Date of Adoption: December 10, 2001.

     Purpose: The department is adopting rules to reflect program changes in MAA's managed care programs. Rules regarding exemptions and disenrollments have been clarified and the CHIP program has been made more consistent and compatible with the healthy options program. Primary care case management has been expanded to allow greater access to managed care for MAA's clients.

     Citation of Existing Rules Affected by this Order: Repealing WAC 388-538-066 Children's health insurance program (CHIP) enrollees; amending WAC 388-538-050 Definitions, 388-538-060 Managed care and choice, 388-538-065 Medicaid eligible basic health plan enrollees, 388-538-070 Managed care payment, 388-538-080 Healthy options exemptions, 388-538-095 Scope of care for managed care enrollees, 388-538-100 Managed care emergency services, 388-538-110 Managed care complaints, appeals and fair hearings, 388-538-120 Enrollee request for a second medical opinion, 388-538-130 Ending enrollment in healthy options, 388-538-140 Quality of care, 388-542-0050 Definitions for children's health insurance program (CHIP) terms, 388-542-0100 CHIP scope of care, 388-542-0125 Access to care, 388-540-0150 Client eligibility requirements for CHIP, 388-542-0200 CHIP managed care enrollment, 388-542-0250 CHIP client costs, 388-542-0275 Reimbursement, 388-542-0300 Waiting period for CHIP coverage following employer coverage and 388-542-0500 Managed care rules that apply to CHIP; and New WAC 388-538-067 Managed care provided through managed care organizations (MCOs), 388-538-068 Managed care provided through primary care case management (PCCM), and 388-542-0220 Ending CHIP client eligibility.

     Statutory Authority for Adoption: RCW 74.09.080.

     Other Authority: RCW 74.08.510, [74.08.]522, 74.09.450, 1115 Waiver, 42 U.S.C. 1396.

      Adopted under notice filed as WSR 01-20-113 on October 3, 2001.

     Changes Other than Editing from Proposed to Adopted Version: As a result of testimony received, the following changes have been made to the text of the proposed rule (added language is underlined; deleted language is struck-through):

     WAC 388-538-068(1) A provider may contract with DSHS as a primary care case management (PCCM) provider to provide health care services to eligible medical assistance administration (MAA) clients under MAA's managed care program. The PCCM provider or the individual providers in a PCCM group or clinic must:...

     WAC 388-542-0220 (3)(b) Serve a waiting period of four consecutive months as described in WAC 388-542-0300. The waiting period begins the day after termination of CHIP coverage for nonpayment of premiums as described in this section. The waiting period ends once four full consecutive months of CHIP noncoverage has elapsed. The client does not have CHIP coverage during the waiting period.

     WAC 388-542-0300 (1)(b) Fails to exercise an optional coverage extension (e.g., COBRA) that meets the following conditions. The waiting period begins on the day there is a documented refusal of the coverage extension when the extended coverage is:

     (i) (a) Subsidized in part or in whole by the employer or union;

     (ii) (b) Available and accessible to the applicant or family; and

     (iii) (c) At a monthly cost to the family meeting the limitations of subsection (32)(b)(iv).

     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 1, Amended 0, Repealed 0.

     Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 3, Amended 20, Repealed 1.

     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 3, Amended 20, Repealed 1.
     Effective Date of Rule: Thirty-one days after filing.

December 10, 2001

Brian H. Lindgren, Manager

Rules and Policies Assistance Unit

     "Ancillary health services" means health services ordered by a provider, including but not limited to, laboratory services, radiology services, and physical therapy.

     "Appeal" means a formal request by a provider or covered enrollee for reconsideration of a decision such as a utilization review recommendation, a benefit payment, an administrative action, or a quality of care or service issue, with the goal of finding a mutually acceptable solution.

     "Assign" or "assignment" means that MAA selects a managed care organization (MCO) or primary care case management (PCCM) provider to serve a client who lives in a mandatory enrollment area and who has failed to select an MCO or PCCM provider.

     "Basic health ((plan)) (BH((P)))" means the health care program authorized by title 70.47 RCW and administered by the health care authority (HCA). MAA considers basic health to be third-party coverage, however, this does not include basic health plus (BH+).

     "Children's health insurance program (CHIP)" means the health insurance program authorized by Title XXI of the Social Security Act and administered by the ((medical assistance administration (MAA))) department of social and health services (DSHS). This program also is referred to as the state children's health insurance program (SCHIP).

     "Children with special health care needs" means children identified by the department of social and health services (DSHS) as having special health care needs. This includes:

     (1) Children designated as having special health care needs by the department of health (DOH) and served under the Title V program;

     (2) Children who meet disability criteria of Title 16 of the Social Security Act (SSA); and

     (3) Children who are in foster care or who are served under subsidized adoption.

     "Client" means an individual eligible for any medical program who is not enrolled with a managed care ((plan)) organization (MCO) or primary care case management (PCCM) provider. In this chapter, client refers to a person before the person is enrolled in managed care, while enrollee refers to an individual eligible for any medical program who is enrolled in managed care.

     "Complaint" means an oral or written expression of dissatisfaction by an enrollee.

     "Emergency medical condition" means a condition meeting the definition in 42 U.S.C. 1396u-2 (b)(2)(C).

     "Emergency services" means services as defined in 42 U.S.C. 1396u-2 (b)(2)(B).

     "End enrollment" means an enrollee is currently enrolled in ((healthy options (HO))) managed care, either with a managed care organization (MCO) or with a primary care case management (PCCM) provider, and requests to discontinue enrollment and return to the fee-for-service delivery system for one of the reasons outlined in WAC 388-538-130. This is also referred to as "disenrollment."

     "Enrollee" means an individual eligible for any medical program who is enrolled in managed care through a ((health)) managed care ((plan)) organization (MCO) or primary care case management (PCCM) provider that has a contract with the state.

     "Enrollees with chronic conditions" means persons having chronic and disabling conditions, including persons with special health care needs that meet all of the following conditions:

     (1) Have a biologic, psychologic, or cognitive basis;

     (2) Have lasted or are virtually certain to last for at least one year; and

     (3) Produce one or more of the following conditions stemming from a disease:

     (a) Significant limitation in areas of physical, cognitive, or emotional function;

     (b) Dependency on medical or assistive devices to minimize limitation of function or activities; or

     (c) In addition, for children, any of the following:

     (i) Significant limitation in social growth or developmental function;

     (ii) Need for psychologic, educational, medical, or related services over and above the usual for the child's age; or

     (iii) Special ongoing treatments, such as medications, special diet, interventions, or accommodations at home or school.

     "Exemption" means a client ((is)), not currently enrolled in ((HO and)) managed care, makes a pre-enrollment request to remain in the fee-for-service delivery system for one of the reasons outlined in WAC 388-538-080.

     (("Health care plan" or "plan" means an organization contracted with the department of social and health services (DSHS) to provide managed care to MAA clients.))

     "Health care service" or "service" ((or item)) means a service or item provided for the prevention, cure, or treatment of an illness, injury, disease, or condition.

     "Healthy options contract or HO contract" means the agreement between the department of social and health services (DSHS) and a ((health)) managed care ((plan)) organization (MCO) to provide ((the)) prepaid contracted services to enrollees.

     "Healthy options program or HO program" means the medical assistance administration's (MAA) prepaid managed care health program for Medicaid-eligible clients and CHIP clients.

     "Managed care" means a ((prepaid)) comprehensive system of medical and health care delivery including preventive, primary, specialty, and ancillary health services. These services are provided either through a managed care organization (MCO) or primary care case management (PCCM) provider.

     "Managed care organization" or "MCO" means a health maintenance organization or health care service contractor that contracts with the department of social and health services (DSHS) under a comprehensive risk contract to provide prepaid health care services to eligible medical assistance administration (MAA) clients under MAA's managed care programs.

     "Nonparticipating provider" means a person or entity that does not have a written agreement with a managed care organization (MCO) but that provides MCO-contracted health care services to managed care enrollees with the authorization of the MCO. The MCO is solely responsible for payment for MCO-contracted health care services that are authorized by the MCO and provided by nonparticipating providers.

     "Participating provider" means a person or entity with a written agreement with a ((plan)) managed care organization (MCO) to provide health care services to managed care enrollees. A participating provider must look solely to the MCO for payment for such services.

     "Primary care case management (PCCM)" means the health care management activities of a provider that contracts with the department to provide primary health care services and to arrange and coordinate other preventive, specialty, and ancillary health services.

     "Primary care provider (PCP)" means a person licensed or certified under Title 18 RCW including, but not limited to, a physician, ((and)) an advanced registered nurse practitioner (ARNP), or a physician assistant who supervises, coordinates, and provides health services to a client or an enrollee, initiates referrals for specialist and ancillary care, and maintains the client's or enrollee's continuity of care.

     "Prior authorization (PA)" means a process by which enrollees or providers must request and receive MAA approval for certain medical services, equipment, drugs, and supplies, based on medical necessity, before the services are provided to clients, as a precondition for provider reimbursement. Expedited prior authorization and limitation extension are forms of prior authorization. See WAC 388-501-0165.

     "Timely" - in relation to the provision of services, means an enrollee has the right to receive medically necessary health care without unreasonable delay.

[Statutory Authority: RCW 74.08.090, 74.09.510 and [74.09.]522 and 1115 Federal Waiver, 42 U.S.C. 1396 (a), (e), (p), 42 U.S.C. 1396r-6(b), 42 U.S.C. 1396u-2. 00-04-080, § 388-538-050, filed 2/1/00, effective 3/3/00. Statutory Authority: RCW 74.08.090 and 1995 2nd sp.s. c 18. 95-18-046 (Order 3886), § 388-538-050, filed 8/29/95, effective 9/1/95. Statutory Authority: RCW 74.08.090. 93-17-039 (Order 3621), § 388-538-050, filed 8/11/93, effective 9/11/93.]

     Reviser's note: RCW 34.05.395 requires the use of underlining and deletion marks to indicate amendments to existing rules. The rule published above varies from its predecessor in certain respects not indicated by the use of these markings.
AMENDATORY SECTION(Amending WSR 00-04-080, filed 2/1/00, effective 3/3/00)

WAC 388-538-060   ((Healthy options)) Managed care and choice.   (1) A client is required to enroll in ((HO)) managed care when that client meets all of the following conditions:

     (a) Is eligible for one of the medical programs for which clients must enroll in ((HO as described in the HO contract)) managed care;

     (b) Resides in an area, determined by the medical assistance administration (MAA), where clients must enroll in ((HO)) managed care;

     (c) Is not exempt from ((HO)) managed care enrollment as determined by MAA, consistent with WAC 388-538-080, and any related fair hearing has been held and decided; and

     (d) Has not had ((HO)) managed care enrollment ended by MAA, consistent with WAC 388-538-130.

     (2) American Indian/Alaska Native (AI/AN) clients who meet the provisions of 25 U.S.C. 1603 (c)-(d) for federally-recognized tribal members and their descendants((,)) may choose one of the following:

     (a) ((Enroll)) Enrollment with ((an HO plan)) a managed care organization (MCO) available in their area;

     (b) ((Enroll)) Enrollment with an ((HO)) Indian or tribal primary care case management (PCCM) provider available in their area; or

     (c) MAA's fee-for-service ((program)) system.

     (3) A client may enroll with ((a plan)) an MCO or PCCM provider by calling MAA's toll-free enrollment line((,)) or by sending a completed ((HO)) enrollment form to MAA.

     (a) Except as provided in subsection (2) of this section for clients who are AI/AN and in subsection (5) of this section for cross-county enrollment, a client required to enroll in ((HO)) managed care must enroll with ((a plan)) an MCO or PCCM provider available in the area where the client lives.

     (b) All family members must either enroll with the same ((plan)) MCO or enroll with PCCM providers.

     (c) Enrollees may request ((a plan)) an MCO or PCCM provider change at any time.

     (d) When a client requests enrollment with ((a plan)) an MCO or PCCM provider, MAA enrolls a client effective the earliest possible date given the requirements of MAA's enrollment system. MAA does not enroll clients retrospectively.

     (4) MAA assigns a client who does not choose ((a plan)) an MCO or PCCM provider as follows:

     (a) If the client has family members enrolled with ((a plan)) an MCO, the client is enrolled with that ((plan)) MCO;

     (b) If the client does not have family members enrolled with ((a plan)) an MCO, and the client was enrolled in the last six months with ((a plan)) an MCO or PCCM provider, the client is re-enrolled with the same ((plan)) MCO or PCCM provider;

     (c) If a client does not choose ((a plan)) an MCO or a PCCM provider, but ((chooses)) indicates a preference for a provider to serve as the client's primary case provider (PCP), MAA attempts to contact the client ((by phone to obtain the client's plan or PCCM provider)) to complete the required choice. If MAA is not able to contact the client in a timely manner, MAA ((attempts to determine whether the client's chosen provider is with a plan, and, if so,)) documents the attempted contacts and, using the best information available, assigns the client ((to that plan;)) as follows. If the client's preferred PCP is:

     (i) Available with one MCO, MAA assigns the client in the MCO where the client's PCP provider is available. The MCO is responsible for PCP choice and assignment;

     (ii) Available only as a PCCM provider, MAA assigns the client to the preferred provider as the client's PCCM provider;

     (iii) Available with multiple MCOs or through an MCO and as a PCCM provider, MAA assigns the client to an MCO as described in (d) of this subsection;

     (iv) Not available through any MCO or as a PCCM provider, MAA assigns the client to an MCO or PCCM provider as described in (d) of this subsection.

     (d) If the client cannot be assigned according to (a), (b), or (c) of this subsection, MAA assigns the client as follows:

     (i) If an AI/AN client does not choose ((a plan)) an MCO or PCCM provider, MAA assigns the client to a tribal PCCM provider if that client lives in a zip code served by a tribal PCCM provider. If there is no tribal PCCM provider in the client's area, the client ((will remain)) continues to be served by MAA's fee-for-service system. A client assigned under this subsection may request to end enrollment ((according to WAC 388-538-130 (2)(b))) at any time.

     (ii) If a non-AI/AN client does not choose ((a plan)) an MCO or PCCM provider, MAA assigns ((a plan)) the client to an MCO or PCCM provider available in the area where the client lives. ((A plan must have at least one PCP available within twenty-five miles of the zip code in which the client lies for the plan to be considered available)) The MCO is responsible for PCP choice and assignment. An MCO must meet the healthy options (HO) contract's access standards unless the MCO has been granted an exemption by MAA. The HO contract standards are as follows:

     (A) There must be two PCPs within ten miles for ninety percent of HO enrollees in urban areas and one PCP within twenty-five miles for ninety percent of HO enrollees in rural areas;

     (B) There must be two obstetrical providers within ten miles for ninety percent of HO enrollees in urban areas and one obstetrical provider within twenty-five miles for ninety percent of HO enrollees in rural areas;

     (C) There must be one hospital within twenty-five miles for ninety percent of HO enrollees in the contractor's service area;

     (D) There must be one pharmacy within ten miles for ninety percent of HO enrolles in urban areas and one pharmacy within twenty-five miles for ninety percent of HO enrollees in rural areas.

     (iii) MAA sends a written notice to each household of one or more clients who are assigned to ((a plan)) an MCO or PCCM provider. The notice includes the name of the ((plan)) MCO or PCCM provider to which each client has been assigned, ((toll-free contact phone numbers for the plan or PCCM provider and MAA,)) the effective date of enrollment, ((and)) the date by which the client must respond in order to change ((plan)) MAA's assignment, and either the toll-free telephone number of:

     (A) The MCO for enrollees assigned to an MCO; or

     (B) MAA for enrollees assigned to a PCCM provider.

     (iv) An assigned client has at least thirty calendar days to contact MAA to change the ((plan)) MCO or PCCM provider assignment before enrollment is effective.

     (5) A client may enroll with a plan in an adjacent county when the client lives in an area, designated by MAA, where residents historically have traveled a relatively short distance across county lines to the nearest available practitioner.

     (6) ((PCP choice)) An MCO enrollee's selection of the enrollee's PCP or the enrollee's assignment to a PCP occurs as follows:

     (a) MCO enrollees may choose:

     (i) A PCP or clinic that is in ((their plan)) the enrollee's MCO and accepting new enrollees; or

     (ii) Different PCPs or clinics participating with the same ((plan)) MCO for different family members.

     (b) The ((plan)) MCO assigns a PCP or clinic ((within reasonable proximity to the enrollee's home)) that meets the access standards set forth in subsection (4)(d)(ii) of this section if the enrollee does not choose ((one)) a PCP or clinic;

     (c) MCO enrollees may change PCPs or clinics in ((a plan)) an MCO at least once a year for any reason, and at any time for good cause; or

     (d) In accordance with this subsection, MCO enrollees may file an appeal with the ((plan)) MCO and/or a fair hearing request with the department of social and health services (DSHS) and may change plans if the ((plan)) MCO denies an enrollee's request to change PCPs or clinics.

[Statutory Authority: RCW 74.08.090, 74.09.510 and [74.09.]522 and 1115 Federal Waiver, 42 U.S.C. 1396 (a), (e), (p), 42 U.S.C. 1396r-6(b), 42 U.S.C. 1396u-2. 00-04-080, § 388-538-060, filed 2/1/00, effective 3/3/00. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057 and 74.08.090. 98-16-044, § 388-538-060, filed 7/31/98, effective 9/1/98. Statutory Authority: RCW 74.08.090 and 1995 2nd sp.s. c 18. 95-18-046 (Order 3886), § 388-538-060, filed 8/29/95, effective 9/1/95. Statutory Authority: RCW 74.08.090. 93-17-039 (Order 3621), § 388-538-060, filed 8/11/93, effective 9/11/93.]

     (2) The administrative rules and regulations that apply to ((HO)) managed care enrollees also apply to Medicaid-eligible clients enrolled through BH((P)), except as follows:

     (a) The process for enrolling in ((HO)) managed care described in WAC 388-538-060(3) does not apply since enrollment is through the health care authority, the state agency that administers BH((P));

     (b) American Indian/Alaska Native (AI/AN) clients cannot choose fee-for-service or PCCM as described in WAC 388-538-060(2). They must enroll in a BH((P health care plan))-contracted MCO.

     (c) If a Medicaid eligible client applying for BH((P)) does not choose ((a plan)) an MCO within ninety days, the client is transferred from ((BHP to HO and is assigned as described in WAC 388-538-060(4))) BH to the department of social and health services (DSHS) for assignment to managed care.

[Statutory Authority: RCW 74.08.090, 74.09.510 and [74.09.]522 and 1115 Federal Waiver, 42 U.S.C. 1396 (a), (e), (p), 42 U.S.C. 1396r-6(b), 42 U.S.C. 1396u-2. 00-04-080, § 388-538-065, filed 2/1/00, effective 3/3/00.]

     (a) Have a certificate of registration from the office of the insurance commissioner (OIC) as either a health maintenance organization (HMO) or a health care services contractor (HCSC).

     (b) Accept the terms and conditions of DSHS' HO contract;

     (c) Be able to meet the network and quality standards established by DSHS; and

     (d) Accept the prepaid rates published by DSHS.

     (2) DSHS reserves the right not to contract with any otherwise qualified MCO.

[]

     (a) Have a core provider agreement with DSHS;

     (b) Hold a current license to practice as a physician, certified nurse midwife, or advanced registered nurse practitioner in the state of Washington;

     (c) Accept the terms and conditions of DSHS' PCCM contract;

     (d) Be able to meet the quality standards established by DSHS; and

     (e) Accept PCCM rates published by DSHS.

     (2) DSHS reserves the right not to contract for PCCM with an otherwise qualified provider.

[]

     (b) Are paid based on legislative allocations for the HO program.

     (2) MAA pays primary care case management (PCCM) providers a monthly case management fee according to contracted terms and conditions.

     (3) MAA does not pay providers on a fee-for-service basis for services that are the ((plan's)) MCO's responsibility under the HO contract, even if the ((plan)) MCO has not paid for the service for any reason. The MCO is solely responsible for payment of MCO-contracted health care services:

     (a) Provided by an MCO-contracted provider; or

     (b) That are authorized by the MCO and provided by nonparticipating providers.

     (4) MAA pays an additional monthly amount, known as an enhancement rate, to federally qualified health care centers (FQHC) and rural health clinics (RHC) for each client enrolled with ((plans)) MCOs through the FQHC or RHC. ((Plans)) MCOs may contract with FQHCs and RHCs to provide services under HO. FQHCs and RHCs receive an enhancement rate from MAA on a per member, per month basis in addition to the negotiated payments they receive from the ((plans)) MCOs for services provided to MCO enrollees.

     (a) MAA pays the enhancement rate only for the categories of service provided by the FQHC or RHC under the HO contact. MAA surveys each FQHC or RHC in order to identify the categories of services provided by the FQHC or RHC.

     (b) MAA bases the enhancement rate on both of the following:

     (i) The upper payment limit (UPL) for the county in which the FQHC or RHC is located; and

     (ii) An enhancement percentage.

     (c) MAA determines the UPL for each category of service based on MAA's historical fee-for-service (FFS) experience, adjusted for inflation and utilization changes.

     (d) MAA determines the enhancement percentage for HO enrollees as follows:

     (i) For FQHCs, the enhancement percentage is equal to the FQHC finalized audit period ratio. The "finalized audit period" is the latest reporting period for which the FQHC has a completed audit approved by, and settled with, MAA.

     (A) For a clinic with one finalized audit period, the ratio is equal to:

     (FQHC total costs) - (((Fee-for-service)) FFS reimbursements + HO reimbursements)/(FFS + HO reimbursements).

     (B) For a clinic with two finalized audit periods, the ratio is equal to the percentage change in the medical services encounter rate from one finalized audit period to the next. A "medical services encounter" is a face-to-face encounter between a physician or mid-level practitioner and a client to provide services for prevention, diagnosis, and/or treatment of illness or injury. A "medical services encounter rate" is the individualized rate MAA pays each FQHC to provide such services to clients, or the rate set by Medicare for each RHC for such services.

     (C) For FQHCs without a finalized audit, the enhancement percentage is the statewide weighted average of all the FQHCs' finalized audit period ratios. Weighting is based on the number of enrollees served by each FQHC.

     (ii) For RHCs, MAA applies the same enhancement percentage statewide.

     (A) On a given month, MAA determines the number of HO enrollees enrolled with each RHC that is located in the same county as an FQHC. This number is expressed as a percentage of the total number of RHC enrollees located in counties that have both FQHCs and RHCs.

     (B) For each county that has both an FQHC and an RHC, MAA multiplies the FQHC enhancement percentage, as determined under subsection (4)(d)(i) of this section, ((the)) by the percentage obtained in section (4)(d)(ii)(A) of this section.

     (C) The sum of all these products is the weighted statewide RHC enhancement percentage.

     (iii) The HO enhancement percentage for FQHCs and RHCs is updated once a year.

     (e) For each category of service provided by the FQHC or RHC, MAA multiplies the UPL, as determined under subsection (4)(c) of this section, by the FQHC's or RHC's enhancement percentage. The sum of all these products is the enhancement rate for the individual FQHC or RHC.

     (f) To calculate the enhancement rate for FQHCs and RHCs that provide maternity and newborn delivery services, MAA applies each FQHC's or RHC's enhancement percentage to the delivery case rate (DCR), which is a one-time rate paid by MAA to the HO plan for each pregnant enrollee who gives birth.

[Statutory Authority: RCW 74.08.090, 74.09.510 and [74.09.]522 and 1115 Federal Waiver, 42 U.S.C. 1396 (a), (e), (p), 42 U.S.C. 1396r-6(b), 42 U.S.C. 1396u-2. 00-04-080, § 388-538-070, filed 2/1/00, effective 3/3/00. Statutory Authority: RCW 74.08.090. 96-24-073, § 388-538-070, filed 12/2/96, effective ˝/97. Statutory Authority: RCW 74.08.090 and 1995 2nd sp.s. c 18. 95-18-046 (Order 3886), § 388-538-070, filed 8/29/95 effective 9/1/95. Statutory Authority: RCW 74.08.090. 93-17-039 (Order 3621), § 388-538-070, filed 8/11/93, effective 9/11/93.]

     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.
AMENDATORY SECTION(Amending WSR 00-04-080, filed 2/1/00, effective 3/3/00)

WAC 388-538-080   ((Healthy options)) Managed care exemptions.   (1) The medical assistance administration (MAA) exempts a client from mandatory enrollment in managed care if MAA becomes aware of the following conditions. The client:

     (a) Is receiving foster care placement services from the division of children and family services (DCFS); or

     (b) Has Medicare, basic health (BH), CHAMPUS/TRICARE, or other accessible third-party health care coverage that would require exemption from enrollment with:

     (i) A managed care organization (MCO) in accordance with MAA's healthy options (HO) contract requirements for MCO enrollment; or

     (ii) A primary care case management provider (PCCM) in accordance with MAA's PCCM contract requirements for PCCM enrollment.

     (2) Only a client or a client's representative (RCW 7.70.065) may request an exemption from ((HO)) managed care enrollment for reasons other than those stated in subsection (1) of this section. If a client asks for an exemption prior to the enrollment effective date, the client is not enrolled until MAA approves or denies the request and any related fair hearing is held and decided.

     (((2))) (3) MAA ((exempts a client)) grants a client's request for an exemption from mandatory enrollment in ((a plan or with a PCCM provider)) managed care if any of the following apply:

     (a) ((Based on MAA's evaluation of objective medical evidence, all of the following are met:

     (i))) The client has ((multiple, complex, or severe medical diagnoses)) a documented and verifiable medical need to continue a client/provider relationship due to an established course of care with a physician, physician assistant or advanced registered nurse practitioner. MAA accepts the established provider's signed statement that the client has:

     (i) A medical need that requires a continuation of the established care relationship; and

     (ii) The client's established provider is not available through any managed care ((plan;

     (iii) There is a written treatment plan;

     (iv) The treatment plan requires frequent change or monitoring; and

     (v) Disruption of client's care would be harmful; or)) organization (MCO) or as a primary care case management (PCCM) provider.

     (b) Prior to enrollment, the client scheduled a surgery with a provider not available to the client ((in a plan)) through managed care and the surgery is scheduled within the first thirty days of enrollment; or

     (c) The client is American Indian/Alaska Native (AI/AN) as specified in WAC 388-538-060(2) and requests exemption; or

     (d) ((The client has private insurance under a managed care arrangement; or

     (e) The client has BHP; or

     (f) The client has CHAMPUS; or

     (g) The client requests enrollment in the same plan with which the client has private insurance under any arrangement; or

     (h))) The client has been identified by MAA as having special needs that meet MAA's definition of children with special health care needs and requests exemption; or

     (e) The client is pregnant and wishes to continue her established course of prenatal care with an obstetrical provider who is not available to her through managed care; or

     (f) On a case-by-case basis, the client presents evidence that ((the HO program)) managed care does not provide medically necessary care that is reasonably available and accessible as offered to the client. MAA considers that medically necessary care is not reasonably available and accessible when any of the following apply:

     (i) The client is homeless or is expected to live in temporary housing for less than one hundred twenty days from the date the client requests the exemption;

     (ii) The client ((is)) speaks limited English ((speaking)) or is hearing impaired and the client can communicate with a provider who communicates in the client's language or in American Sign Language and is not ((in an HO plan;

     (iii) The client is pregnant and wishes to continue her established course of prenatal care with an obstetrical provider who is not available to her through a plan;

     (iv))) available through managed care;

     (iii) The client shows that travel to ((an HO PCP)) a managed care PCP is unreasonable when compared to travel to a non-((HO)) managed care primary care provider (PCP). This is shown when any of the following transportation situations apply to the client:

     (A) It is over twenty-five miles one-way to the nearest ((HO))managed care PCP who is accepting enrollees, and the ((current)) client's PCP is closer and not in an available plan;

     (B) The travel time is over forty-five minutes one-way to the nearest ((HO)) managed care PCP who is accepting enrollees, and the travel time to the ((current)) client's PCP, who is not ((in an)) available ((plan)) in an MCO or as a PCCM provider, is less;

     (C) Other transportation difficulties make it unreasonable to get primary medical services under HO; or

     (((v))) (iv) Other evidence is presented that an exemption is appropriate based on the client's circumstances, as evaluated by MAA.

     (((3))) (4) MAA exempts the client for the time period the circumstances or conditions that led to the exemption are expected to exist. If the request is approved for a limited time, the client is notified in writing or by telephone of the time limitation, the process for renewing the exemption, and ((their)) the client's fair hearing rights.

     (((4))) (5) The client is not enrolled as provided in subsection (((1))) (2) of this section and receives timely notice by telephone or in writing when MAA approves or denies the client's exemption request. If initial denial notice was by telephone, then MAA gives the reasons for the denial in writing before requiring the client to enroll in ((HO)) managed care. The written notice to the client contains all of the following:

     (a) The action MAA intends to take, including enrollment information;

     (b) The reason(s) for the intended action;

     (c) The specific rule or regulation supporting the action;

     (d) The client's right to request a fair hearing, including the circumstances under which the fee-for-service status continues, if a hearing is requested; and

     (e) A translation into the client's primary language when the client has limited English proficiency.

[Statutory Authority: RCW 74.08.090, 74.09.510 and [74.09.]522 and 1115 Federal Waiver, 42 U.S.C. 1396 (a), (e), (p), 42 U.S.C. 1396r-6(b), 42 U.S.C. 1396u-2. 00-04-080, § 388-538-080, filed 2/1/00, effective 3/3/00. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057 and 74.08.090. 98-16-044, § 388-538-080, filed 7/31/98, effective 9/1/98. Statutory Authority: RCW 74.08.090. 96-24-074, § 388-538-080, filed 12/2/96, effective 1/1/97. Statutory Authority: RCW 74.08.090 and 1995 2nd sp.s. c 18. 95-18-046 (Order 3886), § 388-538-080, filed 8/29/95 effective 9/1/95. Statutory Authority: RCW 74.08.090. 93-17-039 (Order 3621), § 388-538-080, filed 8/11/93, effective 9/11/93.]

     (a) A client is entitled to timely access to medically necessary services as defined in WAC 388-500-0005.

     (b) The ((plan)) managed care organization (MCO) covers the services included in the healthy options (HO) contract for ((plan)) MCO enrollees. In addition, ((plans)) MCOs may, at their discretion, cover services not required under the HO contract.

     (c) The medical assistance administration (MAA) covers the categorically needy services not included in the HO contract for ((plan)) MCO enrollees.

     (d) ((Plan enrollees)) MAA covers services on a fee-for-service basis for enrollees with a primary care case management (PCCM) provider. Except for emergencies, the PCCM provider must either provide the covered services needed by the enrollee or refer the enrollee to other providers who are contracted with MAA for covered services. The PCCM provider is responsible for instructing the enrollee regarding how to obtain the services that are referred by the PCCM provider. The services that require PCCM provider referral are described in the PCCM contract. MAA informs enrollees about the enrollee's program coverage, limitations to covered services, and how to obtain covered services.

     (e) MCO enrollees may obtain certain services from either a ((plan)) MCO provider or from a medical assistance provider with a DSHS core provider agreement without needing to obtain a referral from the PCP or ((plan)) MCO. These services are described in the HO contract, and are communicated to enrollees by MAA and ((plans)) MCOs as described in (((e))) (f) of this subsection.

     (((e))) (f) MAA sends each client written information about covered services when the client is required to enroll in managed care, and any time there is a change in covered services. This information describes covered services, which services are covered by MAA, and which services are covered by ((plans)) MCOs. In addition, MAA requires ((plans)) MCOs to provide new enrollees with written information about covered services.

     (((f) MAA covers services on a fee-for-service basis for clients enrolled with a PCCM provider. Except for emergencies, a client's PCCM provider must refer the client for most services not provided by the PCCM provider. The services that require PCCM provider referral are described in the PCCM contract. MAA requires PCCM providers to inform enrollees about covered services and how to obtain them.))

     (2) For services covered by MAA ((for managed care enrollees)) through PCCM contracts for managed care:

     (a) MAA medically necessary covers services included in the categorically needy scope of care and rendered by providers with a current department of social and health services (DSHS) core provider agreement to provide the requested service;

     (b) MAA may require the PCCM provider to obtain authorization from MAA for coverage of nonemergency services;

     (c) ((MAA)) The PCCM provider determines which services are medically necessary; ((and))

     (d) An enrollee may request a fair hearing for review of PCCM provider or MAA coverage decisions; and

     (e) Services referred by the PCCM provider require an authorization number in order to receive payment from MAA.

     (3) For services covered by ((plans)) MAA through contracts with MCOs:

     (a) MAA requires ((plans)) the MCO to ((contract)) subcontract with a sufficient ((number of)) providers ((as determined by MAA,)) to deliver the scope of contracted services ((contracted with the plan in a timely fashion, according to the requirements of the HO contract)) in a timely manner. Except for emergency services, ((plans)) MCOs provide covered services to enrollees through their participating providers;

     (b) MAA requires ((plans)) MCOs to provide new enrollees with written information about how enrollees may obtain covered services;

     (c) For nonemergency services, ((plans)) MCOs may require the enrollee to obtain a referral from the primary care provider (PCP), or the provider to obtain authorization from the ((plan)) MCO, according to the requirements of the HO contract;

     (d) ((Plans)) MCOs and their providers determine which services are medically necessary given the enrollee's condition, according to the requirements included in the HO contract;

     (e) An enrollee may appeal ((plan)) an MCO coverage decisions using the ((plan's)) MCO's appeal process, as described in WAC 388-538-0110. An enrollee may also request a hearing for review of ((a plan)) an MCO coverage decision as described in chapter 388-02 WAC;

     (f) A managed care enrollee does not need a PCP referral to receive women's health care services, as described in RCW 48.42.100 from any women's health care provider participating with the ((plan)) MCO. Any covered services ordered and/or prescribed by the women's health care provider must meet the ((plan's)) MCO's service authorization requirements for the specific service.

     (4) Unless the ((plan)) MCO chooses to cover these services, or an appeal or a fair hearing decision reverses ((a)) an MCO or MAA denial, the following services are not covered:

     (a) For all managed care enrollees:

     (i) Services that are not medically necessary;

     (ii) Services not included in the categorically needy scope of services; and

     (iii) Services, other than a screening exam as described in WAC 388-538-100(3), received in a hospital emergency department for nonemergency medical conditions.

     (b) For ((plan)) MCO enrollees:

     (i) Services received from a participating specialist that require prior authorization from the ((plan)) MCO, but were not authorized by the ((plan)) MCO; and

     (ii) Services received from a nonparticipating provider that require prior authorization from the ((plan)) MCO that were not authorized by the ((plan)) MCO. All nonemergency services covered under the HO contract and received from nonparticipating providers require prior authorization from the ((plan)) MCO.

     (c) For PCCM enrollees, services that require a referral from the PCCM provider as described in the PCCM contract, but were not referred by the PCCM provider.

     (5) A provider may bill an enrollee for noncovered services as described in subsection (4) of this section, if the enrollee and provider sign an agreement. The provider must give the original agreement to the enrollee and file a copy in the enrollee's record.

     (a) The agreement must state all of the following:

     (i) The specific service to be provided;

     (ii) That the service is not covered by either MAA or the ((plan)) MCO;

     (iii) An explanation of why the service is not covered by the ((plan)) MCO or MAA, such as:

     (A) The service is not medically necessary; or

     (B) The service is covered only when provided by a participating provider.

     (iv) The enrollee chooses to receive and pay for the service; and

     (v) Why the enrollee is choosing to pay for the service, such as:

     (A) The enrollee understands that the service is available at no cost from a provider participating with the ((plan)) MCO, but the enrollee chooses to pay for the service from a provider not participating with the ((plan)) MCO;

     (B) The ((plan)) MCO has not authorized emergency department services for nonemergency medical conditions and the enrollee chooses to pay for the emergency department's services rather than wait to receive services at no cost in a participating provider's office; or

     (C) The ((plan)) MCO or PCCM has determined that the service is not medically necessary and the enrollee chooses to pay for the service.

     (b) For limited English proficient enrollees, the agreement must be translated or interpreted into the enrollee's primary language to be valid and enforceable.

     (c) The agreement is void and unenforceable, and the enrollee is under no obligation to pay the provider, if the service is covered by MAA or the ((plan)) MCO as described in subsection (1) of this section, even if the provider is not paid for the covered service because the provider did not satisfy the payor's billing requirements.

[Statutory Authority: RCW 74.08.090. 01-02-076, § 388-538-095, filed 12/29/00, effective 1/29/01. Statutory Authority: RCW 74.08.090, 74.09.510 and [74.09.]522 and 1115 Federal Waiver, 42 U.S.C. 1396 (a), (e), (p), 42 U.S.C. 1396r-6(b), 42 U.S.C. 1396u-2. 00-04-080, § 388-538-095, filed 2/1/00, effective 3/3/00. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057 and 74.08.090. 98-16-044, § 388-538-095, filed 7/31/98, effective 9/1/98. Statutory Authority: RCW 74.08.090 and 1995 2nd sp.s. c 18. 95-18-046 (Order 3886), § 388-538-095, filed 8/29/95, effective 9/1/95. Statutory Authority: RCW 74.08.090. 93-17-039 (Order 3621), § 388-538-095, filed 8/11/93, effective 9/11/93.]

     (a) The ((plan)) managed care organization (MCO) covers emergency services for ((plan)) MCO enrollees.

     (b) MAA covers emergency services for primary care case management (PCCM) enrollees.

     (2) Emergency services for emergency medical conditions do not require prior authorization by the ((plan)) MCO, primary care provider (PCP), PCCM provider, or MAA.

     (3) Emergency services received by an MCO enrollee for nonemergency medical conditions must be authorized by the plan for ((plan enrollees)) enrollee's MCO.

     (4) An enrollee who requests emergency services is entitled to receive an exam to determine if the enrollee has an emergency medical condition.

[Statutory Authority: RCW 74.08.090, 74.09.510 and [74.09.]522 and 1115 Federal Waiver, 42 U.S.C. 1396 (a), (e), (p), 42 U.S.C. 1396r-6(b), 42 U.S.C. 1396u-2. 00-04-080, § 388-538-100, filed 2/1/00, effective 3/3/00. Statutory Authority: RCW 74.08.090 and 1995 2nd sp.s. c 18. 95-18-046 (Order 3886), § 388-538-100, filed 8/29/95, effective 9/1/95. Statutory Authority: RCW 74.08.090. 95-04-033 (Order 3826), § 388-538-100, filed 1/24/95, effective 2/1/95; 93-17-039 (Order 3621), § 388-538-100, filed 8/11/93, effective 9/11/93.]

     (a) For managed care organization (MCO) enrolles, the MCO's complaint and appeal ((process)) processes, and through the department's fair hearing process; or

     (b) For primary care case management (PCCM) enrollees, the complaint and appeal processes of the medical assistance administration (MAA), and through the department's fair hearing process (chapter 388-02 WAC).

     (2) To ensure the rights of MCO enrollees are protected, MAA approves each ((plan's)) MCO's complaint and appeal ((process)) policies and procedures annually or whenever the plan makes a change to the process.

     (3) MAA requires ((plans)) MCOs to inform MCO enrollees in writing within fifteen days of enrollment about their rights and how to use the ((plan's)) MCO's complaint and appeal processes. MAA requires ((plans)) MCOs to obtain MAA approval of all written information sent to enrollees.

     (4) MAA provides PCCM enrollees with information equivalent to that described in subsection (3) of this section.

     (5) MCO enrollees may request assistance from the ((plan)) MCO when using the ((plan's)) MCO's complaint and appeals processes. PCCM enrollees may request assistance from MAA when using MAA's complaint and appeal process.

     (((5))) (6) An MCO enrollee who ((complains to a plan)) submits a complaint under this section is entitled to a written or verbal response from the ((plan)) MCO or from MAA within the timeline in the ((plan's)) MAA-approved complaint process.

     (((6))) (7) When an enrollee is not satisfied with how ((the plan resolves a)) the complaint is resolved by the MCO or by MAA, or if the ((plan does not resolve a)) complaint is not resolved in a timely fashion, the enrollee may submit an appeal to the ((plan)) MCO or to MAA. An enrollee may also appeal ((a plan)) an MAA, MCO, primary care provider (PCP), or provider decision, or reconsideration of any action or inaction. An enrollee who appeals ((a plan, PCP)) an MAA, MCO, PCP, or provider decision is entitled to all of the following:

     (a) A review of the decision being appealed. The review must be conducted by ((a plan)) an MCO or MAA representative who was not involved in the decision under appeal;

     (b) Continuation of the service already being received and which is under appeal, until a final decision is made;

     (c) A written decision from MAA or the ((plan)) MCO, within the timeline(s) in the ((plan)) appeal process standards, in the enrollee's primary language. The ((plan)) decision does not need to ((translate the decision)) be translated if an enrollee with limited English proficiency prefers correspondence in English, and the ((plan)) deciding authority documents the enrollee's preference. The notice must clearly explain all of the following:

     (i) The decision and any action MAA or the ((plan)) MCO intends to take;

     (ii) The reason for the decision;

     (iii) The specific information that supports MAA's or the ((plan's)) MCO's decision; and

     (iv) Any further appeal or fair hearing rights available to the enrollee, including the enrollee's right to continue receiving the service under appeal until a final decision is made.

     (d) An expedited decision when it is necessary to meet an existing or anticipated acute or urgent medical need.

     (((7))) (8) An enrollee may file a fair hearing request without also filing an appeal with MAA or the ((plan)) MCO or exhausting MAA's or the ((plan's)) MCO's appeal process.

     (((8))) (9) The ((plan's)) MCO's medical director or designee reviews all fair hearings requests, and any related appeals, when the issues involve an MCO's determination of medical necessity.

     (10) MAA's medical director or the medical director's designee reviews all fair hearings requests, and any related appeals, when the PCCM enrollee's issues involve an MAA determination of medical necessity.

[Statutory Authority: RCW 74.08.090, 74.09.510 and [74.09.]522 and 1115 Federal Waiver, 42 U.S.C. 1396 (a), (e), (p), 42 U.S.C. 1396r-6(b), 42 U.S.C. 1396u-2. 00-04-080, § 388-538-110, filed 2/1/00, effective 3/3/00. Statutory Authority: RCW 74.08.090. 97-04-004, § 388-538-110, filed 1/24/97, effective 2/24/97. Statutory Authority: RCW 74.08.090 and 1995 2nd sp.s. c 18. 95-18-046 (Order 3886), § 388-538-110, filed 8/29/95, effective 9/1/95. Statutory Authority: RCW 74.08.090. 94-04-038 (Order 3701), § 388-538-110, filed 1/26/94, effective 2/26/94; 93-17-039 (Order 3621), § 388-538-110, filed 8/11/93, effective 9/11/93.]

     Reviser's note: The spelling 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.
AMENDATORY SECTION(Amending WSR 00-04-080, filed 2/1/00, effective 3/3/00)

WAC 388-538-120   Enrollee request for a second medical opinion.   (1) A managed care ((plan)) enrollee has the right to a timely referral for a second opinion upon request when:

     (a) The enrollee needs more information about treatment recommended by the provider or ((plan)) managed care organization (MCO); or

     (b) The enrollee believes the ((plan)) MCO is not authorizing medically necessary care.

     (2) A managed care ((plan)) enrollee has a right to a second opinion from a primary or specialty care physician who is participating with the ((plan)) MCO. At the ((plan's)) MCO's discretion, a clinically appropriate nonparticipating provider who is agreed upon by the ((plan)) MCO and the enrollee may provide the second opinion.

     (3) Primary care case management (PCCM) provider enrollees have a right to a timely referral for a second opinion by another provider who has a core provider agreement with medical assistance administration (MAA).

[Statutory Authority: RCW 74.08.090, 74.09.510 and [74.09.]522 and 1115 Federal Waiver, 42 U.S.C. 1396 (a), (e), (p), 42 U.S.C. 1396r-6(b), 42 U.S.C. 1396u-2. 00-04-080, § 388-538-120, filed 2/1/00, effective 3/3/00. Statutory Authority: RCW 74.08.090 and 1995 2nd sp.s. c 18. 95-18-046 (Order 3886), § 388-538-120, filed 8/29/95, effective 9/1/95. Statutory Authority: RCW 74.08.090. 93-17-039 (Order 3621), § 388-538-120, filed 8/11/93, effective 9/11/93.]

     (2))) MAA ends an enrollee's enrollment in ((HO)) a managed care organization (MCO) or with a primary care case management (PCCM) provider when the enrollee meets any of the following conditions. The enrollee:

     (a) Is no longer eligible for a medical program subject to enrollment; or

     (b) ((Requests to be removed from HO according to WAC 388-538-080 (2)(a), (c), or (h), and MAA approves the request;

     (c) Becomes a Medicare beneficiary;

     (d))) Is receiving foster care placement services from the division of children and family services; or

     (c) Is or becomes eligible for Medicare, basic health (BH), CHAMPUS/TRICARE, or any other accessible third party health care coverage that would require involuntary disenrollment from:

     (i) An MCO in accordance with MAA's healthy options (HO) contract for MCO enrollees; or

     (ii) A PCCM provider in accordance with MAA's PCCM contract for PCCM enrollees.

     (2) An enrollee or the enrollee's representative as defined in RCW 7.70.065 may request MAA to end enrollment as described in subsections (3) through (10) of this section. A managed care organization (MCO) may request MAA to end enrollment for an enrollee as described in subsection (11) of this section. Only MAA has authority to remove an enrollee from managed care. Pending MAA's final decision, the enrollee remains enrolled unless staying in managed care would adversely affect the enrollee's health status.

     (3) MAA grants an enrollee's request to have the enrollee's enrollment ended under the following conditions:

     (a) Is American Indian or Alaska Native (AI/AN) and requests disenrollment; or

     (b) Is identified by DSHS as a child who meets the definition of "children with special health care needs" and requests disenrollment.

     (4) MAA grants an enrollee's requests to be removed from managed care when the client is pregnant or when there is a verified medical need to continue an established course of care. These end enrollments are limited to the following situations: The enrollee:

     (a) Has a documented medical need to continue a client/provider relationship due to an established course of care with a physician, physician assistant, or advanced registered nurse practitioner. The standards for documenting a medical need are those in WAC 388-538-080 (3)(a). The established course of care must begin:

     (i) While the enrollee was enrolled with managed care but the PCP is no longer available to the enrollee under managed care; or

     (ii) Prior to enrollment in managed care and the PCP is not available under any MCO or as a PCCM provider.

     (b) Is pregnant and requests to continue her course of prenatal care that was established with an obstetrical provider:

     (i) While she was enrolled with the MCO but that provider is no longer available to her in managed care; or

     (ii) Prior to enrollment with the current MCO but that provider is not available to her under managed care.

     (c) Is scheduled for a surgery with a provider not available to the enrollee in the enrollee's current ((plan)) MCO and the surgery is scheduled to be performed within the first thirty days of enrollment((;

     (e) Is pregnant and requests to continue her established course of prenatal care with an obstetrical provider who is not available through her current plan;

     (f) Notifies MAA of private insurance under a managed care arrangement;

     (g) Notifies MAA of BHP coverage;

     (h) Notifies MAA of CHAMPUS coverage;

     (i) Notifies MAA of private insurance with the same plan as the enrollee's current HO plan under any arrangement; or

     (j) Asks to be taken out of the current plan in order to stay with the enrollee's established provider but is willing to enroll in the established provider's plan for the next enrollment month. MAA reviews subsection (2)(b), (d), and (e) in this section when reviewing a request to end a client's enrollment per this subsection. MAA's decisions on those requests include all of the following:

     (i) The decision is given verbally or in writing; and

     (ii) Verbal and written notices include the reason for the decision and information on hearings so the enrollee may appeal the decision; and

     (iii) If the request to end enrollment is approved, it may be effective back to the beginning of the month the request is made; and

     (iv) If the request to end enrollment is denied, and the enrollee requests a hearing; the enrollee remains enrolled in the plan until the hearing decision is made as provided in subsection (1) of this section.

     (3))) (5) Except as provided in subsection (4) of this section, MAA does not permit an enrollee to obtain an end enrollment by establishing a course of care with a provider who is not participating with the enrollee's MCO.

     (6) MAA ends enrollment on a case-by-case basis when the enrollee presents evidence that the managed care program does not provide medically necessary care that is reasonable available and accessible as offered to the enrollee. MAA considers enrollee requests under this subsection with the same criteria as listed in WAC 388-538-080 (3)(f).

     (7) MAA ends enrollment temporarily if an enrollee asks to be taken out of the current MCO in order to stay with the enrollee's established provider, but is willing to enroll in the established provider's MCO for the next enrollment month. MAA reviews the enrollee request according to the criteria in subsections (4) and (6) of this section. MAA's decision under this subsection include all of the following:

     (a) The decision is given verbally and in writing;

     (b) Verbal and written notices include the reason for the decision and information on hearings so the enrollee may appeal the decision;

     (c) If the request to end enrollment is approved, it may be effective back to the beginning of the month the request is made; and

     (d) If the request to end enrollment is denied, and the enrollee requests a hearing; the enrollee remains in the MCO or with the PCCM until the hearing decision is made as provided in subsection (2) of this section.

     (8) MAA ends enrollment for the period of time the circumstances or conditions that led to ending the enrollment are expected to exist. If the request to end enrollment is approved for a limited time, the client is notified in writing or by telephone of the time limitation, the process for renewing the disenrollment, and their fair hearing rights.

     (((4))) (9) MAA does not approve an enrollee's request to end enrollment solely to pay for services received but not authorized by the ((plan)) MCO.

     (((5))) (10) The enrollee remains in ((HO)) managed care as provided in subsection (1) of this section and receives timely notice by telephone or in writing when MAA approves or denies the enrollee's request to end enrollment. Except as provided in subsection (((2)(j))) (7) of this section, MAA gives the reasons for a denial in writing. The written denial notice to the enrollee contains all of the following:

     (a) The action MAA intends to take;

     (b) The reason(s) for the intended action;

     (c) The specific rule or regulation supporting the action;

     (d) The enrollee's right to request a fair hearing; and

     (e) A translation into the enrollee's primary language when the enrollee has limited English proficiency.

     (((6))) (11) MAA may end an enrollee's enrollment in a ((plan)) MCO or with a PCCM provider when the enrollee's ((plan)) MCO or PCCM provider substantiates in writing, to MAA's satisfaction, that:

     (a) The enrollee's behavior is inconsistent with the ((plan's)) MCO or PCCM provider rules and regulations, such as intentional misconduct; and

     (b) After the ((plan)) MCO or PCCM provider has provided:

     (i) Clinically appropriate evaluation(s) to determine whether there is a treatable problem contributing to the enrollee's behavior; and

     (ii) If so, has provided clinically appropriate referral(s) and treatment(s), but the enrollee's behavior continues to prevent the provider from safely or prudently providing medical care to the enrollee; and

     (c) The enrollee received written notice from the ((plan)) MCO or PCCM provider of the ((plan's)) MCO or PCCM provider intent to request the enrollee's removal, unless MAA has waived the requirement for the ((plan)) MCO or PCCM provider notice because the enrollee's conduct presents the threat of imminent harm to others. The ((plan's)) MCO or PCCM provider notice to the enrollee must include both of the following:

     (i) The enrollee's right to use the ((plan's)) appeal process as described in WAC 388-538-110 to review the ((plan's)) MCO or PCCM provider request to end the enrollee's enrollment; and

     (ii) The enrollee's right to use the department fair hearing process.

     (((7))) (12) MAA makes a decision to remove an enrollee from enrollment ((with a plan)) in managed care within thirty days of receiving the ((plan's)) MCO or PCCM provider request to do so. Before making a decision, MAA attempts to contact the enrollee and learn the enrollee's perspective. If MAA approves the ((plan's)) MCO or PCCM provider request to remove the enrollee, MAA sends a notice at least ten days in advance of the effective date that enrollment will end. The notice includes the reason for MAA's approval to end enrollment and information about the ((client's)) enrollee's fair hearing rights.

     (((8))) (13) MAA does not approve a ((plan's)) request to remove an enrollee from ((HO)) managed care when the request is solely due to an adverse change in the enrollee's health or the cost of meeting the enrollee's needs.

[Statutory Authority: RCW 74.08.090, 74.09.510 and [74.09.]522 and 1115 Federal Waiver, 42 U.S.C. 1396 (a), (e), (p), 42 U.S.C. 1396r-6(b), 42 U.S.C. 1396u-2. 00-04-080, § 388-538-130, filed 2/1/00, effective 3/3/00. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057 and 74.08.090. 98-16-044, § 388-538-130, filed 7/31/98, effective 9/1/98. Statutory Authority: RCW 74.08.090 and 1995 2nd sp.s. c 18. 95-18-046 (Order 3886), § 388-538-130, filed 8/29/95, effective 9/1/95. Statutory Authority: RCW 74.08.090. 93-17-039 (Order 3621), § 388-538-130, filed 8/11/93, effective 9/11/93.]

     (a) Requires ((plans)) managed care organizations (MCOs) to have a fully operational quality assurance system that meets a comprehensive set of quality improvement program (QIP) standards.

     (b) Monitors ((plan)) MCO performance through on-site visits and other audits, and requires corrective action for deficiencies that are found.

     (c) Requires ((plans)) MCOs to report annually on standardized clinical performance measures that are specified in the contract with MAA, and requires corrective action for substandard performance.

     (d) Contracts with a professional review organization to conduct independent external review studies of selected health care and service delivery.

     (e) Conducts enrollee satisfaction surveys.

     (f) Annually publishes ((plan)) individual MCO performance information and primary care case management (PCCM) program performance ((on)) information including certain clinical measures and enrollee satisfaction surveys and makes reports of site monitoring visits available upon request.

     (2) MAA requires ((plans)) MCOs and PCCM providers to have a method to assure consideration of the unique needs of enrollees with chronic conditions. The method includes:

     (a) Early identification;

     (b) Timely access to health care; and

     (c) Coordination of health service delivery and community linkages.

[Statutory Authority: RCW 74.08.090, 74.09.510 and [74.09.]522 and 1115 Federal Waiver, 42 U.S.C. 1396 (a), (e), (p), 42 U.S.C. 1396r-6(b), 42 U.S.C. 1396u-2. 00-04-080, § 388-538-140, filed 2/1/00, effective 3/3/00. Statutory Authority: RCW 74.08.090 and 1995 2nd sp.s. c 18. 95-18-046 (Order 3886), § 388-538-140, filed 8/29/95, effective 9/1/95. Statutory Authority: RCW 74.08.090. 93-17-039 (Order 3621), § 388-538-140, filed 8/11/93, effective 9/11/93.]

     The following section of the Washington Administrative Code is repealed:

WAC 388-538-066

Children's health insurance program (CHIP) enrollees.

2980.6
AMENDATORY SECTION(Amending WSR 00-07-103, filed 3/17/00, effective 4/17/00)

WAC 388-542-0050   Definitions for children's health insurance program (CHIP) terms.   The following definitions and abbreviations ((and)), those found in WAC 388-538-050 and in 388-500-0005((,)) Medical definitions, apply to this chapter. ((Defined words and phrases are bolded the first time they are used in the text.

     "Age appropriate immunizations" means the recommended childhood immunization schedule as approved by the Advisory Committee on Immunization Practices (ACIP), the American Academy of Pediatrics (AAP), and the American Academy of Family Physicians (AAFP).))

     "Children's health insurance program (CHIP)" means the health insurance program authorized by Title XXI of the Social Security Act and administered by the department of social and health services (DSHS). This program also is referred to as the state children's health insurance program (S((-))CHIP).

     (("Client copay" or "copay" means an amount a CHIP client pays to health care providers for specific services.))

     "Client premium" means a monthly payment a client ((must)) makes to the department of social and health services (DSHS) for CHIP coverage.

     "Creditable coverage" means most types of public and private health coverage, except Indian health services, that provides access to physicians, hospitals, laboratory services, and radiology services. This term applies to the coverage whether or not the coverage is equivalent to that offered under CHIP. "Creditable coverage" is described in 42 U.S.C. Sec. 1397jj.

     "Employer-sponsored dependent coverage" means creditable health coverage for dependents offered by a family member's employer or union, for which the employer or union may contribute in whole or part towards the premium. Extensions of such coverage (e.g., COBRA extensions) also qualify as employer-sponsored dependent coverage as long as there remains a contribution toward the premiums by the employer or union.

     "Finance division" means the division of the department of social and health services that sends out billing statements, monitors accounts, and collects the CHIP client premiums.

[Statutory Authority: RCW 74.08.090, 74.09.450. 00-07-103, § 388-542-0050, filed 3/17/00, effective 4/17/00.]

     (2) ((The following WACs apply to CHIP clients enrolled in managed care:

     (a) WAC 388-538-095; and

     (b) WAC 388-538-100.

     (3) Except for American Indian/Alaska Native (AI/AN) clients who have chosen primary care case management (PCCM) or fee-for-service as described in WAC 388-542-0200(3), CHIP clients must receive medical services from managed care plans in counties where two or more managed care plans are available)) 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 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 pre-hearing review as described in WAC 388-526-2610.

[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 ((managed care. See WAC 388-542-0150 (1)(c))) 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 388-538-080. 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 74.08.090, 74.09.450. 00-07-103, § 388-542-0125, filed 3/17/00, effective 4/17/00.]

     (a) ((Cannot have other creditable coverage. If MAA finds out after eligibility determination that a CHIP client had creditable coverage at the time of application, MAA ends the client's eligibility the first of the following month.

     (b) Must agree to pay both of the following:

     (i) A monthly client premium as described in WAC 388-542-250(1); and

     (ii) A service copay as described in WAC 388-542-250(3).

     (c) Must make a choice concerning how to receive services. The choices vary depending on where the client lives (except as provided for AI/AN in WAC 388-542-0200). In counties with:

     (i) Two or more managed care plans, the client must choose a managed care plan;

     (ii) One managed care plan, the client must choose between a managed care plan and MAA's fee-for-service program; or

     (iii) No managed care plan, the only option is MAA's fee-for-service program.

     (2) The following WACs describe additional eligibility requirements and conditions for a CHIP client:

     (a) WAC 388-505-0210 describes requirements related to children's medical eligibility;

     (b) WACs 388-424-0005 and 388-424-0010 describe requirements related to citizenship and alien status;

     (c) WAC 388-478-0075 describes monthly income standards;

     (d) WAC 388-416-0015 describes eligibility certification periods; and

     (e) WAC 388-418-0025 describes effects of changes on eligibility.

     (3) MAA does not require a client to pay the client premium in advance to be eligible for CHIP.

     (4) MAA ends a client's eligibility for CHIP when the client owes four months of premiums, based on the due dates listed on the bill for the client premium.

     (5) When MAA ends a client's eligibility according to subsection (4) of this section, to become eligible for CHIP again, the client must meet both of the following:

     (a) Pay all unforgiven past due premiums; and

     (b) Serve a waiting period of four consecutive months as described in WAC 388-542-0300. The client does not have CHIP coverage during the waiting period.

     (6) MAA forgives client premiums that are more than twelve months overdue. MAA does not require clients to pay overdue premiums that it has forgiven.

     (7) Unless specifically stated in chapter 388-542 WAC, the department's administrative rules covering children's medical programs apply to CHIP)) Not have other creditable coverage (see WAC 388-542-0220(1)); and

     (b) Meet the CHIP program requirements and conditions in WAC 388-505-0210(3).

     (2) There are no resource standards for a CHIP client. See WAC 388-478-0075(3).

     (3) CHIP eligibility certification periods are described in WAC 388-416-0015.

     (4) CHIP eligibility is affected by changes in a client's circumstances. See WAC 388-418-0025 (2) and (6).

     (5) Ongoing eligibility for CHIP requires the payment of CHIP premiums as described in WAC 388-542-0250. MAA enrolls an otherwise eligible client into the CHIP program in advance of any client premium payment.

[Statutory Authority: RCW 74.08.090, 74.09.450. 00-07-103, § 388-542-0150, filed 3/17/00, effective 4/17/00.]

     (2) The medical assistance administration (MAA) enrolls CHIP clients in MAA's managed care program (with a managed care organization (MCO) or with a primary care case management (PCCM) provider) prospectively only.

     (((2) American Indian/Alaska Native (AI/AN) clients who meet the provisions of 25 U.S.C. 1603 (c)-(d) for federally-recognized tribal members and their descendants, may choose one of the following:

     (a) Enroll with a CHIP plan available in their area;

     (b) Enroll with a CHIP Indian or tribal PCCM provider by calling MAA's toll-free enrollment line, or sending a completed CHIP enrollment form to MAA; or

     (c) MAA's fee-for-service program.

     (3) Clients who are required to enroll in managed care may change plans during the two-month period after enrollment and during an annual open enrollment period. Clients may not change plans otherwise, unless they have "good cause." The "good cause" reasons are any of the following:

     (a) The client is American Indian/Alaska Native (AI/AN);

     (b) The client moves out of the plan's service area;

     (c) To assure all family members are in the same plan;

     (d) To protect the client from a perpetrator of domestic violence, abuse or neglect;

     (e) To rectify a documented department error;

     (f) An administrative law judge orders MAA to disenroll the client; or

     (g) The client's plan stops offering service in the client's county))

     (3) CHIP clients are enrolled in managed care as provided for categorically needy Medicaid clients in WAC 388-538-060.

     (4) A client who is required to enroll in managed care may request a change in the client's MCO or PCCM provider on the same bases as in WAC 388-538-060.

[Statutory Authority: RCW 74.08.090, 74.09.450. 00-07-103, § 388-542-0200, filed 3/17/00, effective 4/17/00.]

     (2) MAA ends a client's eligibility for CHIP when the client owes four consecutive months of premiums, based on the due dates listed on the billing from the finance division for the client premium(s).

     (3) When MAA ends a client's eligibility according to subsection (2) of this section, a client must meet both of the following conditions to become eligible for CHIP again:

     (a) Pay all unforgiven past due premiums (see WAC 388-542-0250(5); and

     (b) Serve a waiting period of four consecutive months. The waiting period begins the day after termination of CHIP coverage for nonpayment of premiums as described in this section. The waiting period ends once four full consecutive months of CHIP noncoverage has elapsed. The client does not have CHIP coverage during the waiting period.

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     (2) The finance division sends bills for client premiums at the beginning of each month of coverage. Client premiums begin the first of the month in which the bill was sent, not the date that the client became eligible for services.

     (3) ((MAA requires a copay for certain services, as follows:

     (a) Five dollars for office visits with physicians, physician assistants, or advanced registered nurse practitioners (ARNP) (i.e., CPT codes 99201 - 99215);

     (b) Five dollars for nongeneric (i.e., brand name, whether single or multiple source) drugs; and

     (c) Twenty-five dollars for emergency department visits that do not result in hospital admission.

     (4) MAA does not require a copay for the following services:

     (a) Consultations (i.e., CPT codes 99241 - 99275);

     (b) Deliveries (births);

     (c) Dental;

     (d) Drug and alcohol treatment;

     (e) Generic drugs;

     (f) Inpatient and outpatient surgery;

     (g) Mental health services (including services with psychiatrists or psychologists);

     (h) Occupational, physical, or speech therapy;

     (i) Office visits with age appropriate immunizations or exams for an EPSDT (well-child check) screening;

     (j) Radiology; or

     (k) Visits to the emergency room that result in an inpatient hospital admission.

     (5) Clients are responsible for client copays from the first day the client is eligible for CHIP.

     (6) For clients who are required to make copays, clients make copays to the health care provider, not MAA. A provider may refuse service to CHIP clients when the copay is not paid at the time of service.

     (7) Client out-of-pocket expenses are subject to a twelve-month maximum. All of the following apply to twelve-month, out-of-pocket expenses for CHIP clients:

     (a) Only client premiums and copays for covered services count towards the twelve-month maximum;

     (b) For those children who incur client premiums and copays, the twelve-month maximums are as follows:

     (i) For one child, three hundred dollars;

     (ii) For two children, six hundred dollars; and

     (iii) For three or more children, nine hundred dollars. The family maximum is nine hundred dollars.

     (c) The client and/or family must do the following:

     (i) Track and document out-of-pocket expenses;

     (ii) Notify MAA when the maximum has been reached; and

     (iii) Provide receipts as proof of payment.

     (8) MAA's starting date for determining twelve-month, out-of-pocket maximum expenses is the date that the first child in a family became eligible for CHIP services. For example, if a family has:

     (a) One child, and that child became eligible for services on April first, the twelve-month period starts on April first;

     (b) Two children, and first child became eligible for services on April first and the second child started three months later on July first, the twelve-month period for both children starts on April first;

     (c) Three or more children, and the first child became eligible for services on April first, and the last child became eligible on November first (within the same twelve-month period), the twelve-month period starts on April first for all the children.

     (9) MAA exempts American Indian/Alaska Native (AI/AN) clients from paying client premiums or service copays)) MAA limits a client's out-of-pocket expenses for covered services the client obtains under the CHIP program rules, to the payment of premiums described in subsection (1) if this section.

     (4) MAA exempts American Indian/Alaska Native (AI/AN) clients from paying client premiums for coverage under the CHIP program.

     (5) MAA forgives client premiums that are more than twelve months overdue.

[Statutory Authority: RCW 74.08.090, 74.09.450. 00-07-103, § 388-542-0250, filed 3/17/00, effective 4/17/00.]

     (2) MAA does not deduct the five dollar copay from providers' reimbursement)) For contractors serving CHIP clients enrolled in managed care, MAA reimburses contracted managed care organizations (MCOs), primary care case management (PCCM) providers and providers of approved or ancillary care in the same way as described in chapter 388-538 WAC.

     (2) For providers of services serving CHIP clients under MAA's fee-for-service system and without the involvement of MCOs or PCCMs, MAA reimburses according to the regulations that apply to categorically needy Medicaid clients under chapters 388-500 through 388-556 WAC.

[Statutory Authority: RCW 74.08.090, 74.09.450. 00-07-103, § 388-542-0275, filed 3/17/00, effective 4/17/00.]

     (a) Chooses to end employer sponsored dependent coverage((, the client must serve a waiting period of four, full, consecutive months before becoming eligible to enroll in CHIP)). The waiting period begins the day after the employment-based coverage ends, and ends on the last day of the fourth full month of noncoverage ((by the employer)); or

     (b) Fails to exercise an optional coverage extension (e.g., COBRA) that meets the following conditions. The waiting period begins on the day there is a documented refusal of the coverage extension when the extended coverage is:

     (i) Subsidized in part or in whole by the employer or union;

     (ii) Available and accessible to the applicant or family; and

     (iii) At a monthly cost to the family meeting the limitation of subsection (2)(b)(iv).

     (2) MAA does not require a waiting period prior to CHIP coverage when:

     (a) The client or family member has a medical condition that, without treatment, would be life-threatening or cause serious disability or loss of function; or

     (b) The loss of employer sponsored dependent coverage is due to any of the following((;)):

     (i) Loss of employment with no post-employment subsidized coverage as described in subsection (1)(b);

     (ii) Death of the employee;

     (iii) The employer discontinues employer-sponsored dependent coverage;

     (iv) The family's total out-of-pocket maximum for employer-sponsored dependent coverage is fifty dollars per month or more;

     (v) The plan terminates employer-sponsored dependent coverage for the client because the client reached the maximum lifetime coverage amount;

     (vi) Coverage under a COBRA extension period expired;

     (vii) Employer-sponsored dependent coverage is not reasonably available (e.g., client would have to travel to another city or state to access care); or

     (viii) Domestic violence ((that leads to)) caused the loss of coverage for the victim.

[Statutory Authority: RCW 74.08.090, 74.09.450. 00-07-103, § 388-542-0300, 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;

     (c) WAC 388-538-080, Managed care exemptions;

     (d) WAC 388-538-095, Scope of care for managed care enrollees;

     (e) WAC 388-538-100, Managed care emergency services;

     (f) WAC 388-538-110. Managed care complaints, appeals and fair hearings;

     (g) WAC 388-538-120, Enrollee requests for a second medical opinion;

     (h) WAC 388-538-130, Ending enrollment in healthy options; and

     (i) WAC 388-538-140, Quality of care.

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     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.

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