WSR 03-18-111

PERMANENT RULES

DEPARTMENT OF

SOCIAL AND HEALTH SERVICES
(Medical Assistance Administration)

[ Filed September 2, 2003, 5:24 p.m. ]

Date of Adoption: September 2, 2003.

Purpose: To bring the managed care program into compliance with the federal Balanced Budget Act (BBA) of 1997. Also to update and clarify the criteria for exemptions and ending enrollment in managed care in order to provide a simpler, more flexible decision-making process while preserving clients' rights.

Citation of Existing Rules Affected by this Order: Amending WAC 388-538-130 and 388-538-140.

Statutory Authority for Adoption: RCW 74.08.090, 74.09.522.

Adopted under notice filed as WSR 03-14-066 on June 25, 2003.

Changes Other than Editing from Proposed to Adopted Version: As a result of comments received, the following changes were made in the rules as proposed (additions indicted by underlined text, deletions indicated by strikethrough text):

WAC 388-538-130(1) The medical assistance administration (MAA) may exempts a client from mandatory enrollment in managed care or may ends an enrollee's enrollment in managed care as specified in this section on a case by case basis.

WAC 388-538-130 (2)(a) If a client requests 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.

WAC 388-538-130(8) ...If MAA approves the request for a limited time, the client or enrollee is notified in writing or by telephone of the time limitation, the process for renewing the exemption or the ending of enrollment and fair hearing rights.

Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 2, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 0, Repealed 0.

Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 2, Repealed 0.
Effective Date of Rule: Thirty-one days after filing.

August 28, 2003

Brian H. Lindgren, Manager

Rules and Policies Assistance Unit

3254.2
AMENDATORY SECTION(Amending WSR 02-01-075, filed 12/14/01, effective 1/14/02)

WAC 388-538-130   Exemptions and ending enrollment in managed care.   (1) ((MAA ends an enrollee's enrollment in 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) 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 MCO and the surgery is scheduled to be performed within the first thirty days of enrollment[.]

(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.

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

(10) The enrollee remains in 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 (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.

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

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

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

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

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

(12) MAA makes a decision to remove an enrollee from enrollment in managed care within thirty days of receiving the 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 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 enrollee's fair hearing rights.

(13) MAA does not approve a request to remove an enrollee from 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)) The medical assistance administration (MAA) exempts a client from mandatory enrollment in managed care or ends an enrollee's enrollment in managed care as specified in this section. Only MAA has authority to exempt a client from enrollment in, or remove an enrollee from, managed care.

(2) A client or enrollee, or the client's or enrollee's representative as defined in RCW 7.70.065, may request MAA to exempt or end enrollment in managed care as described in this section.

(a) If a client requests exemption prior to the enrollment effective date, the client is not enrolled until MAA approves or denies the request.

(b) If an enrollee requests to end enrollment, the enrollee remains enrolled pending MAA's final decision, unless staying in managed care would adversely affect the enrollee's health status.

(c) The client or enrollee receives timely notice by telephone or in writing when MAA approves or denies the client's or enrollee's request. MAA follows a telephone denial by written notification. The written notice contains all of the following:

(i) The action MAA intends to take;

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

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

(iv) The client's or enrollee's right to request a fair hearing; and

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

(3) A managed care organization (MCO) or primary care case management (PCCM) provider may request MAA to end enrollment. The request must be in writing and be sufficient to satisfy MAA that the enrollee's behavior is inconsistent with the MCO's or PCCM provider's rules and regulations (e.g., intentional misconduct). MAA does not approve a request to remove an enrollee from 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 health care needs. The MCO or PCCM provider's request must include documentation that:

(a) The provider furnished clinically appropriate evaluation(s) to determine whether there is a treatable problem contributing to the enrollee's behavior;

(b) Such evaluation either finds no treatable condition to be contributing, or after evaluation and treatment, 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 of the provider's intent to request the enrollee's removal, unless MAA has waived the requirement for provider notice because the enrollee's conduct presents the threat of imminent harm to others. The provider's notice must include:

(i) The enrollee's right to use the provider's grievance system as described in WAC 388-538-110 and 388-538-111; and

(ii) The enrollee's right to use the department's fair hearing process, after the enrollee has exhausted all grievance and appeals available through the provider's grievance system (see WAC 388-538-110 and 388-538-111 for provider grievance systems, and WAC 388-538-112 for the fair hearing process for enrollees).

(4) When MAA receives a request from an MCO or PCCM provider to remove an enrollee from enrollment in managed care, MAA attempts to contact the enrollee for the enrollee's perspective. If MAA approves the request, MAA sends a notice at least ten days in advance of the effective date that enrollment will end. The notice includes:

(a) The reason MAA approved ending enrollment; and

(b) Information about the enrollee's fair hearing rights.

(5) MAA will exempt a client from mandatory enrollment or end an enrollee's enrollment in managed care when any of the following apply:

(a) The client or enrollee is receiving foster care placement services from the division of children and family services (DCFS);

(b) The client has or the enrollee becomes eligible for Medicare, basic health (BH), CHAMPUS/TRICARE, or any other accessible third-party health care coverage that would require exemption or involuntary disenrollment from:

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

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

(6) MAA will grant a client's request for exemption or an enrollee's request to end enrollment when:

(a) The client or enrollee is American Indian/Alaska Native (AI/AN) as specified in WAC 388-538-060(2);

(b) The client or enrollee has been identified by MAA as a child who meets the definition of "children with special health care needs";

(c) The client or enrollee is homeless or is expected to live in temporary housing for less than one hundred twenty days from the date of the request; or

(d) The client or enrollee speaks limited English or is hearing impaired and the client or enrollee can communicate with a provider who communicates in the client's or enrollee's language or in American Sign Language and is not available through the MCO and the MCO does not have a provider available who can communicate in the client's language.

(7) On a case-by-case basis, MAA may grant a client's request for exemption or an enrollee's request to end enrollment when, in MAA's judgment, the client or enrollee has a documented and verifiable medical condition, and enrollment in managed care could cause an interruption of treatment that could jeopardize the client's or enrollee's life or health or ability to attain, maintain, or regain maximum function.

(8) Upon request, MAA may exempt the client or end enrollment for the period of time the circumstances or conditions that lead to exemption or ending enrollment are expected to exist. MAA may periodically review those circumstances or conditions to determine if they continue to exist. If MAA approves the request for a limited time, the client or enrollee is notified in writing or by telephone of the time limitation, the process for renewing the exemption or the ending of enrollment.

(9) An MCO may refer enrollees to MAA's patients requiring regulation (PRR) program in accordance with WAC 388-501-0135.

[Statutory Authority: RCW 74.09.080, 74.08.510, [74.08.]522, 74.09.450, 1115 Waiver, 42 U.S.C. 1396. 02-01-075, 388-538-130, filed 12/14/01, effective 1/14/02. 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.]


AMENDATORY SECTION(Amending WSR 02-01-075, filed 12/14/01, effective 1/14/02)

WAC 388-538-140   Quality of care.   (1) In order to assure that managed care enrollees receive ((appropriate access to)) quality health care ((and)) services, the medical assistance administration (MAA) ((does all of the following)) requires managed care organizations (MCOs) to comply with quality improvement standards as stated in the medical assistance administration (MAA) managed care contract as follows:

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

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

(2) MAA requires 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)) Have a clearly defined quality organizational structure and operation, including a fully operational quality assessment, measurement, and improvement program;

(b) Have effective means to detect both underutilization and overutilization of services;

(c) Maintain a grievance system that includes a process for enrollees to file grievances and appeals according to the requirements of WAC 388-538-110;

(d) Maintain a system for provider and practitioner credentialing and recredentialing;

(e) Ensure that MCO subcontracts and the delegation of MCO responsibilities are in accordance with MAA standards and regulations;

(f) Cooperate with an MAA-contracted qualified independent external review organization (EQRO) conducting review activities as described in 42 C.F.R. 438.358;

(g) Have an effective means to assess the quality and appropriateness of care furnished to enrollees with special health care needs;

(h) Submit annual reports to MAA, including HEDIS performance measures, specified by MAA;

(i) Maintain a health information system that:

(i) Collects, analyzes, integrates, and reports data as requested by MAA;

(ii) Provides information on utilization, grievances and appeals, enrollees ending enrollment for reasons other than the loss of Medicaid eligibility, and other areas as defined by MAA;

(iii) Collects data on enrollees, providers, and services provided to enrollees through an encounter data system, in a standardized format as specified by MAA; and

(iv) Ensures data received from providers is adequate and complete by verifying the accuracy and timeliness of reported data and screening the data for completeness, logic, and consistency.

(j) Conduct performance improvement projects designed to achieve significant improvement, sustained over time, in clinical care outcomes and services, and that involve the following:

(i) Measuring performance using objective quality indicators;

(ii) Implementing system changes to achieve improvement in service quality;

(iii) Evaluating the effectiveness of system changes;

(iv) Planning and initiating activities for increasing or sustaining performance improvement;

(v) Reporting each project status and the results as requested by MAA; and

(vi) Completing each performance improvement project timely so as to generally allow aggregate information to produce new quality of care information every year.

(k) Ensure enrollee access to health care services;

(l) Ensure continuity and coordination of enrollee care; and

(m) Ensure the protection of enrollee rights and the confidentiality of enrollee health information.

(2) MAA may impose intermediate sanctions in accordance with 42 C.F.R. 438.700 and corrective action for substandard rates of clinical performance measures and for deficiencies found in audits and on-site visits.

[Statutory Authority: RCW 74.09.080, 74.08.510, [74.08.]522, 74.09.450, 1115 Waiver, 42 U.S.C. 1396. 02-01-075, 388-538-140, filed 12/14/01, effective 1/14/02. 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.]

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