies underlying the establishment of the rates, and
justifications for the rates;
(b)Give stakeholders a reasonable opportunity
to review and provide written comments on the proposed medicaid hospital rates,
the methodologies underlying the establishment of the rates, and justifications
for the rates; and
(c)Publish the
final medicaid hospital rates, the methodologies underlying the establishment
of such rates, and justifications for such rates.
(4)
(a)
Except as otherwise provided in this section, the agency will determine the
manner of publication of proposed or final medicaid hospital rates.
(b)Publication of proposed medicaid hospital
rates will occur as follows:
(i) The agency
will mail each provider's proposed rate to the affected provider via
first-class mail at least fifteen calendar days before the proposed date for
implementing the rates; and
(ii)
For other stakeholders, the agency will post proposed rates on the agency's web
site.
(c)Publication of
final medicaid hospital rates will occur as follows:
(i) The agency will mail each provider's
final rate to the affected provider via first-class mail at least one calendar
day before implementing the rate; and
(ii) For other stakeholders, the agency will
post final rates on the agency's web site.
(d) The publications required by subsections
(4)(b) and (c) of this section will refer to the appropriate sections of
chapter 182-550 WAC for information on the methodologies underlying the
proposed and final rates.
(5)The agency, when it proposes amendments to
the methodologies underlying the establishment of medicaid hospital rates as
described in WAC
182-550-2900 through
182-550-5500, will adhere to the
notice and comment provisions of the Administrative Procedure Act (chapter
34.05 RCW).
(6) Stakeholders who
wish to receive notice of either proposed and final medicaid hospital rates or
proposed and final amendments to WAC
182-550-2900 through
182-550-5500 must notify the
agency in writing. The agency will send notice of all the actions to the
stakeholders postage prepaid by regular mail.
(7)
(a) The
notice and publication provisions of section 4711(a) of the Balanced Budget Act
of 1997 do not apply when a rate change is:
(i) Necessary to conform to medicare rules,
methods, or levels of reimbursement for clients who are eligible for both
medicare and medicaid;
(ii)
Required by Congress, the legislature, or court order, and no further rule
making is necessary to implement the change; or
(iii) Part of a nonmedicaid
program.
(b) Although
notice and publication are not required for medicaid rate changes described in
subsection (7)(a) of this section, the agency will attempt to timely notify
stakeholders of these rate changes.
(8) The following rules apply when the agency
and an individual hospital negotiate or contractually agree to medicaid rates
for hospital services:
(a) Receipt by the
hospital of the contract or contract amendment form for signature constitutes
notice to the hospital of proposed medicaid rates.
(b) Receipt by the hospital of the contract
or contract amendment form signed by both parties constitutes notice to the
hospital of final medicaid rates.
(c) Notwithstanding subsection (4)(c) of this
section, final medicaid contract rates are effective on the date contractually
agreed to by the agency and the individual hospital.
(d) Before the execution of the contract, the
agency will not publish negotiated contract prices that are agreed to between
the agency and an individual provider to anyone other than the individual
provider. Within fifteen calendar days after the execution of any such
contract, the agency will publish the negotiated contract prices on its web
site.
(9)The following
rules apply when a hospital provider or other stakeholder wishes to challenge
the adequacy of the public notification process followed by the agency in
proposing or implementing a change to medicaid hospital rates, the
methodologies underlying the establishment of the rates, or the justification
for the rates:
(a) If any such challenge is
limited solely to the adequacy of the public notification process, then the
challenge will:
(i) Not be pursued in any
administrative appeal or dispute resolution procedure established in rule by
the agency; and
(ii) Be pursued
only in a court of proper jurisdiction as may be provided by law.
(b) If a hospital provider brings
any such challenge in conjunction with an appeal of its medicaid rate, then the
hospital provider may pursue the challenge in an administrative appeal or
dispute resolution procedure established in rule by the agency under which
hospital providers may appeal their medicaid rates.
11-14-075, recodified as §182-550-5550, filed 6/30/11,
effective 7/1/11. Statutory Authority:
RCW
74.09.500 and
42 USC
1396 a (a)(13)(A). 98-23-036, §
388-550-5550, filed 11/10/98, effective
12/11/98.
