Chapter 388-855 WAC

Last Update: 12/6/00

LIABILITY FOR COSTS OF CARE AND HOSPITALIZATION OF THE MENTALLY ILL

(Formerly chapter 275-16 WAC)

WAC Sections

388-855-0010Authority.
388-855-0015Definitions.
388-855-0030Schedule of charges.
388-855-0035Available assets of estate of patients and responsible relatives.
388-855-0045Exempt income.
388-855-0055Notice and finding of responsibility (NFR)—Appeal procedure.
388-855-0065Determination of liability.
388-855-0075Unusual and exceptional circumstances.
388-855-0085Other pertinent factors.
388-855-0095Failure to cooperate with department.
388-855-0105Petition for review.


388-855-0010
Authority.

The following rules regarding hospitalization charges are hereby adopted under the authority of Title 71 RCW.
[Statutory Authority: RCW 43.20B.335, 43.20B.325, 72.01.090. WSR 01-01-007, recodified as § 388-855-0010, filed 12/6/00, effective 1/6/01. Statutory Authority: RCW 81.02.412 [71.02.412]. WSR 81-08-020 (Order 1627), § 275-16-010, filed 3/25/81. Statutory Authority: RCW 72.01.090. WSR 78-03-029 (Order 1270), § 275-16-010, filed 2/17/78; Order 1, § 275-16-010, filed 2/23/68; Emergency Rules (part), filed 1/26/68, 10/24/67, and 8/2/67.]



388-855-0015
Definitions.

"Adjusted charges" are those [charges levied upon] [amounts charged to] a patient who is or has been confined to a state hospital for the mentally ill, either by voluntary or involuntary admission, and their estates and responsible relatives, which are less than the actual cost of hospitalization as reflected in the schedule of charges herein and which has been established by the issuance of a notice of finding of responsibility.
"Adjusted gross income" is that gross income of the estate of the patient and responsible relatives less any deductions, contributions or payments mandated by law including, but not necessarily limited to, income tax and social security.
"Dependent" means any spouse, minor son or daughter, or permanently disabled son or daughter, of the patient living in the patient's household. If the patient is a minor, then the same definitions shall apply in determining the dependency of members of the parent's household. If a minor son or daughter is not living in the patient's household, that son or daughter shall not be considered a dependent unless the patient is in fact contributing more than fifty percent of that child's support in accordance with a court order or court-recognized agreement.
"Department" means the department of social and health services.
"Determination officer" is that duly appointed and qualified claims investigator who is delegated authority by the secretary to conduct or cause to have conducted an investigation of the financial condition of the estate of the patient and responsible relatives; to evaluate the results of such investigations; to make determinations of the ability to pay hospitalization changes from such investigations and evaluations; and to issue notices of findings of responsibility to the responsible parties.
"Estate of patient and responsible relative" means the total assets available to the patient and his responsible relatives to reimburse the department for hospitalization charges incurred by the patient in a state hospital for the mentally ill in accordance with these regulations.
"Gross income" means the total assets available to the estate of the patient and responsible relatives expressed in terms of their cash equivalent on a monthly basis. The total assets available to the estate of the patient and responsible relatives are converted to a monthly cash equivalent figure by dividing those assets by twelve months. Gross income includes all of the following calculated prior to any mandatory deductions; gross wages for service; net earnings from self-employment; and all other assets divided by twelve months.
"Responsible relative" includes the spouse of a patient, or the parent of a patient who is under eighteen years of age.
"Secretary" means the secretary of the department of social and health services.
[Statutory Authority: RCW 43.20B.335, 43.20B.325, 72.01.090. WSR 01-01-007, amended and recodified as § 388-855-0015, filed 12/6/00, effective 1/6/01. Statutory Authority: RCW 81.02.412 [71.02.412]. WSR 81-08-020 (Order 1627), § 275-16-015, filed 3/25/81.]
Reviser's note: RCW 34.05.395 requires the use of underlining and deletion marks to indicate amendments to existing rules, and deems ineffectual changes not filed by the agency in this manner. The bracketed material in the above section does not appear to conform to the statutory requirement.



388-855-0030
Schedule of charges.

Under RCW 43.20B.325, the department shall base hospitalization charges for patients in state hospitals on the actual operating costs of such hospitals. The department shall require patient's hospitalization charges due and payable on or before the tenth day of each calendar month for services rendered to department patients during the preceding month. A schedule of each hospital's charge rates will be computed under this section based on actual operating costs of the hospital for the previous year. The schedule will be prepared by the secretary's designee, from financial and statistical information contained in hospital records. The schedule will be updated at least annually. All changes under this section shall be prepared in advance of the effective date. Each hospital will make available the schedule of current charge rates upon request.
[Statutory Authority: RCW 43.20B.335, 43.20B.325, 72.01.090. WSR 01-01-007, recodified as § 388-855-0030, filed 12/6/00, effective 1/6/01. Statutory Authority: RCW 43.20B.325. WSR 94-16-048 (Order 3764), § 275-16-030, filed 7/27/94, effective 8/27/94; WSR 93-22-031 (Order 3659), § 275-16-030, filed 10/27/93, effective 11/27/93; WSR 92-17-007 (Order 3434), § 275-16-030, filed 8/6/92, effective 9/6/92; WSR 92-09-118 (Order 3376), § 275-16-030, filed 4/21/92, effective 5/22/92. Statutory Authority: RCW 43.20B.335. WSR 91-21-122 (Order 3267), § 275-16-030, filed 10/23/91, effective 11/23/91; WSR 91-17-064 (Order 3235), § 275-16-030, filed 8/20/91, effective 9/20/91; WSR 91-08-014 (Order 3155), § 275-16-030, filed 3/26/91, effective 4/26/91. Statutory Authority: RCW 43.20B.335 and 71.05.560. WSR 90-18-004 (Order 3061), § 275-16-030, filed 8/23/90, effective 9/23/90. Statutory Authority: RCW 71.02.412. WSR 89-22-128 (Order 2890), § 275-16-030, filed 11/1/89, effective 12/2/89. Statutory Authority: RCW 43.20B.335. WSR 88-21-095 (Order 2715), § 275-16-030, filed 10/19/88. Statutory Authority: RCW 71.02.412. WSR 87-19-026 (Order 2531), § 275-16-030, filed 9/10/87; WSR 86-17-075 (Order 2414), § 275-16-030, filed 8/19/86; WSR 85-17-038 (Order 2273), § 275-16-030, filed 8/15/85; WSR 84-17-011 (Order 2131), § 275-16-030, filed 8/3/84; WSR 83-18-029 (Order 2019), § 275-16-030, filed 8/31/83; WSR 82-17-070 (Order 1866), § 275-16-030, filed 8/18/82; WSR 80-06-087 (Order 1508), § 275-16-030, filed 5/28/80. Statutory Authority: RCW 72.01.090. WSR 79-03-019 (Order 1372), § 275-16-030, filed 2/21/79; WSR 78-03-029 (Order 1270), § 275-16-030, filed 2/17/78; Order 1190, § 275-16-030, filed 2/18/77; Order 1086, § 275-16-030, filed 1/15/76; Order 1002, § 275-16-030, filed 1/14/75; Order 947, § 275-16-030, filed 6/26/74; Order 812, § 275-16-030, filed 6/28/73; Order 14, § 275-16-030, filed 5/11/71; Order 6, § 275-16-030, filed 1/10/69; Order 1, § 275-16-030, filed 2/23/68; Emergency Rules (part), filed 1/26/68, 10/24/67, 8/2/67, and 7/28/67.]



388-855-0035
Available assets of estate of patients and responsible relatives.

(1) The department will include, but not necessarily be limited to, in their determination of the assets of the estates of present and former patients of state hospitals for the mentally ill and their responsible relatives, cash, stocks, bonds, savings, security interests, insurance benefits, guardianship funds, trust funds, governmental benefits, pension benefits and personal property.
(2) Real property shall also be an available asset to the estate: Provided, That the patient's home shall not be considered an available asset if that property is owned by the estate and serves as the principal dwelling and actual residence of the patient, the patient's spouse, and/or minor children and disabled sons or daughters: Provided further, That if the home is not being used for residential purposes by the patient, the patient's spouse, and/or minor children and disabled sons or daughters, and in the opinion of two physicians, there is no reasonable expectancy that the patient will be able to return to the home during the remainder of his life, the home shall be considered an asset available to the estate.
[Statutory Authority: RCW 43.20B.335, 43.20B.325, 72.01.090. WSR 01-01-007, amended and recodified as § 388-855-0035, filed 12/6/00, effective 1/6/01. Statutory Authority: RCW 81.02.412 [71.02.412]. WSR 81-08-020 (Order 1627), § 275-16-035, filed 3/25/81.]



388-855-0045
Exempt income.

Patients whose total resources are insufficient to pay for the actual cost of care shall be entitled to a monthly exemption from income in the amount of forty-one dollars and sixty-two cents or such amount as specified in WAC 388-478-0040.
[Statutory Authority: RCW 43.20B.335, 43.20B.325, 72.01.090. WSR 01-01-007, amended and recodified as § 388-855-0045, filed 12/6/00, effective 1/6/01. Statutory Authority: RCW 72.01.090. WSR 78-03-029 (Order 1270), § 388-16-045 (codified as WAC 275-16-045), filed 2/17/78.]



388-855-0055
Notice and finding of responsibility (NFR)—Appeal procedure.

(1) The determination officer's assessment of the ability and liability of a person or of the person's estate to pay hospitalization charges shall be issued in the form of a notice and finding of responsibility (NFR) as prescribed by RCW 43.20B.340.
(2) When the NFR is for full hospitalization charges as specified under WAC 388-855-0030, the department shall:
(a) Inform the financially responsible person of the current charges; and
(b) Periodically recompute the financially responsible person's charges.
(3) When the NFR is for adjusted charges, the department shall:
(a) Express the charges in a daily or monthly rate; and
(b) Set aside charges for ancillary services.
(4) The right to an adjudicative proceeding to contest the NFR is contained in RCW 43.20B.340.
(a) A financially responsible person wishing to contest the NFR shall, within twenty-eight days of receipt of the NFR:
(i) File a written application for an adjudicative proceeding showing proof of receipt with the Secretary, DSHS, Attn: Determination Officer, P.O. Box 9768, Olympia, WA 98504; and
(ii) Include in or with the application:
(A) A specific statement of the issues and law involved;
(B) The grounds for contesting the department decision; and
(C) A copy of the contested NFR.
(b) The proceeding shall be governed by the Administrative Procedure Act (chapter 34.05 RCW), RCW 43.20B.340, this chapter, and chapter 388-02 WAC. If any provision in this chapter conflicts with chapter 388-02 WAC, the provision in this chapter governs.
[Statutory Authority: RCW 43.20B.335, 43.20B.325, 72.01.090. WSR 01-01-007, amended and recodified as § 388-855-0055, filed 12/6/00, effective 1/6/01. Statutory Authority: RCW 71.05.560. WSR 90-21-030 (Order 3083), § 275-16-055, filed 10/9/90, effective 11/9/90. Statutory Authority: RCW 34.05.220 (1)(a) and 43.20B.335. WSR 90-04-075 (Order 3001), § 275-16-055, filed 2/5/90, effective 3/1/90. Statutory Authority: RCW 81.02.412 [71.02.412]. WSR 81-08-020 (Order 1627), § 275-16-055, filed 3/25/81.]



388-855-0065
Determination of liability.

(1) In determining the ability of the estate of the patient and responsible relative to pay hospitalization charges, first priority shall be given to any third party benefits which might be available. The availability of third party benefits, such as medical insurance, health insurance, medicare, medicaid, CHAMPUS, CHAMPVA, shall be considered as an available asset of the estate and shall justify a finding for actual costs of hospitalization during such period as the coverage is in effect.
(2) In the absence of third party benefits, charges shall be based upon the available assets of the estate giving consideration to any unusual and exceptional circumstances and other pertinent factors. No financial determination of the ability of the estate to pay hospitalization charges shall conflict with the eligibility requirements for medicaid for those patients who are eligible or potentially eligible for such benefits.
(3) The ability of the estate to pay adjusted charges will be determined by applying the following formula:
X
=
(Z-E)F
Where Z
=
(A-Y-N-R)÷D
Z
=
available income per family member
X
=
adjusted charges (daily)
A
=
gross income
Y
=
mandatory deductions
N
=
allowance for unusual and exceptional circumstances
R
=
allowance for other pertinent factors
D
=
number of dependents
E
=
exempt income
F
=
a factor which converts the monthly figures to a daily rate (.0328767).
All calculations are expressed in monthly terms except the final adjusted charge which is converted to a daily rate. All final figures are rounded out to the nearest cent.
(4) The adjusted gross income (A-Y) is determined by first developing the gross income of the estate of the patient and the responsible relative. Gross income (A) includes not only gross wages for services rendered, and/or net earnings from self-employment, but all other available assets which have been divided by twelve months to convert them to a monthly cash equivalent figure. All mandatory deductions (Y), such as income tax and social security, are deducted from the gross income to arrive at the adjusted gross income.
(5) Approved allowances for unusual and exceptional circumstances (N) and for other pertinent factors (R) are then subtracted from the adjusted gross income.
(6) The available income (A-Y-N-R) is then divided by the number of dependents in the household of the patient (D) to determine the available income per family member.
(7) Exempt income (E) as defined in WAC 388-855-0045 is then subtracted from the available income per family member to arrive at the monthly adjusted charges.
(8) The monthly adjusted charges are multiplied by the factor of .0328767 which converts the monthly figure to a daily rate.
[Statutory Authority: RCW 43.20B.335, 43.20B.325, 72.01.090. WSR 01-01-007, amended and recodified as § 388-855-0065, filed 12/6/00, effective 1/6/01. Statutory Authority: RCW 81.02.412 [71.02.412]. WSR 81-08-020 (Order 1627), § 275-16-065, filed 3/25/81.]



388-855-0075
Unusual and exceptional circumstances.

Unusual and exceptional circumstances for these purposes will cover those expenses other than usual or common; rare and extraordinary; that are of a medical nature and must be supplied to the patient for his health, medical or physical well being. Such expenses do not include those expenses that are reimbursable from insurance benefits or can be reasonably obtained from welfare agencies, health maintenance organizations, free clinics, or other free private or governmental sources. The existence and necessity of such unusual and exceptional circumstances must be attested to in writing, by the institution superintendent, that those expenses resulting therefrom are an integral part of the patient's treatment plan and that allowance for such circumstances is necessary for the medical and/or mental well-being of the patient. Upon such written certification, the resources necessary to meet the unusual and exceptional circumstances will not be considered as an asset available to the estate of the patient and responsible relatives for these purposes: Provided, That any such attestation by the institution superintendent must conform with the eligibility criteria of medicaid if the patient is eligible or potentially eligible for such benefits.
[Statutory Authority: RCW 43.20B.335, 43.20B.325, 72.01.090. WSR 01-01-007, recodified as § 388-855-0075, filed 12/6/00, effective 1/6/01. Statutory Authority: RCW 81.02.412 [71.02.412]. WSR 81-08-020 (Order 1627), § 275-16-075, filed 3/25/81.]



388-855-0085
Other pertinent factors.

The determination officer may consider the following other pertinent factors in determining the ability of the estate of the patient and responsible relatives to pay.
(1) The determination officer may consider those factors related to the well-being, education and training, child support obligations set by court order or by administrative finding under chapter 74.20A RCW, and/or rehabilitation of the patient and the patient's immediate family, to whom the patient owes a duty of support. The patient and/or responsible relatives shall show the existence and the necessity for the pertinent factors as defined. Upon such a showing, the determination officer may consider such resources necessary to reasonably provide for such pertinent factors as assets not available to the estate of the patient and responsible relatives.
(2) Consistent with RCW 43.20B.335, the determination officer shall consider a judgment owed by the patient to any victim of an act that would have resulted in criminal conviction of the patient but for a finding of the patient's criminal insanity. A victim shall include an estate's personal representative who has obtained judgment for wrongful death against the criminally insane patient.
[Statutory Authority: RCW 43.20B.335, 43.20B.325, 72.01.090. WSR 01-01-007, amended and recodified as § 388-855-0085, filed 12/6/00, effective 1/6/01. Statutory Authority: RCW 43.20B.335. WSR 96-18-090, § 275-16-085, filed 9/4/96, effective 10/5/96. Statutory Authority: RCW 81.02.412 [71.02.412]. WSR 81-08-020 (Order 1627), § 275-16-085, filed 3/25/81.]



388-855-0095
Failure to cooperate with department.

Any patient, former patient, guardian, or other responsible party or parties who, after diligent effort by the department, has been shown to have failed to cooperate with the financial investigation by the department; or fails to comply with, or ignores, departmental correspondence; or supplies false or misleading information; or willfully conceals assets or potential assets; will be subject to a determination by the department that the estate of the patient and responsible relatives has the ability to pay full hospitalization charges: Provided, That no person adjudged incompetent by a court of this state at the time of said investigation shall be penalized by his or her actions: Provided further, That such a finding of liability to pay full hospitalization charges shall in no way diminish the responsible party's right to appeal such a finding of responsibility.
[Statutory Authority: RCW 43.20B.335, 43.20B.325, 72.01.090. WSR 01-01-007, recodified as § 388-855-0095, filed 12/6/00, effective 1/6/01. Statutory Authority: RCW 81.02.412 [71.02.412]. WSR 81-08-020 (Order 1627), § 275-16-095, filed 3/25/81.]



388-855-0105
Petition for review.

(1) After a finding of responsibility becomes final in accordance with RCW 43.20B.340, the responsible party may petition for a review of such findings to the secretary. The petitioner must show a substantial change in the financial ability of the estate to pay the charges in a petition for review. The burden of proof of a change in financial ability rests with the petitioner.
(2) A petition for review shall be in writing and to the following address:
Secretary, DSHS
Attn: Determination Officer
P.O. Box 9768 MS HJ-21
Olympia, WA 98504
(3) The determination officer, upon receipt of the petition for review, may conduct or cause to have conducted such investigation as may be necessary to verify the alleged changes in financial status or to determine any other facts which would bear upon the financial ability of the estate to pay.
(4) Based upon the review of the facts, the determination officer may modify or vacate the NFR under the provisions of RCW 43.20B.350.
(5) The NFR will not be modified or vacated, if such modification or vacation inflicts or causes the loss of medicaid eligibility; jeopardizes the eligibility for other third-party benefits; or has the potential end result of diminishing or jeopardizing the recovery of hospitalization cost by the department without a clear showing of real benefit, financial or otherwise, to the patient and/or responsible relatives.
(6) Nothing herein is intended to preclude the reinvestigation and/or review of the finding of responsibility by the department of its own volition.
[Statutory Authority: RCW 43.20B.335, 43.20B.325, 72.01.090. WSR 01-01-007, recodified as § 388-855-0105, filed 12/6/00, effective 1/6/01. Statutory Authority: RCW 43.20B.335. WSR 90-23-071 (Order 3096), § 275-16-105, filed 11/20/90, effective 12/21/90. Statutory Authority: RCW 81.02.412 [71.02.412]. WSR 81-08-020 (Order 1627), § 275-16-105, filed 3/25/81.]