Title 7 . Health and Social Services

Chapter 43 . Hearings

Section 380. Out-of-state hospitals

7 AAC 43.380. Out-of-state hospitals

(a) The rate of payment for out-of-state hospitals is the medicaid rate used by the state where the hospital is located or, if no medicaid rate has been established, the medicare rate for the hospital, or if no medicare rate has been established, the Blue Cross rate will be used.

(b) Except in emergency situations, payment will not be made for out-of-state hospital services that are available in Alaska unless the out-of-state hospitalization has been specifically approved by the division.

(c) The department may negotiate a hospital-specific reimbursement agreement for unique expertise or specialized services not available in this state. Factors that the department will consider in making the decision to negotiate a facility-specific reimbursement agreement under this subsection include

(1) the medical necessity for the out-of-state hospital service;

(2) whether the service is widely available out-of-state or available only from a limited number of out-of-state providers;

(3) the professional standing of the facility within the health care services community for the unique expertise or specialized service;

(4) any extreme circumstance concerning the medical needs of the patient; and

(5) whether a facility-specific reimbursement agreement is necessary to ensure access to appropriate medical services that otherwise would not be available.

(d) The hospital-specific reimbursement agreement under (c) of this section is not available for general services offered by the hospital and is limited to the specific services set out in the reimbursement agreement. General services offered by the hospital and not associated with unique expertise or specialized services in the reimbursement agreement will be paid under (a) of this section.

(e) The hospital-specific reimbursement agreement under (c) of this section will be for a specific period of time not to exceed two years.

(f) Except as provided in this section, the department will process claims for out-of-state hospital services in accordance with the claim process established for hospitals in this state under 7 AAC 43.350 - 7 AAC 43.435.

(g) Charges to the department for out-of-state inpatient and outpatient hospital services may not exceed the hospital's usual and customary charges for the same service to the general public.

History: Eff. 8/18/79, Register 71; readopt 8/7/96, Register 139; am 2/2/2005, Register 173

Authority: AS 47.05.010

AS 47.07.070

Editor's note: Effective 8/7/96, Register 139, the Department of Health and Social Services readopted 7 AAC 43.380 in its entirety, without change, under AS 47.05 and AS 47.07. Executive Order No. 72 transferred certain rate-setting authority to the department.

In making the emergency amendment of 7 AAC 43.380(c) and emergency adoption of 7 AAC 43.380(g) permanent in Register 174 (July 2005), the regulations attorney made minor technical amendments not reflected in the history note.