Open Enrollment for Health Benefits Exchange for 2016 Coverage

October 21, 2015

Open Enrollment for Health Benefits Exchange for 2016 Coverage

It’s that time again! Open enrollment for the Exchange’s individual market runs November 1, 2015 to January 31, 2016. Washington’s hospitals play a key role in helping patients enroll in either the Health Benefit Exchange’s subsidized health plans or Apple Health, depending on the enrollee’s income. Individuals and families can access enrollment for either program through Washington’s Healthplanfinder portal. Patients meeting eligibility requirements for Apple Health can enroll at any time. Please read this article for an example of one hospital’s efforts to enroll members of their community. (Chelene Whiteaker,

WSHA and Law Enforcement Organizations Provide Webinar on New Law on Inmate/Suspect Guarding and Payment

On October 15, WSHA staff, along with representatives of the Washington Association of Sheriffs and Police Chiefs and the Association of Washington Counties, provided a webinar overview of significant changes to guarding requirements and payment under recently enacted Senate Bill 5593 and answered webinar participants’ questions regarding the new law. More than 150 staff from hospitals, local government, and law enforcement entities participated in the webinar.

Senate Bill 5593 requires that jails and law enforcement entities provide guards when a patient who is suspected or convicted of a violent or sexual crime is brought by the jail or law enforcement to a hospital for care. The bill also provides a default payment structure for services to inmates and suspects that are the responsibility of the jail or law enforcement entity if there is no contract between the entity and the hospital. Links to our recent bulletin as well as a recording and slides for the webinar can be found here. (Andrew Busz,

HCA Adjusts Inpatient PPS Hospital Rates for Budget Neutrality

Under the inpatient and outpatient Medicaid rebasing for Prospective Payment System (PPS) hospitals effective July 1, 2014, the Washington State Health Care Authority (HCA) makes periodic budget neutrality adjustments to ensure aggregate payment for hospital services is in line with what the same services would have been paid under the prior system. Adjustments are made prospectively rather than through reprocessing of prior claims with the amount of the budget adjustments intended to compensate for aggregate overpayments or underpayments for the entire period since the rebasing. The general methodology used is described in WAC 182-550-3850.

HCA has now determined that overall inpatient payments, compared to what the same services would have been under the prior rates, and methodology were higher than the allowed range and is proposing an overall percentage adjustment factor of 0.9190 to inpatient conversion factors, or a reduction of about 8 percent, effective November 1. This replaces a negative inpatient adjustment of about 1 percent put in place August 1. The upward outpatient budget neutrality adjustment of about 8 percent put in effect in August is unchanged.

A HCA and Navigant webinar recently an overview of the calculation methodology to the WSHA rebasing task force. You may view the slides here. At the task force’s request, WSHA has asked a consultant to review the state’s calculations and methodology for reasonableness. (Andrew Busz,

WSHA to Comment on Proposed Guidance for 340B Pharmacy Program

WSHA is in the process of writing comments to be submitted to the Health Resources and Services Administration regarding proposed guidance governing the federal 340B Drug Pricing Program. The program allows health entities that qualify for the program based on their care for under-served populations to obtain drugs from drug companies at reduced cost, increasing the health entity’s ability to provide services to their patients. Comments are due by 2:00 p.m. PDT on October 27.

In our comment letter we plan to express concerns regarding the guidance’s potential impact to availability of infusion services, availability of discharge medications, and services paid under a payor’s bundled payment mechanism. We encourage member hospitals to let us know of additional concerns and/or comment directly to HRSA. If you comment directly, please send us a copy of your comment letter.  (Andrew Busz,

WSHA to Comment on Medicaid Readmissions Policy, Elective Obstetrical Deliveries

The Washington State Health Care Authority (HCA) is in the midst of rulemaking for changes to its policies regarding readmissions and elective early deliveries with hearings and comments due October 27. Under the new elective delivery policy, HCA will not pay for early (less than 39 weeks) elective obstetrical deliveries unless the delivery is medically necessary based on joint commission criteria. WSHA will comment that in addition to the standard criteria, there needs to be an external review process for review of obstetrical cases where early delivery is determined by the physician to be medically necessary, but does not meet the specific criteria.

HCA is also replacing its current policy on readmissions with a policy based on a comparison of the hospital’s readmission rates to an expected rate based on the Hospital’s mix of cases using a 3M software program. Hospitals with greater than expected admission rates are subject to reductions to their overall inpatient Medicaid payment rates. WSHA will comment that it is critical that hospitals receive usable and timely data from the state to drive care improvements. WSHA will also voice its concerns that the measurement may not adequately adjust for factors affecting readmissions that are beyond the control of the hospital.

We encourage hospitals to either let us know of your concerns to incorporate in our comments or to comment directly. The comment and hearing information are in the links below. If you do comment directly to HCA, we ask that you send WSHA a copy of your comments.

182-550-3000, -3840, Potentially Preventable Readmissions (WSR 15-19-159)
Purpose: The agency is filing these rules to implement a population-based, data-driven approach to affect inpatient hospital readmission rates and related costs. The anticipated result is a more efficient use of health care dollars. By improving the quality of care provided during an inpatient admission, improving discharge planning, improving community provider connections to deliver post-discharge care, and assuring post-discharge care coordination, preventable readmissions will be avoided. As a result of these changes, the agency needs to revise WAC 182-550-2900 and will file those amendments under a separate CR-102.

182-550-2900, Payment Limits (WSR 15-19-161)
Purpose: The agency is striking WAC 182-550-2900(2)(f), which states that the agency will not pay for two hospitalizations within 14 days for the same client in certain cases. The amendment aligns with amendments proposed under WSR 15-19-159 which will implement a population-based, data-driven approach to reduce hospital readmission rates and related costs.

The agency is adding 182-550-2900(2)(i). The amendment aligns with amendments proposed under WSR 15-19-157. The agency will no longer pay for early deliveries before 39 weeks of gestation unless medically necessary, including inductions and cesarean sections. The American College of Obstetricians and Gynecologists advises against these deliveries as they can increase the risk of signification complications for the mother and the baby. (Andrew Busz,


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