SB 5083: Ensuring access to primary care, behavioral health, and affordable hospital services. - Washington

Engrossed Second Substitute Bill → Second Substitute Passed Legislature · 7 edits

MODERATE

The bill was amended to clarify definitions regarding Medicare reimbursement calculations and to significantly expand financial protections for hospitals. Key changes include adding specific reimbursement rates for pediatric specialty hospitals in King and Pierce counties, extending protections to out-of-network hospitals, and ensuring rural hospitals receive at least 101% of allowable costs.

Scope change

The bill's scope was expanded to include out-of-network hospitals and specific pediatric facilities in King and Pierce counties, while narrowing the definition of exempt hospitals to exclude those with high Medicaid/Medicare usage on tribal land.

DEFINITION

Added a specific definition for 'total amount medicare would have reimbursed' to clarify how reimbursement caps are calculated.

REQUIREMENT

Added requirements for claims to include all necessary Medicare modifiers to ensure accurate rebate and adjustment calculations.

Replaced a general mandate for hospitals to contract with insurers upon offer with a specific requirement for contractors to meet defined reimbursement rates.

Established specific reimbursement caps for pediatric specialty hospitals in King and Pierce counties based on Medicaid inpatient cost-to-charge ratios.

Added reimbursement requirements for out-of-network hospitals, including specific caps for pediatric facilities in King and Pierce counties.

Added a provision prohibiting out-of-network hospitals from charging patients additional amounts beyond the statutory reimbursement limits.

ELIGIBILITY

Modified exemptions for rural hospitals to exclude those located on federally recognized Indian tribe land that meet specific high Medicaid/Medicare usage criteria.

Second Substitute Bill → Engrossed Second Substitute Bill · 2 edits · Apr 24, 2025

MINOR

The bill was reclassified from a 'Second Substitute' to an 'Engrossed Second Substitute' version, indicating it has passed through an additional legislative step. The most significant policy change expands the category of rural hospitals eligible for enhanced reimbursement rates to include those certified as 'sole community hospitals' that receive specific enhanced rates, in addition to existing 'critical access hospitals'.

Scope change

The scope of the bill was expanded to include a new class of rural hospitals (sole community hospitals receiving enhanced rates) that were previously excluded from the specific reimbursement protections.

ELIGIBILITY

Updated the list of exempt hospitals to include rural hospitals certified as sole community hospitals receiving enhanced rates under RCW 74.09.5225(3)(a), alongside existing critical access hospitals.

TECHNICAL

Changed the bill title from 'Second Substitute Senate Bill' to 'Engrossed Second Substitute Senate Bill'.

Substitute Bill → Second Substitute Bill · 6 edits

MODERATE

The bill was reclassified as a Second Substitute Bill and moved to the Ways & Means committee, indicating it has advanced in the legislative process. The most significant change is a major restructuring of exemptions for rural and tribal hospitals: the previous single exemption for critical access hospitals was split into two distinct categories, and a new exemption was added for specific tribal hospitals that previously did not qualify.

Scope change

The bill's applicability was expanded to include a new category of eligible hospitals: those located on federally recognized Indian tribal land that meet specific criteria regarding Medicaid/Medicare usage and current critical access status.

TIMELINE

The bill's reading date was updated from February 12, 2025, to February 28, 2025, and its status changed from a Substitute Bill to a Second Substitute Bill.

SCOPE

The committee assignment changed from Senate Health & Long-Term Care to Senate Ways & Means, reflecting a shift in the bill's primary legislative focus or oversight.

ELIGIBILITY

The exemption for rural hospitals was modified to explicitly exclude those owned by health systems operating more than two acute care hospitals, raising the threshold from one to two.

A new exemption was added for hospitals located on federally recognized Indian tribal land that are not currently designated as critical access hospitals but meet specific patient volume thresholds.

The exemption for Skagit County island hospitals was moved from a general exception clause to a specific list of exemptions to clarify its scope.

REQUIREMENT

A new reporting requirement was added mandating a second report by December 31, 2034, to analyze the long-term impacts of the reimbursement rules.

Bill → Substitute Bill · 4 edits

MODERATE

The bill was converted from a Senate Bill to a Substitute Bill, indicating it has been amended by the Senate. Key substantive changes include narrowing the scope of hospital reimbursement limits to apply only to 'in-network' providers located in Washington, adding a specific exemption for certain rural and island hospitals, and clarifying that reimbursement limits do not cover professional service charges. Additionally, the required annual report now includes 'cost sharing' as a metric to analyze.

Scope change

The bill's applicability was narrowed from all providers to only 'in-network' providers located in Washington, and specific exemptions were created for rural and island hospitals to prevent them from being subject to the new reimbursement caps.

ELIGIBILITY

Reimbursement caps now apply only to 'in-network' providers located in Washington, removing coverage for out-of-network providers.

EXEMPTIONS

Added an exemption for services provided by rural critical access hospitals, sole community hospitals, and specific island hospitals in Skagit County.

DEFINITION

Clarified that the reimbursement limits for inpatient and outpatient services do not include charges for professional services.

REQUIREMENT

Updated the required legislative report to include an analysis of changes to 'cost sharing' for enrollees.

Ensuring access to primary care, behavioral health, and affordable hospital services.

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