SOCIAL AND HEALTH SERVICES
(Medical Assistance Administration)
Date of Adoption: June 6, 2003.
Purpose: To incorporate into rule the disease management program, new chapter 388-557 WAC, Disease management program.
Statutory Authority for Adoption: RCW 74.08.090.
Other Authority: Washington State Omnibus Operating Budget 2001-03 (section 209(6)), part II, chapter 7, Laws of 2001).
Adopted under notice filed as WSR 03-09-119 on April 22, 2003.
Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 7, Amended 0, Repealed 0.
Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.
Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.
Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 0, Repealed 0.
Number of Sections Adopted Using Negotiated Rule Making:
Pilot Rule Making:
or Other Alternative Rule Making:
Effective Date of Rule: Thirty-one days after filing.
June 6, 2003
Brian H. Lindgren, Manager
Rules and Policies Assistance Unit3220.2
DISEASE MANAGEMENT PROGRAM
(2) Disease management program services do not:
(a) Change the scope of services available to a client eligible under a Title XIX Medicaid program;
(b) Interfere with the relationship between an enrolled client and the client's chosen MAA-enrolled provider(s);
(c) Duplicate case management activities available to a client in the client's community; or
(d) Substitute for established activities that are available to a client and provided by programs administered through other department of social and health services (DSHS) divisions or state agencies.
"Disease management organization (DMO)" - See "MAA-contracted disease management organization (DMO)."
"Disease management program services" are specialized services provided through medical assistance administration (MAA)-contracted disease management organizations (DMOs) to clients with multiple health, behavioral, and social needs. Disease management program services are aimed at care coordination, client education, and improved client self-care.
"Eligible client" means a medical assistance administration (MAA) client who has the disease management program's specified combination of eligibility and disease factors.
"Enrolled client" means an eligible client who has been notified in writing by the medical assistance administration (MAA) of enrollment in the disease management program and eligibility to receive disease management program services, and who has not declined to participate.
"Evidence-based healthcare practice" means a clinical approach to practicing medicine based on the clinician's awareness of evidence and the strength of that evidence to support the management of a disease treatment process.
"MAA-contracted disease management organization (DMO)" means a clinically-qualified disease management company that has a valid disease management program contract with the medical assistance administration (MAA).
(a) A client must:
(i) Be a recipient of the temporary assistance for needy families (TANF) program or a children's medical program that is not a managed care program and be diagnosed with asthma; or
(ii) Be a recipient of the supplemental security income (SSI) program or general assistance with expedited medical categorically needy (GAX) program and be diagnosed with at least one of the following medical conditions:
(B) Congestive heart failure;
(D) Chronic kidney disease; or
(E) End stage renal disease.
(b) A client must not be:
(i) Receiving Medicare benefits;
(ii) Residing in an institution, as defined in WAC 388-71-0202, for more than thirty days;
(iii) Eligible for third party coverage that provides disease management program services or requires administrative controls that would duplicate or interfere with MAA's disease management program;
(iv) Enrolled with a managed care organization contracted with MAA; or
(v) Receiving case management services that disease management program services would duplicate.
(2) MAA may add other targeted diseases and client populations to the disease management program based on one or more of the following:
(a) The availability of a contractor to serve clients in a disease group;
(c) Available funding from the state legislature; and
(d) Other applicable criteria as determined by MAA.
(3) MAA selects and assigns a client to an appropriate disease management organization (DMO).
(4) A client meeting the eligibility requirements in this section:
(a) Is automatically enrolled in the disease management program;
(b) Is notified of the enrollment in writing by MAA;
(c) May request disenrollment at any time; and
(d) May request re-enrollment at any time.
(5) If an enrolled client who receives disease management program services subsequently becomes a mandatory enrollee in an MAA managed care program, the client:
(a) Is no longer eligible for disease management services through an MAA-contracted DMO;
(b) Is not eligible for an enrollment exemption from the managed care program because of their existing relationship with a DMO's contracted vendor(s); and
(c) May only be exempt from mandatory enrollment in the managed care program under the provisions of WAC 388-538-080(3).
(6) A client who does not agree with a decision regarding disease management program services has a right to a fair hearing under chapter 388-02 WAC.
(1) An appropriate method for using MAA healthcare data to identify populations with targeted diseases;
(2) An evidence-based healthcare practice guideline for each targeted disease;
(3) Existing collaborative healthcare practice models that include MAA's contracted providers, including physicians and support-service providers;
(4) Patient self-care management methods and education materials appropriate to each population with targeted diseases;
(5) Provisions for clients to access a nurse consultant twenty-four hours a day, seven days a week;
(6) Existing systems for process and outcomes measurement, evaluation, and management of the disease management program;
(7) Verifiable financial resources or backing that guarantee program savings and cost-effectiveness;
(8) Existing processes for routine reporting that support MAA's disease management program goals; and
(9) Successful and demonstrable experience in providing disease management program services to the targeted disease populations.
(a) Shares healthcare data with MAA-contracted DMOs under the provisions of RCW 70.02.050 and the Health Insurance Portability and Accountability Act of 1996 (HIPAA); and
(b) May limit provider participation:
(i) To protect the integrity of data collection; or
(ii) For other administrative or program reasons.
(a) The conditions of the contract between the medical assistance administration (MAA) and the DMO;
(b) The scope of practice appropriate to the provider of the services; and
(c) Other applicable WAC and federal requirements.
(2) A DMO:
(a) Evaluates each client enrolled in the disease management program;
(b) May prioritize disease management program services provided to an enrolled client based on the client's need or other criteria, as appropriate; and
(c) May contact and coordinate with a department or department-authorized case manager(s) for planned service delivery to an enrolled client.
(3) Disease management program services must provide one or more of the following to each enrolled client:
(a) Assistance in locating an MAA-enrolled provider or source of routine outpatient preventive healthcare. (Refer to chapter 388-529 WAC for the scope of covered medical services available to eligible clients.)
(b) Educational materials.
(c) Instruction regarding self-managing the targeted condition(s).
(d) Assessment of available services, equipment, and supplies that might enhance the client's ability to manage the client's disease process(es).
(e) Coordination with a department or department-authorized case manager(s).
(4) MAA evaluates a request for a disease management program service that is in excess of the program's limitations or restrictions, or is not included in the disease management program's scope of services, according to the provisions of WAC 388-501-0165.