SOCIAL AND HEALTH SERVICES
(Medical Assistance Administration)
Preproposal statement of inquiry was filed as WSR 04-04-095.
Title of Rule: Amending WAC 388-505-0110 Medical assistance coverage for adults not covered under family medical programs and new WAC 388-538-063 Mandatory enrollment in managed care for GAU clients.
Purpose: The Medical Assistance Administration (MAA) is designing a medical care services management pilot project for clients who receive general assistance benefits.
Statutory Authority for Adoption: RCW 74.08.090, 74.09.035, 74.09.522, and ESSB 5404 (section 209(15), chapter 25, Laws of 2003 1st sp.s.).
Statute Being Implemented: ESSB 5404 (section 209(15), chapter 25, Laws of 2003 1st sp.s.).
Summary: The proposed rule is designed to maximize care coordination, high-risk medical management, and chronic care management to achieve better health outcomes for clients who receive general assistance (GAU) benefits. The medical care services management pilot project will be operated in King and Pierce counties, which contain the highest concentration of general assistance clients. The pilot project will require GAU clients in these two designated counties to be enrolled in a managed care organization contracted with MAA in order to continue their general assistance benefits. GAU scope of care and GAU medical/financial eligibility requirements are not changing. The pilot project will not be conducted as a "pilot rule-making" under chapter 34.05 RCW.
Reasons Supporting Proposal: These rules are necessary to implement a medical care services management pilot project for clients who receive general assistance benefits as established by the 2003 legislature, ESSB 5404 (section 209(15), chapter 25, [Laws of 2003] 1st sp.s.).
Name of Agency Personnel Responsible for Drafting: Wendy Boedigheimer, MAA, P.O. Box 45533, Olympia, WA 98504-5533, (360) 725-1306; Implementation and Enforcement: Amandalei Bennett, MAA, P.O. Box 45530, Olympia, WA 98504-5530, (360) 725-1646.
Name of Proponent: Department of Social and Health Services, governmental.
Rule is not necessitated by federal law, federal or state court decision.
Explanation of Rule, its Purpose, and Anticipated Effects: See Purpose, Summary, and Reasons Supporting Proposal above.
Proposal Changes the Following Existing Rules: See Summary and Reasons Supporting Proposal above.
No small business economic impact statement has been prepared under chapter 19.85 RCW. The proposed amendments are exempt from a small business economic impact statement (SBEIS) according to RCW 19.85.025(3) because the proposed changes are explicitly and specifically directed by the 2003 legislature (section 209(15), chapter 25, Laws of 2003).
RCW 34.05.328 does not apply to this rule adoption. The proposed rules are exempt from preparing a cost benefit analysis (CBA) according to RCW 34.05.328 (5)(b)(iii) because the proposed revisions are explicitly and specifically directed by the 2003 legislature in section 209(15), chapter 25, Laws of 2003 1st sp.s., and under RCW 34.05.328 (5)(b)(vii), exempting DSHS rules relating to client medical or financial eligibility.
Hearing Location: Office Building 2 Auditorium (DSHS Headquarters) (public parking at 11th and Jefferson), 1115 Washington, Olympia, WA 98504, on May 25, 2004, at 10:00 a.m.
Assistance for Persons with Disabilities: Contact Andy Fernando, DSHS Rules Coordinator, by May 21, 2004, phone (360) 664-6094, TTY (360) 664-6178, e-mail firstname.lastname@example.org.
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 email@example.com, by 5:00 p.m., May 25, 2004.
Date of Intended Adoption: Not sooner than May 26, 2004.
April 15, 2004
Brian H. Lindgren, Manager
Rules and Policies Assistance Unit3394.3
(2) The only sections of chapter 388-538 WAC that apply to GAU clients described in this section are incorporated by reference into this section.
(3) To receive medical assistance administration (MAA) paid medical care, GAU clients must enroll in a managed care plan as required by WAC 388-505-0110(7) when they reside in a county designated as a mandatory managed care plan county.
(4) GAU clients are exempt from mandatory enrollment in managed care if they:
(a) Are American Indian or Alaska Native (AI/AN); and
(b) Meet the provisions of 25 U.S.C. 1603 (c)-(d) for federally recognized tribal members and their descendants.
(5) In addition to subsection (4), MAA will exempt a GAU client from mandatory enrollment in managed care or end an enrollee's enrollment in managed care in accordance with WAC 388-538-130(3) and 388-538-130(4).
(6) On a case-by-case basis, MAA may grant a GAU client's request for exemption from managed care or a GAU enrollee's request to end enrollment when, in MAA's judgment:
(a) The client or enrollee has a documented and verifiable medical condition; and
(b) Enrollment in managed care could cause an interruption of treatment that could jeopardize the client's or enrollee's life or health or ability to attain, maintain, or regain maximum function.
(7) MAA enrolls GAU clients in managed care effective on the earliest possible date, given the requirements of the enrollment system. MAA does not enroll clients in managed care on a retroactive basis.
(8) Managed care organizations (MCOs) that contract with MAA to provide services for GAU clients must meet the qualifications and requirements in WAC 388-538-067 and 388-538-095 (3)(a), (b), (c), and (d).
(9) MAA pays MCOs capitated premiums for GAU enrollees based on legislative allocations for the GAU program.
(10) GAU enrollees are eligible for the scope of care as described in WAC 388-529-0200 for medical care services (MCS). Other scope of care provisions that apply:
(a) A client is entitled to timely access to medically necessary services as defined in WAC 388-500-0005;
(b) MCOs cover the services included in the managed care contract for GAU enrollees. MCOs may, at their discretion, cover services not required under the MCO's contract for GAU enrollees;
(c) MAA pays providers on a fee-for-service basis for the medically necessary, covered medical care services not covered under the MCO's contract for GAU enrollees;
(d) Even if a service is covered by MAA on a fee-for-service basis, it is the MCO, and not MAA, from whom a GAU enrollee must obtain prior authorization before receiving the service; and
(e) A GAU enrollee may obtain emergency services in accordance with WAC 388-538-100.
(11) MAA does not pay providers on a fee-for-service basis for services covered under the MCO's contract for GAU enrollees, even if the MCO has not paid for the service, regardless of the reason. The MCO is solely responsible for payment of MCO-contracted health care services that are:
(a) Provided by an MCO-contracted provider; or
(b) Authorized by the MCO and provided by nonparticipating providers.
(12) The following services are not covered for GAU enrollees unless the MCO chooses to cover these services at no additional cost to MAA:
(a) Services that are not medically necessary;
(b) Services not included in the medical care services scope of care;
(c) Services, other than a screening exam as described in WAC 388-538-100(3), received in a hospital emergency department for nonemergency medical conditions; and
(d) Services received from a nonparticipating provider requiring prior authorization from the MCO that were not authorized by the MCO.
(13) A provider may bill a GAU enrollee for noncovered services described in subsection (12), if the requirements of WAC 388-502-0160 and 388-538-095(5) are met.
(14) The grievance and appeal process found in WAC 388-538-110 applies to GAU enrollees described in this section.
(15) The fair hearing process found in chapter 388-02 WAC and WAC 388-538-112 applies to GAU enrollees described in this section.
(a) Meets citizenship/immigrant, residency, and Social Security number requirements as described in WAC 388-503-0505; and
(b) Has CN countable income and resources that do not exceed the income and resource standards in WAC 388-478-0080; and
(c) Is sixty-five years of age or older, or meets the blind and/or disability criteria of the federal SSI program.
(2) An adult not meeting the conditions of subsection (1)(b) is eligible for CN medical coverage if the person:
(a) Is a current beneficiary of Title II of the Social Security Act (SSA) benefits who:
(i) Was a concurrent beneficiary of Title II and Supplemental Security Income (SSI) benefits;
(ii) Is ineligible for SSI benefits and/or state supplementary payments (SSP); and
(iii) Would be eligible for SSI benefits if certain cost-of-living (COLA) increases are deducted from the client's current Title II benefit amount:
(A) All Title II COLA increases under P.L. 94-566, section 503 received by the client since their termination from SSI/SSP; and
(B) All Title II COLA increases received during the time period in subsection (1)(d)(iii)(A) of this section by the client's spouse or other financially responsible family member living in the same household.
(b) Is an SSI beneficiary, no longer receiving a cash benefit due to employment, who meets the provisions of section 1619(b) of Title XVI of the SSA;
(c) Is a currently disabled client receiving widow's or widower's benefits under section 202 (e) or (f) of the SSA if the disabled client:
(i) Was entitled to a monthly insurance benefit under Title II of the SSA for December 1983; and
(ii) Was entitled to and received a widow's or widower's benefit based on a disability under section 202 (e) or (f) of the SSA for January 1984;
(iii) Became ineligible for SSI/SSP in the first month in which the increase provided under section 134 of P.L. 98-21 was paid to the client;
(iv) Has been continuously entitled to a widow's or widower's benefit under section 202 (e) or (f) of the SSA;
(v) Would be eligible for SSI/SSP benefits if the amount of that increase, and any subsequent COLA increases provided under section 215(i) of the SSA, were disregarded;
(vi) Is fifty through fifty-nine years of age; and
(vii) Filed an application for Medicaid coverage before July 1, 1988.
(d) Was receiving, as of January 1, 1991, Title II disabled widow or widower benefits under section 202 (e) or (f) of the SSA if the person:
(i) Is not eligible for the hospital insurance benefits under Medicare Part A;
(ii) Received SSI/SSP payments in the month before receiving such Title II benefits;
(iii) Became ineligible for SSI/SSP due to receipt of or increase in such Title II benefits; and
(iv) Would be eligible for SSI/SSP if the amount of such Title II benefits or increase in such Title II benefits under section 202 (e) or (f) of the SSA, and any subsequent COLA increases provided under section 215(i) of the act were disregarded.
(e) Is a disabled or blind client receiving Title II Disabled Adult Childhood (DAC) benefits under section 202(d) of the SSA if the client:
(i) Is at least eighteen years old;
(ii) Lost SSI/SSP benefits on or after July 1, 1988, due to receipt of or increase in DAC benefits; and
(iii) Would be eligible for SSI/SSP if the amount of the DAC benefits or increase under section 202(d) of the DAC and any subsequent COL increases provided under section 215(i) of the SSA were disregarded.
(f) Is a client who:
(i) In August 1972, received:
(A) Old age assistance (OAA);
(B) Aid to blind (AB);
(C) Aid to families with dependent children (AFDC); or
(D) Aid to the permanently and totally disabled (APTD); and
(ii) Was entitled to or received retirement, survivors, and disability insurance (RSDI) benefits; or
(iii) Is eligible or OAA, AB, AFDC, SSI, or APRD solely because of the twenty percent increase in Social Security benefits under P.L. 92-336.
(3) An adult who does not meet the institutional status requirement as defined in WAC 388-513-1320 and who does not receive waiver services as described in chapter 388-515 WAC is considered for medically needy (MN) coverage under this chapter. Persons excluded from this section have rules applied to eligibility from chapter 388-513 WAC. Under this section a person is eligible for MN coverage when the person:
(a) Meets citizenship/immigrant, residency, and Social Security number requirements as described in WAC 388-503-0505; and
(b) Has MN countable income that does not exceed the income standards in WAC 388-478-0070, or meets the excess income spenddown requirements in WAC 388-519-0110; and
(c) Meets the countable resource standards in WAC 388-478-0070; and
(d) Is sixty-five years of age or older or meets the blind and/or disability criteria of the federal SSI program.
(4) MN coverage is available for an aged, blind, or disabled ineligible spouse of an SSI recipient. See WAC 388-519-0100 for additional information.
(5) An adult may be eligible for the alien emergency medical program as described in WAC 388-438-0110.
(6) An adult is eligible for the state-funded general assistance - expedited Medicaid disability (GA-X) program when they:
(a) Meet the requirements of the cash program in WAC 388-400-0025 and 388-478-0030; or
(b) Meet the SSI-related disability standards but cannot get the SSI cash grant due to immigration status or sponsor deeming issues.
Clients may be eligible for GA cash benefits and CN medical coverage due to different sponsor deeming requirements.
(7) An adult is eligible for the state-funded medical
care services (MCS) program when the person is eligible for
GAU or ADATSA program coverage as described in WAC
(8) An adult is eligible for the state-funded medical indigent (MI) program when the person meets the requirements listed in WAC 388-438-0100)) 388-400-0025 and 388-800-0048. GAU clients residing in counties designated as mandatory managed care plan counties must enroll in a plan, pursuant to WAC 388-538-063.
[Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057 and 74.08.090. 98-16-044, § 388-505-0110, filed 7/31/98, effective 9/1/98. Formerly WAC 388-503-0350 and 388-503-0370.]
Reviser's note: The typographical errors in 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.