SOCIAL AND HEALTH SERVICES
(Medical Assistance Administration)
Title of Rule: Chapter 388-542 WAC, Children's health insurance plan (CHIP).
Purpose: To correct cross-references and terms rendered incorrect by recent amendments to chapter 388-538 WAC, Managed care.
Statutory Authority for Adoption: RCW 74.08.090, 74.09.450, 74.09.510, 74.09.522.
Statute Being Implemented: 1115 Waiver per 42 U.S.C. 1396.
Summary: See Title of Rule above.
Reasons Supporting Proposal: See Title of Rule above and Explanation of Rule below.
Name of Agency Personnel Responsible for Drafting: Ann Myers, P.O. Box 45533, Olympia, WA 98507, (360) 725-1345; Implementation and Enforcement: Diane Kessel, P.O. Box 45536, Olympia, WA 98507, (360) 725-1715.
Name of Proponent: Department of Social and Health Services, Medical Assistance Administration, governmental.
Rule is not necessitated by federal law, federal or state court decision.
Explanation of Rule, its Purpose, and Anticipated Effects: The rule in general explains the federally funded, state children's health insurance plan (CHIP). The amendments to this rule are solely to correct terms and cross references that have become incorrect due to recent amendments to chapter 388-538 WAC, Managed care. The anticipated effect of these corrections is that users will be referred to the correct WAC cite.
Proposal Changes the Following Existing Rules: See Title
of Rule and Explanation of Rule above.
THIS RULE IS BEING PROPOSED UNDER AN EXPEDITED RULE-MAKING PROCESS THAT WILL ELIMINATE THE NEED FOR THE AGENCY TO HOLD PUBLIC HEARINGS, PREPARE A SMALL BUSINESS ECONOMIC IMPACT STATEMENT, OR PROVIDE RESPONSES TO THE CRITERIA FOR A SIGNIFICANT LEGISLATIVE RULE. IF YOU OBJECT TO THE USE OF THE EXPEDITED RULE-MAKING PROCESS, YOU MUST EXPRESS YOUR OBJECTIONS IN WRITING AND THEY MUST BE SENT TO Rules Coordinator, Rules and Policies Assistance Unit, Department of Social and Health Services, P.O. Box 45850, Olympia, WA 98504-5850, 4500 10th Avenue S.E., Lacey, WA , AND RECEIVED BY 5:00 p.m., November 17, 2003.
September 8, 2003
Brian H. Lindgren, Manager
Rules and Policies Assistance Unit3310.1
(2) 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)) grievance 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 prehearing review as described in WAC 388-526-2610.
[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, § 388-542-0100, filed 12/14/01, effective 1/14/02. 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 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 ((
388-538-130. 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 74.09.080, 74.08.510, [74.08.]522, 74.09.450, 1115 Waiver, 42 U.S.C. 1396. 02-01-075, § 388-542-0125, filed 12/14/01, effective 1/14/02. Statutory Authority: RCW 74.08.090, 74.09.450. 00-07-103, § 388-542-0125, 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;
WAC 388-538-080, Managed care exemptions;
(d))) WAC 388-538-095, Scope of care for managed care enrollees;
(e))) (d) WAC 388-538-100, Managed care emergency
(f))) (e) WAC 388-538-110(( .[,])), The grievance system for managed
care (( complaints, appeals and fair hearings)) organizations
(g))) (f) WAC 388-538-120, Enrollee requests for a
second medical opinion;
(h))) (g) WAC 388-538-130, Exemptions and ending
enrollment in (( healthy options)) managed care; and
(i))) (h) WAC 388-538-140, Quality of care.
[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, § 388-542-0500, filed 12/14/01, effective 1/14/02.]