WSR 04-07-135

PROPOSED RULES

DEPARTMENT OF

SOCIAL AND HEALTH SERVICES
(Medical Assistance Administration)

[ Filed March 22, 2004, 4:05 p.m. ]

Original Notice.

Preproposal statement of inquiry was filed as WSR 03-21-151.

Title of Rule: WAC 388-538-112 The Medical Assistance Administration's (MAA's) fair hearing process for enrollees of managed care organization (MCO) actions.

Purpose: When chapter 388-538 WAC was amended on September 2, 2003, under WSR 03-18-110, "the department" was inadvertently omitted as a party to the fair hearing in WAC 388-538-112. This amendment corrects that omission. In addition, the department is clarifying that "days" referred to in this section are "calendar days," and making other clarifications.

Statutory Authority for Adoption: RCW 74.08.090, 74.09.522.

Statute Being Implemented: RCW 74.09.522, 74.09.450.

Summary: See Purpose above.

Reasons Supporting Proposal: See Purpose above.

Name of Agency Personnel Responsible for Drafting: Ann Myers, P.O. Box 45533, Olympia, WA 98507-5533, (360) 725-1345; Implementation and Enforcement: Michael Paulson, P.O. Box 45530, Olympia, WA 98507-5530, (360) 753-7315.

Name of Proponent: Department of Social and Health Services, Medical Assistance Administration, governmental.

Rule is not necessitated by federal law, federal or state court decision.

Explanation of Rule, its Purpose, and Anticipated Effects: See Purpose above.

Proposal Changes the Following Existing Rules: The proposal adds "the department" as a party to fair hearings for managed care enrollees, and clarifies that the "days" in this section are "calendar days."

No small business economic impact statement has been prepared under chapter 19.85 RCW. The department has analyzed the proposed rule and concludes that it does not have a more than minor impact on the small businesses affected by it. Therefore, it is not necessary to prepare a small business economic impact statement.

RCW 34.05.328 does not apply to this rule adoption. The department has analyzed the proposed rule and concludes that it does not meet the definition of a "significant legislative rule." Therefore, it is not necessary to prepare a cost/benefit analysis.

Hearing Location: Office Building 2, Auditorium, 14th and Jefferson, Olympia, Washington 98504, on April 27, 2004, at 10:00 a.m.

Assistance for Persons with Disabilities: Contact Andy Fernando, DSHS Rules Coordinator, by March 23, 2004, phone (360) 664-6097, TTY (360) 664-6178, e-mail swensFH@dshs.wa.gov.

Submit Written Comments to: Identify WAC Numbers, DSHS Rules Coordinator, Rules and Policies Assistance Unit, mail to P.O. Box 45850, Olympia, WA 98504-5850, deliver to 4500 10th Avenue S.E., Lacey, WA, fax (360) 664-6185, e-mail fernaax@dshs.wa.gov, by 5:00 p.m., April 27, 2004.

Date of Intended Adoption: Not sooner than April 28, 2004.

March 18, 2004

Brian H. Lindgren, Manager

Rules and Policies Assistance Unit

3378.1
AMENDATORY SECTION(Amending WSR 03-18-110, filed 9/2/03, effective 10/3/03)

WAC 388-538-112   The medical assistance administration's (MAA's) fair hearing process for enrollee appeals of managed care organization (MCO) actions.   (1) The fair hearing process described in chapter 388-02 WAC applies to the fair hearing process described in this chapter. Where a conflict exists, the requirements in this chapter take precedence.

(2) An MCO enrollee must exhaust all levels of resolution and appeal within the MCO's grievance system prior to filing an appeal (a request for a department fair hearing) with MAA. See WAC 388-538-110 for the MCO grievance system.

(3) If an MCO enrollee does not agree with the MCO's resolution of the enrollee's appeal, the enrollee may file a request for a department fair hearing within the following time frames:

(a) For appeals regarding a standard service, within ninety calendar days of the date of the MCO's notice of the resolution of the appeal.

(b) For appeals regarding termination, suspension, or reduction of a previously authorized service, or the enrollee is requesting continuation of services, within ten calendar days of the date on the MCO's notice of the resolution of the appeal.

(4) The entire appeal process, including the MCO appeal process, must be completed within ninety calendar days of the date the MCO enrollee filed the appeal with the MCO, not including the number of days the enrollee took to subsequently file for a department fair hearing.

(5) Parties to the ((MAA)) fair hearing include the department, the MCO, the enrollee, and the enrollee's representative or the representative of a deceased enrollee's estate.

(6) If an enrollee disagrees with the ((department)) fair hearing decision, then the enrollee may request an independent review (IR) ((per)) in accordance with RCW 48.43.535.

(7) If there is disagreement with the IR decision, the ((state)) department of social and health services (DSHS) board of appeals (BOA) issues the final administrative decision.

[Statutory Authority: RCW 74.08.090, 74.09.522. 03-18-110, 388-538-112, filed 9/2/03, effective 10/3/03.]

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