HCA Working on HIV PEP Meds Payment
WSHA advised the Health Care Authority (HCA) that hospitals are experiencing denials from HCA and Medicaid managed care organizations (MCOs) for HIV postexposure prophylaxis (PEP) drugs dispensed in accordance with ESSB 6127. The new law requires HCA and Medicaid MCOs to pay for a 28-day supply of HIV PEP medication provided in the emergency department to patients for take home use as a separately reimbursed expense from the bundled payment for the emergency service. This requirement was effective January 1, 2025. Under the bill, hospitals were required to adopt policies and procedures to ensure that hospital staff dispense a 28-day supply of human immunodeficiency virus PEP drugs or therapies following the patient’s possible exposure to human immunodeficiency virus.
HCA notified WSHA it is working on getting the payment issue addressed for both Medicaid fee-for-service and managed care and will be updating fees schedules and billing guides and ensure MCOs have appropriate configuration in place. Once in place, hospitals will be able to resubmit claims for medication provided retroactive to January 1, 2025. WSHA will work with HCA to provide hospitals with updates on this issue. (Katerina LaMarche, katerinal@wsha.org)
Bill Rescinding Separate Payment for Ancillary Services During Administrative Days Signed by Governor
In a disappointing budget-related development, the legislature passed and Governor Ferguson signed Substitute House Bill 2051, which removes separate Medicaid payment from the Health Care Authority (HCA) and Medicaid managed care organizations (MCOs) for medically necessary ancillary services. Effective July 27 2025, ancillary services such as dialysis, diagnostic services and therapies provided during administrative days stays are no longer separately payable. The bill removes the additional payment authorized under Substitute Senate Bill 5103 passed during the 2023 legislative session. WSHA strongly opposed SSB 2051 but was able to get it modified to continue payment for the administrative day per diems at the current rate as well as payment at cost for drugs administered in the facility.
SSB 2051 is effective July 27, 2025 and charges for ancillary services incurred following that date will not be covered, though the administrative day per diem payment for room and board costs, and payment for drugs will continue. WSHA hopes to get the ancillary service payment restored in future state budgets. We strongly recommend that hospitals bill for eligible ancillary services that are incurred before the effective date of the bill as soon as possible.
In the meantime, WSHA recommends hospitals continue to bill for these ancillary services to HCA and the MCOs to help document and quantify the financial impact of the unreimbursed expenses. Billing instructions are here starting at page 86. HCA may be updating its billing instructions and WSHA will provide member hospitals with a more comprehensive bulletin. (Andrew Busz, andrewb@wsha.org)