WSR 97-03-038

PERMANENT RULES

DEPARTMENT OF

SOCIAL AND HEALTH SERVICES

(Public Assistance)

[Filed January 9, 1997, 1:13 p.m.]

Purpose: Include clients enrolled in managed care in the PRR program to control overutilization and protect the clients' health and safety.

Citation of Existing Rules Affected by this Order: Amending WAC 388-501-0135 Patients requiring regulation (PRR).

Statutory Authority for Adoption: RCW 74.08.090.

Other Authority: RCW 74.09.522.

Adopted under notice filed as WSR 96-24-076 on December 2, 1996.

Number of Sections Adopted in Order to Comply with Federal Statute: New 0, amended 0, repealed 0; Federal Rules or Standards: New 0, amended 0, repealed 0; or Recently Enacted State Statutes: New 0, amended 0, repealed 0.

Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, amended 0, repealed 0.

Number of Sections Adopted on the Agency's own Initiative: New 0, amended 1, repealed 0.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, amended 0, repealed 0.

Number of Sections Adopted using Negotiated Rule Making: New 0, amended 0, repealed 0; Pilot Rule Making: New 0, amended 0, repealed 0; or Other Alternative Rule Making: New 0, amended 1, repealed 0.

Effective Date of Rule: Thirty-one days after filing.

January 9, 1997

Merry A. Kogut, Manager

Rules and Policies Assistance Unit

AMENDATORY SECTION (Amending Order 3732, filed 5/3/94, effective 6/3/94)

WAC 388-501-0135 Patient requiring regulation. (1) The department shall operate a patient requiring regulation (PRR) program to identify a client overutilizing, unnecessarily, or inappropriately obtaining medical care under the federally funded and state-funded medical programs. The department may restrict such a client to a single primary care provider and pharmacy for medical care.

(2) The purpose of the PRR program shall be to:

(a) Protect the client's health and safety;

(b) Provide continuity of medical care;

(c) Avoid duplication of services by providers;

(d) Avoid excessive, contraindicated, or potentially harmful use of prescription medications.

(3) For the purposes of this section, "primary care provider (PCP)" means a provider who has responsibility for supervising, coordinating and providing initial and primary care to clients, initiating referrals for specialist care, and maintaining the continuity of patient care. A PCP shall be either:

(a) A physician ((specializing in internal or general medicine)) who meets the criteria under WAC 388-87-007; ((or))

(b) ((Physician or)) An advanced registered nurse practitioner ((specializing in adult health care or family practice who agrees to provide, manage, and coordinate an eligible client's medical care)) (ARNP) who meets the criteria under WAC 388-87-007; or

(c) A licensed physician assistant, practicing with a sponsoring or supervising physician.

(4) For a client not enrolled in a department-contracted managed care plan, the department shall designate staff to determine the client's overuse, inappropriate, or unnecessary usage of medical care by reviewing medical assistance administration (MAA) payment records and other medical information.

(5) For a client enrolled in a department-contracted managed care plan, the department shall designate staff to evaluate the medical records and other documents provided by the client's managed care plan to determine the client's inappropriate or unnecessary use of medical care.

(6) When a client has been enrolled in more than one managed care plan during the review period, the department shall obtain and evaluate the client's medical records and other documents from all department-contracted managed care plan(s) in which the client is or has been enrolled during the review period.

(7) The department shall use medical review guidelines established by nurse advisors, physicians ((and)), pharmacy consultants, ((and the drug utilization and education (DUE) council shall establish the medical review guidelines)) and other reference sources ((that the department uses for such determinations)).

(((6))) (8) The department ((established)) shall consider the following levels of utilization during a ((three-month)) period of three consecutive months or less as medical review guidelines for the PRR program:

(a) Repeated and documented efforts by the client to seek medically unnecessary health services, including but not limited to prescription medication, after having been counseled at least once by a health care provider or managed care plan representative concerning appropriate utilization of health care services;

(b) Services from four different physicians;

(((b))) (c) Prescriptions from four different pharmacies;

(((c))) (d) Ten prescriptions received;

(((d))) (e) Two emergency room visits; or

(((e))) (f) Four prescribers.

(((7) Medical assistance administration)) (9) The department shall notify the client in writing that the client is assigned to PRR, when the ((information)) medical review indicates the client overuses medical services, or uses medical services inappropriately or unnecessarily as determined by the department's review of the client's:

(a) Medical records and other documents which indicate ((a)) the client's use of medical services meets the criteria in subsection (8)(a) of this section or meets or exceeds three of the five guidelines under ((subsection (6))) subsections (8)(b) through (f) of this section; and

(b) ((Client's)) Diagnoses, the history of services provided or other medical information supplied by the health care provider or managed care plan.

(((8))) (10) The department shall notify the client of the right to:

(a) A fair hearing as required under chapter 388-08 WAC; and

(b) Continue ((not restricted)) as unrestricted when a fair hearing is requested in a timely ((requested)) manner.

(((9))) (11) A client shall respond to the department's notice within twenty calendar days by:

(a) Writing or calling the PRR representative identified in the notice;

(b) Requesting a fair hearing;

(c) Selecting a PCP and pharmacy. For a client enrolled with a department-contracted managed care plan, the client must select a PCP and pharmacy from those identified as available within their managed care plan;

(((b))) (d) Requesting assistance in selecting a PCP and pharmacy; or

(((c))) (e) Submitting additional medical information.

(((10))) (12) The department shall assign a PCP and pharmacy for any client who fails to select a PCP and pharmacy within twenty calendar days, unless the client requests a fair hearing. The selected or assigned PCP and pharmacy shall be:

(a) Located in the client's local geographic area; or ((be))

(b) Reasonably accessible to the client.

(((11))) (13) The client shall not change ((a selected)) PCP or pharmacy for ((six)) twelve months except when the:

(a) Client moves to a new residence outside the designated geographic area of the providers;

(b) PCP or pharmacy moves from the client's geographical area;

(c) PCP or pharmacy refuses to continue as the designated provider; ((or))

(d) A client ((selects a)) may change, once within the initial sixty days, the PCP ((or)) and pharmacy ((other than the department-))assigned ((PCP or pharmacy)) by the department under subsection (((9))) (12) of this section. For a client enrolled with a department-contracted managed care plan, the client must select a PCP and pharmacy from those identified as available within their managed care plan;

(e) PCP or pharmacy no longer participates in a department-contracted managed care plan;

(f) PCP is no longer contracted with the client's managed care plan. The client shall have the option of:

(i) Selecting a new PCP from the list of available PCPs provided by the plan; or

(ii) Transferring enrollment of all family members to the new department-contracted plan which the established PCP has joined.

(g) Client chooses a new plan during an open enrollment period which occurs in the twenty-four-month restriction period.

(((12))) (14) For a client enrolled in the PRR program, the department shall:

(a) Assign a client to the program for a period of twenty-four months ((and shall));

(b) Review the client's utilization at the end of the twenty-four-month period((.));

(c) Continue the client ((shall remain restricted if)) in the PRR program when the client continues to meet the criterion in subsection (8)(a) of this section or meet or exceed three of the ((overutilization)) five criteria in subsection (((6))) (8)(b) through (f) of this section; ((and shall be))

(d) Review((ed)) continuation of the client in the PRR program at least ((twenty-four)) every twelve months thereafter; and

(e) Allow the client the opportunity to change PCP or pharmacy after twelve months; except as allowed under subsection (13)(d) of this subsection.

(((13))) (15) When the department designates a PCP and pharmacy for the client, the department shall issue a medical identification card identifying the client as a patient requiring regulation.

(((14))) (16) When an emergency occurs as defined under WAC 388-500-0005, a provider other than the selected PCP may see the client.

(((15))) (17) The PCP may refer the client to a specialist.

(((16))) (18) For a client not enrolled in a department-contracted managed care plan, the department shall only pay for MAA-covered services authorized by the PCP, referred specialist, ((or)) selected pharmacy((. The department shall apply billing limitations as described under WAC 388-87-010 and 388-87-015)), and those services specified in subsections (16) and (20) of this section.

(((17))) (19) The client shall be responsible for payment of covered services not authorized by the PCP, referred specialists or selected pharmacist with the exception of services described under subsections (16) and (20) of this section.

(20) A client assigned to the PRR program may self-refer for family planning services.

(21) A client may self-refer to women's health care services. For a client enrolled with a department-contracted plan, the client must self-refer within the plan network.

[Statutory Authority: RCW 74.08.090. 94-10-065 (Order 3732), 388-501-0135, filed 5/3/94, effective 6/3/94.]

Reviser's note: The typographical error in the above section occurred in the copy filed by the agency and appears in the Register pursuant to the requirements of RCW 34.08.040.

Legislature Code Reviser

Register

Washington State Code Reviser's Office