Section 182-543-9400. Reimbursement method—Medical supplies and related services.

(1) The agency sets, evaluates and updates the maximum allowable fees for medical supplies and nondurable medical equipment (DME) items at least once yearly using one or more of the following:

(a) The current medicare rate, as established by the federal Centers for Medicare and Medicaid Services (CMS), if a medicare rate is available;

(b) A pricing cluster;

(c) Based on input from stakeholders or other relevant sources that the agency determines to be reliable and appropriate; or

(d) On a by report basis.

(2) Establishing reimbursement rates for medical supplies and non-DME items based on pricing clusters.

(a) A pricing cluster is based on a specific health care common procedure coding system (HCPCS) code.

(b) The agency's pricing cluster is made up of all the brands for which the agency obtains pricing information. However, the agency may limit the number of brands included in the pricing cluster if doing so is in the best interests of its clients as determined by the agency. The agency considers all of the following when establishing the pricing cluster:

(i) A client's medical needs;

(ii) Product quality;

(iii) Cost; and

(iv) Available alternatives.

(c) When establishing the fee for medical supplies or other non-DME items in a pricing cluster, the maximum allowable fee is the median amount of available manufacturers' list or manufacturers' suggested retail prices (MSRP).

(3) The agency evaluates a by-report (BR) item, procedure, or service for its medical necessity, appropriateness and reimbursement value on a case-by-case basis. The agency calculates the reimbursement rate at eighty-five percent of the manufacturer's list or manufacturer's suggested retail price (MSRP) as of July 31st of the base year or one hundred twenty-five percent of the wholesale acquisition cost from the manufacturer's invoice.

(4) The agency may adopt policies, procedure codes, and/or rates that are inconsistent with those set by medicare if the agency determines that such actions are necessary.

(5) For clients residing in skilled nursing facilities, see WAC 182-543-5700.

[Statutory Authority: RCW 41.05.021. WSR 12-16-059, § 182-543-9400, filed 7/30/12, effective 8/30/12; WSR 12-07-022, § 182-543-9400, filed 3/12/12, effective 4/12/12. WSR 11-14-075, recodified as § 182-543-9400, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.04.050. WSR 11-14-052, § 388-543-9400, filed 6/29/11, effective 8/1/11.]

RCW 41.05.021. WSR 12-16-059, § 182-543-9400, filed 7/30/12, effective 8/30/12; WSR 12-07-022, § 182-543-9400, filed 3/12/12, effective 4/12/12. WSR 11-14-075, recodified as § 182-543-9400, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.04.050. WSR 11-14-052, § 388-543-9400, filed 6/29/11, effective 8/1/11.

Rules

182-543-5700,