Section 182-552-1600. Respiratory care equipment and supplies—Reimbursement—Methodology for purchase, rental, and repair.

(1) The medicaid agency sets, evaluates, and updates the maximum allowable fees for purchased respiratory care equipment and supplies 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), for a new purchase if a medicare rate is available;

(b) A pricing cluster; or

(c) On a by-report basis.

(2) Establishing reimbursement rates for purchased respiratory care equipment and supplies based on pricing clusters.

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

(b) The medicaid agency's pricing cluster is made up of all the brands/models for which the agency obtains pricing information. However, the medicaid agency may limit the number of brands/models included in the pricing cluster. The medicaid agency considers all of the following when establishing the pricing cluster:

(i) A client's medical needs;

(ii) Product quality;

(iii) Introduction, substitution, or discontinuation of certain brands/models;

(iv) Cost; and/or

(v) Available alternatives.

(c) When establishing the fee for purchased respiratory care equipment and supplies in a pricing cluster, the maximum allowable fee is the median amount of available manufacturer's list or suggested retail prices for all brands/models as noted in (b) of this subsection.

(3) The medicaid agency evaluates items, procedures, and services billed using miscellaneous procedure codes, when an established code is not available, on a case-by-case basis for medical necessity, appropriateness, and reimbursement value. The medicaid agency calculates the purchase reimbursement rate for these items at eighty percent of the manufacturer's list or suggested retail price as of October thirty-first of the base year or the cost from the manufacturer's invoice.

(4) The medicaid agency's maximum allowable fees for monthly rental are updated at least once yearly and are established using one of the following:

(a) For items with a monthly rental rate on the current medicare fee schedule, as established by CMS, the medicaid agency equates its maximum allowable fee for monthly rental to the current medicare monthly rental rate;

(b) For items that have a new purchase rate but no monthly rental rate on the current medicare fee schedule, as established by CMS, the medicaid agency sets the maximum allowable fee for monthly rental at one-tenth of the new purchase price of the current medicare rate; or

(c) For items not included in the current medicare fee schedule, as established by CMS, the medicaid agency considers the maximum allowable monthly reimbursement rate as by-report. The medicaid agency calculates the monthly reimbursement rate for these items at one-tenth of eighty percent of the manufacturer's list or suggested retail price as of October thirty-first of the base year or one-tenth the cost from the manufacturer's invoice.

(5) The medicaid agency's maximum allowable fees for daily rental are updated at least once yearly and are established using one of the following:

(a) For items with a daily rental rate on the current medicare fee schedule, as established by CMS, the medicaid agency equates its maximum allowable fee for daily rental to the current medicare daily rental rate;

(b) For items that have a new purchase rate but no daily rental rate on the current medicare fee schedule, as established by CMS, the medicaid agency sets the maximum allowable fee for daily rental at one three-hundredth of the new purchase price of the current medicare rate; or

(c) For items not included in the current medicare fee schedule, as established by CMS, the medicaid agency considers the maximum allowable daily reimbursement rate as by-report. The medicaid agency calculates the daily reimbursement rate for these items at one three-hundredth of eighty percent of the manufacturer's list or suggested retail price as of October thirty-first of the base year or one three-hundredth of the cost from the manufacturer's invoice.

(6) The medicaid agency, with prior authorization, will pay for repairs of client-owned equipment only. In addition to agency-specific forms identified in the respiratory care medicaid provider guide, all of the following requirements must be met in order to receive authorization and reimbursement for a repair of client-owned equipment:

(a) The provider must submit a manufacturer pricing sheet showing manufacturer's list or suggested retail price (MSRP) or manufacturer invoice showing the cost of the repair identifying and itemizing the parts. The invoice must indicate the wholesale acquisition cost, the manufacturer's list or suggested retail price (MSRP) for all parts used in the repair for which reimbursement is being sought. Reimbursement for parts used in a repair will be:

(i) Eighty percent of the manufacturer's list or suggested retail price as of October thirty-first of the base year; or

(ii) The cost from the manufacturer's invoice.

(b) Reimbursement for actual labor charges will be made according to the medicaid agency's current fee schedule. The provider must follow HCPCS coding guidelines and submit an authorization request accordingly with actual labor units identified and supported by documentation. Base labor charges or other administrative-like fees will not be reimbursed.

[Statutory Authority: RCW 41.05.021. WSR 12-14-022, § 182-552-1600, filed 6/25/12, effective 8/1/12.]

RCW 41.05.021. WSR 12-14-022, § 182-552-1600, filed 6/25/12, effective 8/1/12.