wa-26-21-070: Health, Department of — WSR 26-21-070

WSR 26-21-070 (26-21)WSR 26-21-070PROPOSED RULESDEPARTMENT OF HEALTH[Filed October 20, 2026, 8:18 a.m.]Supplemental Notice to WSR 26-16-047.Preproposal statement of inquiry was filed as WSR 22-20-069.Title of Rule and Other Identifying Information: Chapter 246-453 WAC, Hospital charity care. The department of health (department) is proposing to add four new sections, make housekeeping changes, and add an expiration date to WAC 246-453-050. Amendments are proposed throughout chapter 246-453 WAC to implement requirements in SSB 6273 (chapter 623, Laws of 2018) and SHB 1616 (chapter 197, Laws of 2022), codified under chapter 70.170 RCW, and to integrate housekeeping changes from other recent legislation and align the rules with current best practices.This supplemental filing further amends the rules to update the definition section, amend process requirements in WAC 246-453-019, address Health Insurance Portability and Accountability Act of 1996 (HIPAA) concerns expressed by interested parties, provide clarity for billing and data collection activities related to an initial determination of charity care eligibility, and add the ability for hospitals to rely on an initial determination of charity care eligibility for a period of six months. Additionally, the expiration date of WAC 246-453-050 has been extended in the supplemental proposal to provide additional time to comply. Hearing Location(s): On December 1, 2026, at 11:00 a.m. Register in advance for this webinar at https://us02web.zoom.us/webinar/register/WN_4gw2XCk8TVGkV3aQEs86QA. After registering, you will receive a confirmation email containing information about joining the webinar.Date of Intended Adoption: December 8, 2026.Submit Written Comments to: Carrie Baranowski, P.O. Box 47852, Olympia, WA 98504-7852, email charitycare@doh.wa.gov, web https://fortress.wa.gov/doh/policyreview/, beginning the date and time of this filing, by December 1, 2026, at 11:59 p.m.Assistance for Persons with Disabilities: Contact Carrie Baranowski, phone 360-236-4210, TTY 711, email charitycare@doh.wa.gov, by November 17, 2026.Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: The purpose of this proposal is to update and modernize chapter 246-453 WAC to align with legislation that impacted chapter 70.170 RCW, Health data and charity care. The goal of the proposed changes is to establish uniform standards for charity care procedures and processes. To accomplish this, the department proposed updates to chapter 246-453 WAC under WSR 26-16-047 and held a public hearing on September 8, 2026. The changes that were proposed at the September 8, 2026, hearing included:•Amendments to the definitions within WAC 246-453-010 to align with changes made by SSB 6273 and SHB 1616, remove terms duplicated in the statute and rule, remove terms no longer used in the chapter, and make housekeeping changes. The proposed updates also remove the definition of "Initial determination of sponsorship status," "Final determination of sponsorship status," and "Publicly available." These definitions were removed and instead incorporated into new sections of rule to describe the minimum standards for each.•New WAC 246-453-015 specifies the minimum standards regarding a hospital's notification of the availability of charity care.•New WAC 246-453-019 creates general procedures that apply throughout the entire process of determining charity care eligibility.•Amendments to WAC 246-453-020 standardize the initial determination of charity care eligibility process and minimum procedures.•New WAC 246-453-021 provides a new section for existing final determination requirements and standardizes the process for the final determination of charity care eligibility.•New WAC 246-453-025 provides a new section for existing appeal requirements and further specifies the appeal procedure for all hospitals to provide an opportunity to submit additional information if denied charity care.•Amendments to WAC 246-453-030 standardize the procedure for hospitals and charity care applicants to submit and review documentation of income for eligibility purposes.•Amendments to WAC 246-453-040 incorporate income eligibility ranges, discounts, and asset data collection standards per chapter 70.170 RCW.•Amendments to WAC 246-453-050 remove most of the section as it is no longer necessary due to SHB 1616, which specified prescriptive discounts for hospitals based on income and family size and removes any reference to a sliding fee schedule. One subsection remains, but it will expire on December 31, 2027. Additionally, the rule title was changed to reflect remaining content.•Amendments to WAC 246-453-060 directly incorporate changes made by ESSB 5557 (chapter 182, Laws of 2025) and other housekeeping changes.•Amendments to WAC 246-453-070 state that hospitals must also submit their asset consideration policies and procedures to the department for review if the hospital considers assets, as permitted under chapter 70.170 RCW. Additional changes include removal of specific time frames for submission in favor of a more general submission requirement.•Amendments to WAC 246-453-080 require hospitals to retain records related to charity care screening and eligibility determination for a period of no less than six years.•Amendments to WAC 246-453-090 simplify the section related to penalties and action that may be taken by the department due to violations by incorporating and referencing chapter 70.170 RCW.Supplemental proposal: Comments received at the public hearing expressed concerns about HIPAA, clarity of the rule, and questions regarding the billing, process, and data collection procedures. After reviewing the comments and feedback received, the department is proposing the following changes: •WAC 246-453-010, providing clarification to the definition of "medically necessary hospital health care."•WAC 246-453-019 and 246-453-025, eliminating the requirement that hospitals accept charity care applications, appeals, and related documents by email.•WAC 246-453-019, revising the date that a responsible party has made a charity care related submission to the date the hospital received the documents.•WAC 246-453-020, providing clarification that hospitals are provided the opportunity to collect information for eligibility purposes under chapter 74.09 RCW and that information can also be also used for charity care eligibility determination. The proposal also adds a new subsection that provides the ability for hospitals to rely on an initial determination of charity care eligibility for a period of six months once an initial determination of charity care eligibility has been determined, unless there is a request for an updated determination.•WAC 246-453-050, extending the section's expiration date.Reasons Supporting Proposal: In 2018 and 2022, legislation passed that amended chapter 70.170 RCW, providing flexibility on when a responsible party can apply for charity care and what income information could be used, new notification requirements, increasing the income thresholds for charity care eligibility, eliminating the sliding fee schedule of discounts, allowing for the consideration of patient or responsible party assets to reduce any discount, and requiring hospitals to identify and assist with eligibility and application to apple health and the Washington health benefit exchange.Chapter 246-453 WAC was last amended in 1994, and the current rule does not align with changes that have been made to chapter 70.170 RCW in the subsequent years. The proposed rules are needed to ensure chapter 246-453 WAC conforms to chapter 70.170 RCW and provides procedural clarity for hospitals and applicants. Additionally, RCW 70.170.060 provides the department with broad rule-making authority to establish and maintain uniform procedures, data requirements, criteria for identifying patients receiving charity care, and a definition of bad debt, including uniform standards for collection procedures to be used in efforts to collect unpaid portions of hospital charges. The current chapter of rule does not specify procedures for charity care eligibility determination or data requirements in a clear and uniform manner. This has led to several different interpretations and varying eligibility processes and requirements for applicants. Beyond aligning with statute, these proposed rules are necessary to set clear minimum standards for notifications, create more uniformity in the processes and procedures for charity care eligibility determination, and establish modern data requirements for both proof of income and for tracking charity care applications and data.Supplemental proposal: As a result of the initial public hearing, the department determined that clarification and adjustments were necessary to help hospitals comply with the rules. The supplemental proposal changes include amendments that align with RCW 70.170.060 by improving clarity and consistency within the chapter, allow for additional time to comply with the changes made to WAC 246-453-050, adjust the requirements to ensure the rules follow HIPAA regulations and address privacy concerns, and provide more flexibility for hospitals to operationalize the rules.Statutory Authority for Adoption: RCW 70.170.060.Statute Being Implemented: SSB 6273 (chapter 623, Laws of 2018), codified at chapter 70.170 RCW; SHB 1616 (chapter 197, Laws of 2022), codified at chapter 70.170 RCW; and ESSB 5557 (chapter 182, Laws of 2025), codified in chapter 70.41 RCW and RCW 70.170.060.Rule is not necessitated by federal law, federal or state court decision.Name of Proponent: Department of health, governmental.Name of Agency Personnel Responsible for Drafting, Implementation, and Enforcement: Carrie Baranowski, 111 Israel Road S.E., Tumwater, WA 98501, 360-236-4210.A school district fiscal impact statement is not required under RCW 28A.305.135.A cost-benefit analysis is required under RCW 34.05.328. A preliminary cost-benefit analysis may be obtained by contacting Carrie Baranowski, P.O. Box 47852, Olympia, WA 98504-7852, phone 360-236-4210, TTY 711, email charitycare@doh.wa.gov.This rule proposal, or portions of the proposal, is exempt from requirements of the Regulatory Fairness Act because the proposal: Is exempt under RCW 19.85.025(4).Explanation of exemptions: The rule proposal applies only to hospitals, as defined in RCW 70.170.020(3), as any hospital licensed under chapter 70.41 RCW, or as a behavioral health hospital under chapter 71.12 RCW. There are no hospitals or behavioral health hospitals in Washington state that qualify as small businesses as defined under RCW 19.85.020(3). Scope of exemption for rule proposal:Is fully exempt.October 19, 2026Kristin Peterson, JDChief of Policyfor Dennis E. WorshamSecretary of HealthRDS-6528.10AMENDATORY SECTION(Amending WSR 94-12-089, filed 6/1/94, effective 7/2/94)WAC 246-453-010Definitions.((As used in this chapter, unless the context requires otherwise,(1) "Department" means the Washington state department of health created by chapter 43.70 RCW;(2) "Hospital" means any health care institution which is required to qualify for a license under RCW 70.41.020(2); or as a psychiatric hospital under chapter 71.12 RCW;(3) "Manual" means the Washington State Department of Health Accounting and Reporting Manual for Hospitals, adopted under WAC 246-454-020;(4) "Indigent persons" means those patients who have exhausted any third-party sources, including medicare and medicaid, and whose income is equal to or below 200% of the federal poverty standards, adjusted for family size or is otherwise not sufficient to enable them to pay for the care or to pay deductibles or coinsurance amounts required by a third-party payor;(5) "Charity care" means appropriate hospital-based medical services provided to indigent persons, as defined in this section;(6) "Bad debts" means uncollectible amounts, excluding contractual adjustments, arising from failure to pay by patients whose care has not been classified as charity care;(7) "Appropriate hospital-based medical services" means those hospital services which are reasonably calculated to diagnose, correct, cure, alleviate, or prevent the worsening of conditions that endanger life, or cause suffering or pain, or result in illness or infirmity, or threaten to cause or aggravate a handicap, or cause physical deformity or malfunction, and there is no other equally effective more conservative or substantially less costly course of treatment available or suitable for the person requesting the service. For purpose of this section, "course of treatment" may include mere observation or, where appropriate, no treatment at all;(8) "Medical staff" means physicians, dentists, nurses, and other professional individuals who have admitting privileges to the hospital, and may also participate as members of the medical staff committees, serve as officers of the medical staff, and serve as directors or chiefs of hospital departments;(9) "Third-party coverage" and "third-party sponsorship" means an obligation on the part of an insurance company or governmental program which contracts with hospitals and patients to pay for the care of covered patients and services, and may include settlements, judgments, or awards actually received related to the negligent acts of others which have resulted in the medical condition for which the patient has received hospital services;(10) "Unusually costly or prolonged treatment" means those services or combinations of services which exceed two standard deviations above the average charge, and/or three standard deviations above the average length of stay, as determined by the department's discharge database;(11) "Emergency care or emergency services" means services provided for care related to an emergency medical or mental condition;(12) "Emergency department" and "emergency room" means that portion of the hospital facility organized for the purpose of providing emergency care or emergency services;(13) "Emergency medical condition" means a medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, such that the absence of immediate medical attention could reasonably be expected to result in:(a) Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy;(b) Serious impairment of bodily functions;(c) Serious dysfunction of any bodily organ or part.With respect to a pregnant woman who is having contractions the term shall mean:(d) That there is inadequate time to effect a safe transfer to another hospital before delivery; or(e) That transfer may pose a threat to the health or safety of the woman or the unborn child;(14) "Responsible party" means that individual who is responsible for the payment of any hospital charges which are not subject to third-party sponsorship;(15) "Limited medical resources" means the nonavailability of services or medical expertise which are required or are expected to be required for the appropriate diagnosis, treatment, or stabilization per federal requirements of an individual's medical or mental situation;(16) "Publicly available" means posted or prominently displayed within public areas of the hospital, and provided to the individual in writing and explained, at the time that the hospital requests information from the responsible party with regard to the availability of any third-party coverage, in any language spoken by more than ten percent of the population in the hospital's service area, and interpreted for other non-English speaking or limited-English speaking or other patients who can not read or understand the writing and explanation;(17) "Income" means total cash receipts before taxes derived from wages and salaries, welfare payments, Social Security payments, strike benefits, unemployment or disability benefits, child support, alimony, and net earnings from business and investment activities paid to the individual;(18) "Family" means a group of two or more persons related by birth, marriage, or adoption who live together; all such related persons are considered as members of one family;(19) "Initial determination of sponsorship status" means an indication, pending verification, that the services provided by the hospital may or may not be covered by third party sponsorship, or an indication from the responsible party, pending verification, that he or she may meet the criteria for designation as an indigent person qualifying for charity care; and(20) "Final determination of sponsorship status" means the verification of third party coverage or lack of third party coverage, as evidenced by payment received from the third party sponsor or denial of payment by the alleged third party sponsor, and verification of the responsible party's qualification for classification as an indigent person, subsequent to the completion of any appeals to which the responsible party may be entitled and which on their merits have a reasonable chance of achieving third-party sponsorship in full or in part.))The definitions in this section and in RCW 70.170.020 apply throughout this chapter unless the context clearly requires otherwise:(1) "Bad debts" means uncollectible amounts, excluding contractual adjustments, arising from failure to pay by patients whose care has not been classified as charity care.(2) "Collection efforts" means any request or demand for any payment, including a deposit, or communication or transmission of account documents or information that is not clearly identified as being intended solely for the purpose of providing information to the responsible party and not for the purpose of requesting or demanding payment.(3) "Emergency care" means health care services provided to evaluate or treat an emergency medical condition or active labor.(4) "Emergency department" means that portion of the hospital facility organized for the purpose of providing emergency care.(5) "Emergency medical condition" means:(a) A condition of such severity that the absence of immediate medical attention could result in:(i) Placing the health of an individual or, with respect to a pregnant person, the health of the pregnant person or their embryo or fetus in serious jeopardy;(ii) Serious impairment to bodily functions; or(iii) Serious dysfunction of a bodily organ or part;(b) With respect to a pregnant person who is having contractions:(i) That there is inadequate time to effect a safe transfer to another hospital before delivery; or(ii) That transfer may pose a threat to the health or safety of the pregnant person or their embryo or fetus; or(c) Any of the following conditions: Ectopic pregnancy; emergent complications resulting from pregnancy or of pregnancy loss; previable preterm premature rupture of membranes; emergent placental abnormalities; or emergent hypertensive disorders, such as preeclampsia.(6) "Family" means an individual and their spouse or registered domestic partner, and any dependent children whether living with the individual or not.(7) "Income" means total monetary payments received before taxes derived from wages and salaries, net earnings from business activities, temporary assistance for needy families (TANF), unemployment compensation, Social Security, veterans' payments, survivor benefits, pension or retirement income, interest, dividends, rental income, royalties, income from estates, trust distributions, spousal maintenance, and child support paid to the responsible party.(8) "Medically necessary hospital health care" means those health care services provided in or by a licensed hospital facility that a reasonably prudent qualified health care provider would provide to a patient for the purpose of preventing, diagnosing, or treating an illness, injury, disease, or its symptoms in a manner that is in accordance with generally accepted standards of medical practice and clinically appropriate in terms of type, frequency, extent, site, and duration.(9) "Responsible party" means that individual who is responsible for the payment of any hospital charges that are not subject to third-party coverage.NEW SECTIONWAC 246-453-015Standards for notification of charity care availability.A hospital shall:(1) Post and prominently display notice of charity care availability for medically necessary hospital health care in at least all languages spoken by more than 10 percent of the population of the hospital service area within public areas of the hospital, including at least the following:(a) Areas where patients are admitted or registered;(b) Emergency departments, if any; and(c) Financial service or billing areas where accessible to patients;(2) Using the notice issued by the department, provide notice of charity care availability for medically necessary hospital health care to every responsible party at the time that the hospital requests information about the availability of any third-party coverage or as soon thereafter as is reasonably possible;(3) Post to the hospital's website current versions of the hospital's approved charity care policy, a plain language summary of the hospital's charity care policy, and the hospital's charity care application form, of which the summary and application form must be available in at least all languages spoken by more than 10 percent of the population of the hospital service area;(4) Include on all hospital billing statements and other written communications concerning billing or collection of a hospital bill the following or a substantially similar statement prominently displayed on the first page of the statement in at least both English and the second most spoken language in the hospital's service area:"You may qualify for free care or a discount on your hospital bill, whether or not you have insurance. Please contact our financial assistance office at [website] and [phone number].";(5) Comply with hospital obligations under federal and state laws to provide meaningful access for limited-English proficiency and non-English-speaking patients that apply to information regarding billing and charity care. All notices must include instructions on how to request communication and accessibility options and explain that these services are free;(6) Develop standardized training programs on the hospital's charity care policy and use of interpreter services, and provide regular training for appropriate staff, including the relevant and appropriate staff who perform functions relating to registration, admissions, or billing; and(7) Comply with all directions issued by the department concerning the provision of any notice required under this section and provide any other notice as directed by the department.Reviser's note: The brackets and enclosed material in the text of the above section occurred in the copy filed by the agency and appear in the Register pursuant to the requirements of RCW 34.08.040.NEW SECTIONWAC 246-453-019General procedures for determination of charity care eligibility.(1) A hospital shall implement the requirements provided in WAC 246-453-020 and 246-453-021 and comply with this section.(2) A hospital may use data-based software tools or information other than that provided by a responsible party to determine the existence of third-party coverage, to grant charity care for the full amount of the patient responsibility portion of the hospital charges, and for purposes of WAC 246-453-020 (3) and (7)(a).(3) A hospital, whether directly or through a third party, may initiate collection efforts directed at a responsible party only as permitted in WAC 246-453-020 and 246-453-021 and only if the hospital has complied with the requirements of this chapter and chapter 70.170 RCW.(4) A hospital may not impose procedures that place an unreasonable burden upon the responsible party, taking into account any physical, mental, intellectual, or sensory deficiencies, language barriers, or other personal circumstances which may hinder the responsible party's capability of complying with hospital policy and procedures. It is an unreasonable burden to require a patient to apply for any state or federal program where the patient is obviously or categorically ineligible or has been deemed ineligible in the prior 12 months.(5) Upon the request of a responsible party, a hospital shall provide a reasonable extension of any applicable deadline.(6) A hospital's charity care procedures must permit a responsible party to make submissions to the hospital by all reasonable means, including by submitting documents and information in hard copy in person and by mail and digitally by a website accessible by smartphone and personal computer.(7) Upon request, a hospital shall provide responsible parties timely and accurate assistance with applying for charity care, including via telephone and email.(8) A responsible party is deemed to have made a submission on the date received by the hospital.AMENDATORY SECTION(Amending WSR 91-05-048, filed 2/14/91, effective 3/17/91)WAC 246-453-020((Uniform procedures for the identification of indigent persons.))Procedures for initial determination of charity care eligibility.((For the purpose of identifying those patients that will be classified as indigent persons, all hospitals shall adopt and implement the following procedures:(1) The initiation of collection efforts directed at the responsible party shall be precluded pending an initial determination of sponsorship status, provided that the responsible party is cooperative with the hospital's efforts to reach an initial determination of sponsorship status;(a) Collection efforts shall include any demand for payment or transmission of account documents or information which is not clearly identified as being intended solely for the purpose of transmitting information to the responsible party;(b) The initial determination of sponsorship status shall be completed at the time of admission or as soon as possible following the initiation of services to the patient;(c) If the initial determination of sponsorship status indicates that the responsible party may meet the criteria for classification as an indigent person, as described in WAC 246-453-040, collection efforts directed at the responsible party will be precluded pending a final determination of that classification, provided that the responsible party is cooperative with the hospital's reasonable efforts to reach a final determination of sponsorship status;(d) During the pendency of the initial determination of sponsorship status and/or the final determination of the applicability of indigent person criteria, hospitals may pursue reimbursement from any third-party coverage that may be identified to the hospital;(e) The requirements of this subsection shall not apply to clinics operated by disproportionate share hospitals, as defined and identified by the department of social and health services, medical assistance services, provided that patients are advised of the availability of charity care at the time that services are provided and when presented with a request for payment.(2) Notice shall be made publicly available that charges for services provided to those persons meeting the criteria established within WAC 246-453-040 may be waived or reduced.(3) Any responsible party who has been initially determined to meet the criteria identified within WAC 246-453-040 shall be provided with at least fourteen calendar days or such time as the person's medical condition may require, or such time as may reasonably be necessary to secure and to present documentation as described within WAC 246-453-030 prior to receiving a final determination of sponsorship status.(4) Hospitals must make every reasonable effort to determine the existence or nonexistence of third-party sponsorship that might cover in full or in part the charges for services provided to each patient.(5) Hospitals may require potential indigent persons to use an application process attesting to the accuracy of the information provided to the hospital for purposes of determining the person's qualification for charity care sponsorship. Hospitals may not impose application procedures for charity care sponsorship which place an unreasonable burden upon the responsible party, taking into account any physical, mental, intellectual, or sensory deficiencies or language barriers which may hinder the responsible party's capability of complying with the application procedures. The failure of a responsible party to reasonably complete appropriate application procedures shall be sufficient grounds for the hospital to initiate collection efforts directed at the patient.(6) Hospitals may not require deposits from those responsible parties meeting the criteria identified within WAC 246-453-040 (1) or (2), as indicated through an initial determination of sponsorship status.(7) Hospitals must notify persons applying for charity care sponsorship of their final determination of sponsorship status within fourteen calendar days of receiving information in accordance with WAC 246-453-030; such notification must include a determination of the amount for which the responsible party will be held financially accountable.(8) In the event that the hospital denies the responsible party's application for charity care sponsorship, the hospital must notify the responsible party of the denial and the basis for that denial. (9) All responsible parties denied charity care sponsorship under WAC 246-453-040 (1) or (2) shall be provided with, and notified of, an appeals procedure that enables them to correct any deficiencies in documentation or request review of the denial and results in review of the determination by the hospital's chief financial officer or equivalent.(a) Responsible parties shall be notified that they have thirty calendar days within which to request an appeal of the final determination of sponsorship status. Within the first fourteen days of this period, the hospital may not refer the account at issue to an external collection agency. After the fourteen day period, if no appeal has been filed, the hospital may initiate collection activities.(b) If the hospital has initiated collection activities and discovers an appeal has been filed, they shall cease collection efforts until the appeal is finalized.(c) In the event that the hospital's final decision upon appeal affirms the previous denial of charity care designation under the criteria described in WAC 246-453-040 (1) or (2), the responsible party and the department of health shall be notified in writing of the decision and the basis for the decision, and the department of health shall be provided with copies of documentation upon which the decision was based.(d) The department will review the instances of denials of charity care. In the event of an inappropriate denial of charity care, the department may seek penalties as provided in RCW 70.170.070.(10) Hospitals should make every reasonable effort to reach initial and final determinations of charity care designation in a timely manner; however, hospitals shall make those designations at any time upon learning of facts or receiving documentation, as described in WAC 246-453-030, indicating that the responsible party's income is equal to or below two hundred percent of the federal poverty standard as adjusted for family size. The timing of reaching a final determination of charity care status shall have no bearing on the identification of charity care deductions from revenue as distinct from bad debts.(11) In the event that a responsible party pays a portion or all of the charges related to appropriate hospital-based medical care services, and is subsequently found to have met the charity care criteria at the time that services were provided, any payments in excess of the amount determined to be appropriate in accordance with WAC 246-453-040 shall be refunded to the patient within thirty days of achieving the charity care designation.))Each hospital shall implement the following requirements for making an initial determination of charity care eligibility, except that a hospital may modify its procedures to be less burdensome for a responsible party:(1) The hospital shall ask every responsible party what third-party coverage the patient or their guarantor has, if any, and request the minimum information necessary for the hospital to determine the extent of available coverage and seek reimbursement. The hospital may pursue co-payments and third-party coverage reimbursement.(2) The hospital shall implement procedures for identifying patients who may be eligible for health care coverage through medical assistance programs under chapter 74.09 RCW or the Washington health benefit exchange and actively assisting patients to apply for any available coverage. If a hospital determines that a patient or their guarantor is qualified for retroactive health care coverage through the medical assistance programs under chapter 74.09 RCW, a hospital shall assist the patient or guarantor with applying for such coverage. If a hospital determines that a patient or their guarantor qualifies for retroactive health care coverage through the medical assistance programs under chapter 74.09 RCW, a hospital is not obligated to provide charity care to any patient or their guarantor if the patient or their guarantor fails to make reasonable efforts to cooperate with the hospital's efforts to assist them in applying for such coverage. If the hospital chooses not to provide charity care on this basis, the hospital shall proceed in accordance with subsection (8) of this section. A hospital may not impose application procedures for assistance with retroactive coverage applications which place an unreasonable burden upon the patient or guarantor, taking into account any physical, mental, intellectual, or sensory deficiencies, language barriers, or other personal circumstances which may hinder the responsible party's capability of complying with application procedures. It is an unreasonable burden to require a patient to apply for any state or federal program where the patient is obviously or categorically ineligible or has been deemed ineligible in the prior 12 months.(3) The hospital shall notify the responsible party if the hospital has reason to believe, based on information in the hospital's possession, that the responsible party may be eligible for charity care.(4) The hospital shall inform the responsible party that Washington law requires hospitals to provide a discount on medical bills to people whose family income is under a certain amount as described in the notice of charity care availability provided under WAC 246-453-015(2), and offer the responsible party the opportunity to obtain an initial determination of charity care eligibility. The hospital shall document the date and method by which it provided the foregoing communications and the responsible party's choice whether to obtain an initial determination.(5) If the responsible party accepts the offer to obtain an initial determination of charity care eligibility, the hospital shall permit the responsible party to choose to provide the following information orally, by selecting from a document, or by completing a form issued by the department or a form with equivalent information:(a) Whether the responsible party is unhoused or is currently enrolled in a means-tested state or federal public assistance program with an income threshold for eligibility of 200 percent of the federal poverty level, adjusted for family size, or lower. The hospital shall provide the responsible party with clear written guidance on what public assistance programs meet these criteria. The hospital may require the responsible party to provide documentation of current enrollment by a reasonable deadline provided in MM/DD/YYYY format that takes into account the responsible party's personal circumstances and the difficulty of securing and submitting the documentation requested by the hospital, though under no circumstances may the deadline be less than 30 days after the hospital sent the request;(b) Within which income range in RCW 70.170.060(5) the responsible party's estimated annual family income falls. The hospital shall provide the responsible party with clear written guidance on how annual family income is determined under applicable law; and(c) The responsible party's preferred method of receiving subsequent communications about the charity care eligibility determination process, whether mail, email, or electronic record.(6) The hospital may require the responsible party to attest to the accuracy of the information provided under subsection (5) of this section. The hospital shall document any information the responsible party provides orally or by selecting from a form under subsection (5) of this section.(7) In the event that a responsible party:(a) Declines the offer to obtain an initial determination of charity care eligibility or starts the initial determination process but fails to make reasonable efforts to cooperate with the hospital's efforts to complete the process, the hospital shall make an initial determination of charity care eligibility based on the information in the hospital's possession and proceed in accordance with (b) or (c) of this subsection, or subsection (8) of this section, as applicable.(b) Is unhoused, enrolled in a means-tested state or federal public assistance program as described in subsection (5)(a) of this section and has provided the hospital any documentation of current enrollment requested by the hospital under that subsection, or is eligible, as determined by the hospital in subsection (2) of this section, for health care coverage through a medical assistance program under chapter 74.09 RCW that requires a qualifying income at a level that qualifies for charity care in the full amount of the patient responsibility portion of the hospital charges, then the responsible party is initially and finally determined eligible for charity care and the hospital shall grant the responsible party charity care for the full amount of the patient responsibility portion of their hospital charges, provided the patient or their guarantor makes reasonable efforts to cooperate with the hospital's efforts to assist them in applying for retroactive coverage, when applicable.(i) The hospital may not require the responsible party to provide additional documentation or information or to complete the final determination process beyond that expressly provided for in this section.(ii) The hospital shall provide prompt notice of the determination to the responsible party. The notice must include a statement indicating that the responsible party has been granted charity care for the full amount of the patient responsibility portion of their hospital charges, and the dates of past services and prospective services, if any, to which the grant of charity care will be applied.(iii) If a responsible party fails to submit documentation of current enrollment requested by the hospital under subsection (5)(a) of this section but an alternative ground for qualifying for charity care under this subsection applies, the hospital shall grant charity care in accordance with this subsection. If no such alternative ground applies, the hospital shall make an initial determination of charity care eligibility based on the information provided under subsection (5) of this section and proceed in accordance with (c) of this subsection or subsection (8) of this section, as applicable.(c) Has an estimated annual family income within an applicable income range specified in RCW 70.170.060(5), the responsible party is initially determined eligible for charity care and the hospital shall promptly provide the following to the responsible party:(i) Notice that the responsible party has been initially determined eligible for charity care, including the applicable percentage discount;(ii) A copy of the hospital's charity care application and instructions for completing and submitting the application;(iii) Any request for documentation, as permitted under WAC 246-453-030;(iv) The URL for the website where charity care information and materials can be accessed, as required under WAC 246-453-015;(v) A reasonable deadline provided in MM/DD/YYYY format for the responsible party to submit a charity care application that takes into account the responsible party's personal circumstances and the difficulty of securing and submitting the documentation requested by the hospital, though under no circumstances may the deadline be less than 30 days after the hospital sent the notice; and(vi) The following statement: "You may request an extension of the deadline by emailing or calling our financial assistance office at [email address] or [telephone number]."(8) If neither subsection (7)(b) nor (c) of this section applies to the responsible party or the patient or their guarantor fails to make reasonable efforts to cooperate with the hospital's efforts to assist the patient or their guarantor in applying for retroactive health care coverage under subsection (2) of this section, the responsible party is initially determined ineligible for charity care. The responsible party may obtain a final determination of charity care eligibility.(a) The hospital shall promptly provide the following to a responsible party initially determined ineligible:(i) Notice that the responsible party has been initially determined ineligible for charity care with an explanation of the basis for the determination, including the statement: "Even though you have been initially determined ineligible for charity care, you still have the right to submit a full application to obtain a final determination of your eligibility for charity care.";(ii) A copy of the hospital's charity care application and instructions for completing and submitting the application;(iii) If applicable, information on how the patient or their guarantor can make reasonable efforts to cooperate in applying for retroactive health care coverage, as addressed in subsection (2) of this section;(iv) Any request for documentation, as permitted under WAC 246-453-030;(v) The URL for the website where charity care information and materials can be accessed, as required under WAC 246-453-015;(vi) A reasonable deadline provided in MM/DD/YYYY format for the responsible party to submit a charity care application that takes into account the responsible party's personal circumstances and the difficulty of securing and submitting the documentation requested by the hospital, though under no circumstances may the deadline be less than 30 days after the hospital sent the notice; and(vii) The following statement: "You may request an extension of the deadline by emailing or calling our financial assistance office at [email address] or [telephone number]."(b) The hospital may initiate collection efforts directed at the responsible party initially determined ineligible 30 days after the hospital sent the required notice. If the responsible party applies for a final determination of eligibility for charity care, the hospital may initiate or continue collection efforts directed at the responsible party while the final determination process is being completed, except that the hospital may not refer the responsible party's account to an external collection agency until collection efforts are permitted to be initiated under WAC 246-453-021(8), subject to WAC 246-453-021(9).(9) A hospital may forego the requirements of this section and apply the most recent determination of charity care eligibility issued to a responsible party within the six months preceding the patient encounter, if any, provided that, at each patient encounter, the hospital informs the responsible party that the hospital will be applying the most recently issued determination, informs the responsible party of the result of said determination, and offers the responsible party the opportunity to obtain a new initial determination of charity care eligibility. If the responsible party chooses to obtain a new initial determination, the hospital may not apply the most recently issued determination and must comply with the requirements of this section.Reviser's note: The brackets and enclosed material in the text of the above section occurred in the copy filed by the agency and appear in the Register pursuant to the requirements of RCW 34.08.040.NEW SECTIONWAC 246-453-021Procedures for final determination of charity care eligibility.Each hospital shall implement the following requirements for making a final determination of charity care eligibility, except that a hospital may modify its process to be less burdensome for a responsible party:(1) A hospital may require a responsible party who has been initially determined eligible for charity care under WAC 246-453-020 (7)(c) to complete the final determination process. A hospital, in its discretion, may deem an initial determination that a responsible party is eligible for charity care to be a final determination, though the hospital shall permit a responsible party to complete the final determination process if the responsible party so chooses.(2) A hospital shall permit a responsible party who is initially determined ineligible for charity care under WAC 246-453-020(8) to complete the final determination process if the responsible party so chooses.(3) A responsible party who was initially determined ineligible for the patient's or guarantor's failure to make reasonable efforts to cooperate with the hospital's efforts to assist the patient or guarantor in applying for retroactive health care coverage under WAC 246-453-020(2) must be provided another opportunity during the final determination process to cooperate, and the hospital shall assist them in applying for retroactive health coverage and make a final determination in accordance with this section.(4) A hospital may require a responsible party to submit a charity care application, including any requested documentation as permitted under WAC 246-453-030, by a reasonable deadline provided in MM/DD/YYYY format that takes into account the responsible party's personal circumstances and the difficulty of securing and submitting the documentation requested by the hospital, though under no circumstances may the deadline be less than 30 days after the hospital sent the notice required under WAC 246-453-020 (7)(c) or (8), as applicable.(a) A hospital may use the charity care application template issued by the department or an application that is equivalent to the department's template and does not request additional information or documentation beyond what is allowable in this chapter and chapter 70.170 RCW.(b) The hospital shall assist the responsible party with completing the charity care application as needed.(c) The hospital may require the responsible party to attest to the accuracy of the information provided.(5) In making a final determination of charity care eligibility, the hospital shall rely on the information the responsible party provides on the charity care application and in any submitted documentation. The hospital shall determine within which, if any, of the applicable income ranges specified in RCW 70.170.060(5) the responsible party's annual income, adjusted for family size, falls. The hospital shall determine the patient responsibility portion of the hospital charges by applying to the hospital charges the applicable percentage discount under RCW 70.170.060(5) or the hospital's policy, whichever is higher, making, in the hospital's discretion, any permitted reduction to the amount of the discount for amounts reasonably related to assets. If the hospital is permitted to and chooses to consider the responsible party's assets to reduce the discount under RCW 70.170.060(5), the hospital may require the responsible party to submit asset information, as permitted under WAC 246-453-030, by a reasonable deadline provided in MM/DD/YYYY format that takes into account the responsible party's personal circumstances and the difficulty of securing and submitting the documentation requested by the hospital, though under no circumstances may the deadline be less than 30 days after the hospital sent the request.(6) The hospital shall provide a responsible party notice of the final determination within 30 days of submission of the charity care application and supporting documentation, which must include the information listed in this subsection. If any of the information is not available at the time when notice is required to be provided, the hospital shall provide the responsible party an updated notice within 15 days of when the information becomes available.(a) A statement indicating whether the responsible party has been granted or denied charity care;(b) The responsible party's income, as determined by the hospital, presented as a total and broken down into the categories included in the definition of income in WAC 246-453-010;(c) The composition of the responsible party's family, as determined by the hospital;(d) The amount of the hospital charges;(e) The amount of the patient responsibility portion of the hospital charges;(f) If applicable, the percentage discount applied, the amount of the discount, and the amount of any reduction made to the discount for amounts reasonably related to assets;(g) The dates of past services and prospective services, if any, to which the discounts will be applied; and(h) Information about the opportunity to appeal under WAC 246-453-025.(7) If a responsible party expressly declines to complete the final determination process, fails to meet an applicable deadline, or fails to make reasonable efforts to cooperate with the hospital's efforts to complete the final determination process, the responsible party is finally determined ineligible for charity care. The hospital shall provide the responsible party notice of the final determination, which must include:(a) A statement that the responsible party has been finally determined ineligible for charity care with an explanation of the basis for the determination; and(b) Information about the opportunity to appeal under WAC 246-453-025.(8) Provided, that the hospital has complied with all applicable requirements, the hospital may initiate collection efforts directed at a responsible party who:(a) Expressly declines to complete the final determination process, fails to meet an applicable deadline, or fails to make reasonable efforts to cooperate with the hospital's efforts to complete the final determination process, 30 days after the hospital sent the required notice;(b) Is finally determined ineligible for charity care, 30 days after the hospital sent the required notice; or(c) Is finally determined to be eligible for charity care, but responsible for a portion of the hospital charges, though such collection efforts may be directed only at the patient responsibility portion of the hospital charges and may commence only after 30 days after the date the hospital sent the required notice.(9) A hospital may not refer the account of any responsible party who is entitled to appeal under WAC 246-453-025 to an external collection agency until the appeal period expires and any submitted appeal is decided.(10) A hospital shall promptly cease any collection efforts directed at a responsible party who is finally determined eligible for charity care for the full amount of the patient responsibility portion of their hospital charges.(11) A hospital shall reimburse within 30 days a responsible party who is finally determined eligible for charity care for any funds collected in excess of the patient responsibility portion of their hospital charges.NEW SECTIONWAC 246-453-025Appeal procedures.(1) Each hospital shall provide every responsible party who receives a final determination of charity care eligibility that includes any amount of patient responsibility, an opportunity to appeal under this section. The appeal process must enable the responsible party to correct any deficiencies in documentation and provide for review of the final determination by the hospital's chief financial officer or equivalent or a delegate.(2) The hospital shall give the responsible party at least 30 days after receiving a notice of final determination to submit an appeal. Upon request of a responsible party, a hospital shall provide a reasonable extension of the appeal deadline. A hospital's appeal procedure must permit a responsible party to make submissions to the hospital by all reasonable means, including by submitting documents and information in hard copy in person and by mail and digitally by a website accessible by smartphone and personal computer.(3) As required under WAC 246-453-021, a hospital shall provide information about the opportunity to appeal under this section. Such notice must include the following or a substantially similar statement: "If you disagree with the final determination of charity care eligibility, you may appeal by submitting additional documentation to correct deficiencies within your application or request review of the denial. Please submit your request and any additional documentation to our financial assistance office [insert relevant information]."(4) A hospital shall provide a responsible party notice of its appeal decision within 30 days of submission of the appeal. The notice must include a detailed explanation of the basis for the decision and the information listed in WAC 246-453-021. An appeal may not result in an increase in the patient responsibility portion of the hospital charges.(5) A hospital shall provide the department a copy of any appeal decision that does not grant the responsible party charity care for the full amount of the patient responsibility portion of their hospital charges and the documentation upon which the decision was based within 30 days of submission of the appeal.Reviser's note: The brackets and enclosed material in the text of the above section occurred in the copy filed by the agency and appear in the Register pursuant to the requirements of RCW 34.08.040.AMENDATORY SECTION(Amending WSR 91-05-048, filed 2/14/91, effective 3/17/91)WAC 246-453-030Data requirements for the identification of indigent persons.(((1) For the purpose of reaching an initial determination of sponsorship status, hospitals shall rely upon information provided orally by the responsible party. The hospital may require the responsible party to sign a statement attesting to the accuracy of the information provided to the hospital for purposes of the initial determination of sponsorship status.(2) Any one of the following documents shall be considered sufficient evidence upon which to base the final determination of charity care sponsorship status, when the income information is annualized as may be appropriate:(a) A "W-2" withholding statement;(b) Pay stubs;(c) An income tax return from the most recently filed calendar year;(d) Forms approving or denying eligibility for medicaid and/or state-funded medical assistance;(e) Forms approving or denying unemployment compensation; or(f) Written statements from employers or welfare agencies.(3) In the event that the responsible party's identification as an indigent person is obvious to hospital personnel, and the hospital personnel are able to establish the position of the income level within the broad criteria described in WAC 246-453-040 or within income ranges included in the hospital's sliding fee schedule, the hospital is not obligated to establish the exact income level or to request the aforementioned documentation from the responsible party, unless the responsible party requests further review.(4) In the event that the responsible party is not able to provide any of the documentation described above, the hospital shall rely upon written and signed statements from the responsible party for making a final determination of eligibility for classification as an indigent person.(5) Information requests, from the hospital to the responsible party, for the verification of income and family size shall be limited to that which is reasonably necessary and readily available to substantiate the responsible party's qualification for charity sponsorship, and may not be used to discourage applications for such sponsorship. Only those facts relevant to eligibility may be verified, and duplicate forms of verification shall not be demanded.))(1) A hospital shall base charity care eligibility determinations made under this chapter on the responsible party's annual family income as follows:(a) If the charity care application is made within two years of the time of service and the responsible party has been making good faith efforts towards payment of health care services provided, which include the responsible party making reasonable efforts to reach an agreement with the hospital regarding payment and to make payments in accordance with such agreement, the hospital shall use the responsible party's income as of the time of application; or(b) If subsection (a) of this section does not apply, the hospital shall use the responsible party's income as of the time the health care services were provided. The hospital, in its discretion, may use the responsible party's income as of the time of application, if lower.(2) A hospital may consider only the categories of income included in the definition of income in WAC 246-453-010 and request documentation of income only as permitted in this chapter and chapter 70.170 RCW. A hospital may consider and request documentation of assets only as permitted in this chapter and chapter 70.170 RCW.(3) A hospital may request only such documentation as is reasonably necessary to establish with reasonable accuracy the responsible party's income and assets at the applicable time under subsection (1) of this section. A hospital shall not make requests that place an unreasonable burden on the responsible party or discourage requests for charity care, and a hospital shall not request documentation that is not readily available, is unlikely to show the responsible party's income or assets at the applicable time under subsection (1) of this section, is irrelevant, or is duplicative. A hospital shall not request the responsible party's Social Security number for purposes of making charity care determinations.(4) A hospital shall accept a representation from a responsible party that they do not have income in a category listed in WAC 246-453-010 or assets in a category about which the hospital has requested information. A hospital shall accept any reasonably reliable form of documentation provided by a responsible party even if different from the form of documentation requested by the hospital. A hospital shall accept a representation from a responsible party that they do not have certain requested documentation and rely on the responsible party's representation as to the amount of such income or value of such asset.(5) If a responsible party chooses to submit documentation that the hospital did not request, the hospital shall give due regard to such documentation in determining the responsible party's income and assets. The hospital shall provide the responsible party the opportunity to submit explanatory information about the responsible party's income and assets including, but not limited to, information about any recent changes that would make any requested documentation an inaccurate source of information, and the hospital shall give due regard to such information in determining the responsible party's income.AMENDATORY SECTION(Amending WSR 91-05-048, filed 2/14/91, effective 3/17/91)WAC 246-453-040Uniform criteria for the identification of indigent persons.For the purpose of identifying indigent persons, all hospitals shall use the following criteria:(1) ((All responsible parties with family income equal to or below one hundred percent of the federal poverty standard, adjusted for family size, shall be determined to be indigent persons qualifying for charity sponsorship for the full amount of hospital charges related to appropriate hospital-based medical services that are not covered by private or public third-party sponsorship;(2) All responsible parties with family income between one hundred one and two hundred percent of the federal poverty standard, adjusted for family size, shall be determined to be indigent persons qualifying for discounts from charges related to appropriate hospital-based medical services in accordance with the hospital's sliding fee schedule and policies regarding individual financial circumstances;(3) Hospitals may classify any individual responsible party whose income exceeds two hundred percent of the federal poverty standard, adjusted for family size, as an indigent person eligible for a discount from charges based upon that responsible party's individual financial circumstances.))At a minimum, a hospital owned or operated by a health system that owns or operates three or more acute hospitals licensed under chapter 70.41 RCW, an acute care hospital with over 300 licensed beds located in the most populous county in Washington, or an acute care hospital with over 200 licensed beds located in a county with at least 450,000 residents and located on Washington's southern border shall grant charity care per the following guidelines:(a) All patients and their guarantors whose income is not more than 300 percent of the federal poverty level, adjusted for family size, shall be deemed charity care patients for the full amount of the patient responsibility portion of their hospital charges;(b) All patients and their guarantors whose income is between 301 and 350 percent of the federal poverty level, adjusted for family size, shall be entitled to a 75 percent discount for the full amount of the patient responsibility portion of their hospital charges, which may be reduced by amounts reasonably related to assets considered pursuant to subsection (3) of this section;(c) All patients and their guarantors whose income is between 351 and 400 percent of the federal poverty level, adjusted for family size, shall be entitled to a 50 percent discount for the full amount of the patient responsibility portion of their hospital charges, which may be reduced by amounts reasonably related to assets considered pursuant to subsection (3) of this section.(2) At a minimum, a hospital not subject to subsection (1) of this section shall grant charity care per the following guidelines:(a) All patients and their guarantors whose income is not more than 200 percent of the federal poverty level, adjusted for family size, shall be deemed charity care patients for the full amount of the patient responsibility portion of their hospital charges;(b) All patients and their guarantors whose income is between 201 and 250 percent of the federal poverty level, adjusted for family size, shall be entitled to a 75 percent discount for the full amount of the patient responsibility portion of their hospital charges, which may be reduced by amounts reasonably related to assets considered pursuant to subsection (3) of this section; and(c) All patients and their guarantors whose income is between 251 and 300 percent of the federal poverty level, adjusted for family size, shall be entitled to a 50 percent discount for the full amount of the patient responsibility portion of their hospital charges, which may be reduced by amounts reasonably related to assets considered pursuant to subsection (3) of this section.(3)(a) If a hospital considers the existence, availability, and value of assets in order to reduce the discount extended, it must establish and make publicly available, as described in WAC 246-453-015, a policy on asset considerations and corresponding discount reductions.(b) If a hospital considers assets, the following types of assets shall be excluded from consideration:(i) The first $5,000 of monetary assets for an individual or $8,000 of monetary assets for a family of two, and $1,500 of monetary assets for each additional family member. The value of any asset that has a penalty for early withdrawal shall be the value of the asset after the penalty has been paid;(ii) Any equity in a primary residence;(iii) Retirement plans other than 401(k) plans;(iv) One motor vehicle and a second motor vehicle if it is necessary for employment or medical purposes;(v) Any prepaid burial contract or burial plot; and(vi) Any life insurance policy with a face value of $10,000 or less.(c) In considering assets, a hospital may not impose procedures which place an unreasonable burden on the responsible party. Information requests from the hospital to the responsible party for the verification of assets shall be limited to that which is reasonably necessary and readily available to substantiate the responsible party's qualification for charity sponsorship and may not be used to discourage application for such sponsorship. Only those facts relevant to eligibility may be verified and duplicate forms of verification may not be demanded.(i) In considering monetary assets, one current account statement shall be considered sufficient for a hospital to verify a patient's assets.(ii) In the event that no documentation for an asset is available, a hospital shall rely upon a written and signed statement from the responsible party.(d) Asset information obtained by the hospital in evaluating a patient for charity care eligibility shall not be used for collection activities.(e) Nothing in this section prevents a hospital from considering assets as required by the Centers for Medicare and Medicaid Services related to medicare cost reporting.AMENDATORY SECTION(Amending WSR 94-12-089, filed 6/1/94, effective 7/2/94)WAC 246-453-050((Guidelines for the development of sliding fee schedules.))Charges for professional medical staff services.((All hospitals shall, within ninety days of the adoption of these rules, implement a sliding fee schedule for determination of discounts from billed charges for responsible parties meeting the criteria in WAC 246-453-040(2). These sliding fee schedules must be made available upon request.(1) In developing these sliding fee schedules, hospitals shall consider the following guidelines:(a) The sliding fee schedule shall consider the level of charges that are not covered by any public or private sponsorship in relation to or as a percentage of the responsible party's family income;(b) The sliding fee schedule shall determine the maximum amount of charges for which the responsible party will be expected to provide payment, with flexibility for hospital management to hold the responsible party accountable for a lesser amount after taking into account the specific financial situation of the responsible party;(c) The sliding fee schedule shall take into account the potential necessity for allowing the responsible party to satisfy the maximum amount of charges for which the responsible party will be expected to provide payment over a reasonable period of time, without interest or late fees; and(d) Hospital policies and procedures regarding the sliding fee schedule shall specify the individual financial circumstances which may be considered by appropriate hospital personnel for purposes of adjusting the amount resulting from the application of the sliding fee schedule, such as:(i) Extraordinary nondiscretionary expenses relative to the amount of the responsible party's medical care expenses;(ii) The existence and availability of family assets, which may only be considered with regard to the applicability of the sliding fee schedule;(iii) The responsible party's future income earning capacity, especially where his or her ability to work in the future may be limited as a result of illness; and(iv) The responsible party's ability to make payments over an extended period of time.(2) Examples of sliding fee schedules which address the guidelines in the previous subsection are:(a) A person whose annual family income is between one hundred one and two hundred percent of the federal poverty standard, adjusted for family size, shall have his/her hospital charges that are not covered by public or private sponsorship limited to forty percent of the excess of that person's annual family income over one hundred percent of the federal poverty standard, adjusted for family size. This responsibility may be adjusted by appropriate hospital personnel after taking into consideration the individual financial circumstances of the responsible party. The responsible party's financial obligation which remains after the application of this sliding fee schedule may be payable in monthly installments over a reasonable period of time, without interest or late fees, as negotiated between the hospital and the responsible party.(b) A person whose family income is between one hundred one and two hundred percent of the federal poverty standard, adjusted for family size, shall have his/her hospital charges that are not covered by public or private sponsorship reduced according to the schedule below. The resulting responsibility may be adjusted by appropriate hospital personnel after taking into consideration the individual financial circumstances of the responsible party. The responsible party's financial obligation which remains after the application of this sliding fee schedule may be payable in monthly installments over a reasonable period of time, without interest or late fees, as negotiated between the hospital and the responsible party. The schedule is as follows:income as a percentageof federal poverty levelpercentage discountOne hundred one to one hundred thirty-threeSeventy-five percentOne hundred thirty-four to one hundred sixty-sixFifty percentOne hundred sixty-seven to two hundredTwenty-five percent(3)))(1) The provisions of ((this section and)) RCW 70.170.060(5) shall not apply to the professional services of the hospital's medical staff, provided that the charges for such services are either submitted by the individual medical staff or are separately identified within the hospital's billing system.(2) This section expires on July 31, 2028.AMENDATORY SECTION(Amending WSR 91-05-048, filed 2/14/91, effective 3/17/91)WAC 246-453-060Denial of access to emergency care based upon ability to pay and transfer of patients with emergency medical conditions or active labor.(1) No hospital or its medical staff shall adopt or maintain admission practices or policies which result in:(a) A significant reduction in the proportion of patients who have no third-party coverage and who are unable to pay for hospital services;(b) A significant reduction in the proportion of individuals admitted for inpatient hospital services for which payment is, or is likely to be, less than the anticipated charges for or costs of such services; or(c) The refusal to admit patients who would be expected to require unusually costly or prolonged treatment for reasons other than those related to the appropriateness of the care available at the hospital.(2) No hospital shall adopt or maintain practices or policies which would deny access to emergency care based on ability to pay. No hospital which maintains an emergency department shall transfer a patient with an emergency medical condition or who is in active labor unless the transfer is performed at the request of the patient or is due to the limited medical resources of the transferring hospital. Hospitals must make transfers to other hospitals in such circumstances and as promptly as dictated by the standard of care and follow reasonable procedures in making transfers to other hospitals including confirmation of acceptance of the transfer by the receiving hospital.(3) The department shall monitor hospital compliance with subsections (1) and (2) of this section. The department shall report ((to the legislature and the governor on hospital compliance with these requirements and shall report)) individual instances of possible noncompliance to the state attorney general or the appropriate federal agency((. For purposes of monitoring compliance with subsection (2) of this section, the department is to follow all definitions and requirements of federal law)).(4) Except as required by federal law and subsection (2) of this section, nothing in this section shall be interpreted to indicate that hospitals and their medical staff are required to provide ((appropriate hospital-based medical services))medically necessary hospital health care, including experimental services, to any individual.(5) For the purpose of this section:(a) "Active labor" means a stage of labor during which a person is having contractions and:(i) There is inadequate time to effect a safe transfer to another hospital before delivery; or(ii) Transfer may pose a threat to the health or safety of the pregnant person or their embryo or fetus.(b) "Limited medical resources" means the nonavailability of services or medical expertise which are required or are expected to be required for the appropriate diagnosis, treatment, or stabilization per federal requirements of an individual's medical or mental situation;(c) "Medical staff" means health care providers delivering or overseeing the delivery of health care services in a hospital.(d) "Unusually costly or prolonged treatment" means those services or combinations of services the cost of which is two standard deviations or more above the average charge or the duration of which is three standard deviations or more above the average length of stay, as determined by the department's discharge database.AMENDATORY SECTION(Amending WSR 94-12-089, filed 6/1/94, effective 7/2/94)WAC 246-453-070Standards for acceptability of hospital policies for charity care and bad debts.(1) Each hospital shall develop((,)) and submit to the department((,))prior to implementation by the hospital charity care policies((,))and procedures((, and sliding fee schedules)) consistent with the requirements ((included in WAC 246-453-020, 246-453-030, 246-453-040, and 246-453-050))of chapter 70.170 RCW and this chapter. Any subsequent modifications to ((those)) policies((,))or procedures((, and sliding fee schedules)) must be submitted to the department ((no later than thirty days prior to their adoption))prior to implementation by the hospital.(2) Each hospital shall develop((,)) and submit to the department((,))prior to implementation by the hospital bad debt policies and procedures, including reasonable and uniform standards for collection of the unpaid portions of hospital charges that are the patient's responsibility. These standards are to be part of each hospital's system of accounts receivable management manuals, which support hospital collection policies. Manuals ((should))must cover procedures for preadmission, admission, discharge, outpatient registration and discharge, billing, and credit and collections. All subsequent modifications to these bad debt policies must be submitted to the department ((no later than thirty days prior to their adoption))prior to implementation by the hospital.(3) Each hospital that considers the existence, availability, and value of assets in order to lower the charity care discount, as permitted under chapter 70.170 RCW and this chapter, shall develop and submit to the department prior to implementation by the hospital, asset consideration policies and procedures consistent with the requirements of chapter 70.170 RCW and this chapter. Any subsequent modifications to those policies and procedures must be submitted to the department prior to implementation by the hospital.(4) The department shall review the ((charity care and bad debt))submitted policies and procedures ((submitted in accordance with the provisions of this section)). If any of the policies and procedures ((do))does not meet the requirements of ((this section or WAC 246-453-020, 246-453-030, 246-453-040, or 246-453-050))chapter 70.170 RCW or this chapter, the department shall reject the policies and procedures and ((shall so)) notify the hospital. Such notification ((shall))must be in writing, addressed to the hospital's chief executive officer or equivalent, and ((shall))must specify the reason(s) that the policies and procedures have been rejected. ((Any such notification must be mailed within fourteen calendar days of the receipt of the hospital's policies and procedures. Within fourteen days of the date of the rejection notification,))The hospital shall revise and resubmit the policies and procedures for review by the department. The hospital shall comply with any deadline for submitting, revising, or implementing a policy or procedure that the department may impose.AMENDATORY SECTION(Amending WSR 91-05-048, filed 2/14/91, effective 3/17/91)WAC 246-453-080Reporting requirements.Each hospital shall:(1) Compile and report data to the department with regard to the amount of charity care provided, in accordance with instructions issued by the department;(2) Retain records related to charity care screening and eligibility determinations for a period of no less than six years from the date received; and(3) Provide records or information related to charity care to the department as directed.AMENDATORY SECTION(Amending WSR 94-12-089, filed 6/1/94, effective 7/2/94)WAC 246-453-090Penalties for violation.(((1) Failure to file the policies, procedures, and sliding fee schedules as required by WAC 246-453-070 or the reports required by WAC 246-453-080 shall constitute a violation of RCW 70.170.060, and the department will levy a civil penalty of one thousand dollars per day for each day following official notice of the violation. The department may grant extensions of time to file the reports, in which cases failure to file the reports shall not constitute a violation until the extension period has expired.(2) Failure to comply with other provisions of chapter 70.170 RCW, and chapter 246-453 WAC, shall result in civil penalties as provided within RCW 70.170.070(2), with the exception that the terms "not exceeding" and "not to exceed" will be read to mean "of."))The department may take action under RCW 70.170.070 in response to a violation of this chapter or chapter 70.170 RCW. Chapter 246-10 WAC governs any proceedings initiated under this section.