SOCIAL AND HEALTH SERVICES
(Medical Assistance Administration)
Date of Adoption: March 26, 2004.
Purpose: To correct cross-references and terms rendered incorrect by recent amendments to chapter 388-538 WAC, Managed care.
Citation of Existing Rules Affected by this Order: Amending WAC 388-542-0100, 388-542-0125, and 388-542-0500.
Statutory Authority for Adoption: RCW 74.08.090, 74.09.450, 74.09.510, 74.09.522.
Adopted under notice filed as WSR 03-19-067 on September 12, 2003.
Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.
Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.
Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.
Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 3, Repealed 0.
Number of Sections Adopted Using Negotiated Rule Making:
Pilot Rule Making:
or Other Alternative Rule Making:
Effective Date of Rule: Thirty-one days after filing.
March 26, 2004
Brian H. Lindgren, Manager
Rules and Policies Assistance Unit3310.1
(2) The medical assistance administration (MAA) requires CHIP clients, except for clients who are American Indian or Alaska Native (AI/AN), to enroll in managed care according to WAC 388-538-060 (1)(b) through (5)(d). AI/AN clients may choose to receive services under MAA's fee-for-service system.
(3) For eligible CHIP clients who are not enrolled in managed care:
(a) MAA determines which services are medically necessary;
(b) Clients must obtain covered services from providers who have core provider agreements with MAA; and
(c) As a condition of coverage, MAA may require the service provider to obtain authorization from MAA for coverage of nonemergency services.
(4) A CHIP client enrolled in managed care may submit a
complaint)) grievance or appeal as described in WAC 388-538-110.
(5) Any CHIP client may request a fair hearing as described in chapter 388-02 WAC for review of MAA coverage decisions. Clients may elect to participate in a prehearing review as described in WAC 388-526-2610.
[Statutory Authority: RCW 74.09.080, 74.08.510, [74.08.]522, 74.09.450, 1115 Waiver, 42 U.S.C. 1396. 02-01-075, § 388-542-0100, filed 12/14/01, effective 1/14/02. Statutory Authority: RCW 74.08.090, 74.09.450. 00-07-103, § 388-542-0100, filed 3/17/00, effective 4/17/00.]
(2) Not all CHIP clients are required to enroll in an MCO or with a PCCM provider. The same enrollment criteria are applied to CHIP clients as to categorically needy Medicaid clients under WAC 388-538-060.
(3) If a CHIP client is not already enrolled in managed
care, the client may request an exemption to mandatory
enrollment under the process described in WAC ((
388-538-130. MAA provides fee-for-service coverage while a
client's request for exemption from mandatory enrollment in an
MCO or with a PCCM provider is being considered and until a
final decision is made.
(4) If a CHIP client is already enrolled in an MCO or with a PCCM provider and requests to end the enrollment, the client remains enrolled in the client's MCO or with the PCCM provider pending MAA's final decision. The process for ending enrollment is described in WAC 388-538-130.
(5) If a CHIP client has no MCO or PCCM provider available or is permitted to choose the fee-for-service system under this chapter, the rules that apply to service coverage and payment for the children's health program apply to CHIP coverage (chapters 388-550 through 388-556 WAC).
[Statutory Authority: RCW 74.09.080, 74.08.510, [74.08.]522, 74.09.450, 1115 Waiver, 42 U.S.C. 1396. 02-01-075, § 388-542-0125, filed 12/14/01, effective 1/14/02. Statutory Authority: RCW 74.08.090, 74.09.450. 00-07-103, § 388-542-0125, filed 3/17/00, effective 4/17/00.]
(a) WAC 388-538-060, Managed care and choice, with the exception of subsection (1)(a);
(b) WAC 388-538-070, Managed care payment;
WAC 388-538-080, Managed care exemptions;
(d))) WAC 388-538-095, Scope of care for managed care enrollees;
(e))) (d) WAC 388-538-100, Managed care emergency
(f))) (e) WAC 388-538-110(( .[,])), The grievance system for managed
care (( complaints, appeals and fair hearings)) organizations
(g))) (f) WAC 388-538-120, Enrollee requests for a
second medical opinion;
(h))) (g) WAC 388-538-130, Exemptions and ending
enrollment in (( healthy options)) managed care; and
(i))) (h) WAC 388-538-140, Quality of care.
[Statutory Authority: RCW 74.09.080, 74.08.510, [74.08.]522, 74.09.450, 1115 Waiver, 42 U.S.C. 1396. 02-01-075, § 388-542-0500, filed 12/14/01, effective 1/14/02.]