WAC 388-550-2650   Base community psychiatric hospitalization payment method for medicaid and SCHIP clients and nonmedicaid and non-SCHIP clients.  (1) Effective for dates of admission from July 1, 2005 through June 30, 2007, and in accordance with legislative directive, the department implemented two separate base community psychiatric hospitalization payment rates, one for medicaid and SCHIP clients and one for nonmedicaid and non-SCHIP clients. Effective for dates of admission on and after July 1, 2007, the base community psychiatric hospitalization payment method for medicaid and SCHIP clients and nonmedicaid and non-SCHIP clients is no longer used. (For the purpose of this section, a "nonmedicaid or non-SCHIP client" is defined as a client eligible under the general assistance-unemployable (GA-U) program, the Alcoholism and Drug Addiction Treatment and Support Act (ADATSA), the psychiatric indigent inpatient (PII) program, or other state-administered program, as determined by the department.)

     (a) The medicaid base community psychiatric hospital payment rate is a minimum per diem for claims for psychiatric services provided to medicaid and SCHIP 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 388-500-0005. In addition, the department 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 department does not consider detoxification 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 mental health division (MHD) designee prior to admission for covered diagnoses.

     (iv) Meet the criteria in WAC 388-550-2600.

     (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 MHD designee.

     (iii) Be approved by the professional in charge of the hospital or hospital unit.

     (iv) Be prior authorized by the regional support network (RSN) or its designee.

     (v) Meet the criteria in WAC 388-550-2600.

     (4) The provider requesting payment must complete the appropriate sections of the Involuntary Treatment Act patient claim information (form DSHS 13-628) in triplicate and route both the form and each claim form submitted for payment, to the county involuntary treatment office.

     (5) Payment for all claims is based on covered days within a client's approved length of stay (LOS), subject to client eligibility and department-covered services.

     (6) The medicaid base community psychiatric hospitalization payment rate applies only to a medicaid or SCHIP client admitted to a nonstate-owned free-standing psychiatric hospital located in Washington state.

     (7) The nonmedicaid base community psychiatric hospitalization payment rate applies only to a nonmedicaid or SCHIP client admitted to a hospital:

     (a) Designated by the department as an ITA-certified hospital; or

     (b) That has a department-certified ITA bed that was used to provide ITA services at the time of the nonmedicaid or non-SCHIP admission.

     (8) For inpatient hospital psychiatric services provided to eligible clients for dates of admission on and after July 1, 2005, through June 30, 2007, the department pays:

     (a) A hospital's department of health (DOH)-certified distinct psychiatric unit as follows:

     (i) For medicaid and SCHIP clients, inpatient hospital psychiatric services are paid using the department-specific nondiagnosis related group (DRG) payment method.

     (ii) For nonmedicaid and non-SCHIP 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 department-specified non-DRG payment method if no relative weight exists for the DRG in the department'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 SCHIP clients, inpatient hospital psychiatric services are paid using:

     (A) The DRG payment method; or

     (B) The department-specified non-DRG payment method if no relative weight exists for the DRG in the department's payment system.

     (ii) For nonmedicaid and SCHIP 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 department-specified non-DRG payment method if no relative weight exists for the DRG in the department'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 SCHIP 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-SCHIP clients, inpatient hospital psychiatric services are paid the same as for medicaid and SCHIP 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 SCHIP clients, inpatient hospital psychiatric services are paid using the methods identified in WAC 388-550-4650.

     (ii) For nonmedicaid and non-SCHIP clients, inpatient hospital psychiatric services are paid using the methods identified in WAC 388-550-4650 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 SCHIP clients, inpatient hospital psychiatric services are paid using the department-specified non-DRG payment method.

     (ii) For nonmedicaid [and] non-SCHIP clients, inpatient hospital psychiatric services are paid using the department-specified non-DRG payment method.



[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.]