Original Notice.

     Preproposal statement of inquiry was filed as WSR 04-16-086.

     Title of Rule and Other Identifying Information: Part 1 of 2. Amending WAC 388-538-050 Definitions and 388-538-060 Managed care and choice; and adding new WAC 388-538-061 Managed care provided through the Washington Medicaid integration partnership (WMIP) or Medicare/Medicaid integration program (MMIP).

     Hearing Location(s): Blake Office Park East (behind Goodyear Courtesy Tire), Rose Room, 4500 10th Avenue S.E., Lacey, WA, on November 23, 2004, at 10:00 a.m.

     Date of Intended Adoption: Not sooner than November 24, 2004.

     Submit Written Comments to: DSHS Rules Coordinator, P.O. Box 45850, Olympia, WA 98504, delivery 4500 10th Avenue S.E., Lacey, WA, e-mail fernaax@dshs.wa.gov, fax (360) 664-6185, by 5:00 p.m., November 23, 2004.

     Assistance for Persons with Disabilities: Contact Fred Swenson, DSHS Rules Consultant, by November 19, 2004, TTY (360) 664-6178 or (360) 664-6097.

     Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: The department is revising the above referenced sections of the managed care rules to incorporate the following changes: (1) Clarify existing language; (2) revise WAC 388-538-060 to remove language regarding contract access standards and to simplify the enrollment process for managed care clients; and (3) add new WAC 388-538-061 to establish the Washington Medicaid integration partnership (WMIP) and the Medicare/Medicaid integration program (MMIP). These programs are designed to slow the progression of illness and disability and better manage Medicaid expenditures for the aged and disabled client population.

     Reasons Supporting Proposal: See above.

     Statutory Authority for Adoption: RCW 74.08.090.

     Statute Being Implemented: ESSB 5404, section 201(4), chapter 25, Laws of 2003; section 201(4), chapter 276, Laws of 2004, 42 U.S.C. 1396n (Sec. 1915(b) and (c) of the Social Security Act of 1924); RCW 74.09.522.

     Rule is not necessitated by federal law, federal or state court decision.

     Name of Proponent: Department of Social and Health Services, governmental.

     Name of Agency Personnel Responsible for Drafting: Wendy L. Boedigheimer, P.O. Box 45533, Olympia, WA 98504-5533, (360) 725-1306; Implementation and Enforcement: Alison Robbins, P.O. Box 45530, Olympia, WA 98504-5530, (360) 725-1634.

     No small business economic impact statement has been prepared under chapter 19.85 RCW. The department has analyzed the proposed rule amendments and concludes the managed care organizations currently contracted with the department employ more than fifty persons each and do not meet the definition of a small business under RCW 19.85.020; therefore the preparation of a comprehensive small business economic impact statement is not required.

     A cost-benefit analysis is required under RCW 34.05.328. A preliminary cost-benefit analysis may be obtained by contacting Alison Robbins, Medical Assistance Care Coordination, P.O. Box 44530, Olympia, WA 98504-5530, phone (360) 725-1634, fax (360) 753-7315, e-mail robbiaa@dshs.wa.gov.

October 15, 2004

Brian H. Lindgren, Manager

Rules and Policies Assistance Unit

     "Action" means:

     (1) The denial or limited authorization of a requested service, including the type or level of service;

     (2) The reduction, suspension, or termination of a previously authorized service;

     (3) The denial, in whole or in part, of payment for a service;

     (4) The failure to provide services in a timely manner, as defined by the state; or

     (5) The failure of an MCO to act within the time frames provided in 42 C.F.R. 438.408(b).

     "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 request by a provider or covered enrollee for reconsideration of an action.

     "Assign" or "assignment" means that the medical assistance administration (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.

     "Auto enrollment" means that MAA automatically enrolls a client into an MCO in his or her area, rather than waiting for the client to enroll with an MCO.

     "Basic health (((BH))) " or "BH" " means the health care program authorized by chapter 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 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 organization (MCO) or primary care case management (PCCM))) an MCO or PCCM provider. In this chapter, "client" refers to a person before ((the person)) he or she is enrolled in managed care, while "enrollee" refers to an individual eligible for any medical program who is enrolled in managed care.

     "Emergency medical condition" means a condition meeting the definition in 42 C.F.R. 438.114(a).

     "Emergency services" means services as defined in 42 C.F.R. 438.114(a).

     "End enrollment" means an enrollee is currently enrolled in managed care, either with ((a managed care organization (MCO) or with a primary care case management (PCCM))) an MCO or with a 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 managed care organization (MCO) or primary care case management (PCCM))) an MCO or PCCM provider that has a contract with the state.

     "Enrollees with special health care needs" 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, not currently enrolled in managed care, makes a pre-enrollment request to remain in the fee-for-service delivery system for one of the reasons outlined in WAC 388-538-130.

     "Grievance" means an expression of dissatisfaction about any matter other than an action, as "action" is defined in this section.

     "Grievance system" means the overall system that includes grievances and appeals handled at the MCO level and access to the state fair hearing process.

     "Health care service" or "service" 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 managed care organization (MCO))) DSHS and an MCO to provide 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 enrolled in the children's health insurance program (CHIP).

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

     "Managed care organization" or "MCO" means an organization having a certificate of authority or certificate of registration from the office of insurance commissioner 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)) the department's managed care programs.

     "Mandatory service area" means a service area in which eligible clients are required to enroll in an MCO.

     "Medicare/Medicaid Integration Program" or "MMIP" means DSHS's prepaid managed care program that integrates medical and long-term care services for clients who are sixty-five years of age or older and eligible for Medicare only or eligible for Medicare and Medicaid. Clients eligible for Medicaid only are not eligible for this program.

     "Nonparticipating provider" means a person or entity that does not have a written agreement with ((a managed care organization ()) an 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 managed care organization ()) an 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)))" or "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)))" or PCP" means a person licensed or certified under Title 18 RCW including, but not limited to, a physician, 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)))" or PA" means a process by which enrollees or providers must request and receive MAA approval for services provided through MAA's fee-for-service program, or MCO approval for services provided through the MCO, 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 as expeditiously as the enrollee's health condition requires. In relation to authorization of services and grievances and appeals, means in accordance with the ((healthy options (HO)/state childrens health insurance program (SCHIP) contract)) department's managed care programs and the time frames stated in this chapter.

     "Washington Medicaid Integration Partnership" or "WMIP" means the managed care program that integrates medical, mental health, chemical dependency treatment, and long-term care services into a single coordinated health plan for eligible aged, blind, or disabled clients

[Statutory Authority: RCW 74.08.090, 74.09.522. 03-18-109, § 388-538-050, filed 9/2/03, effective 10/3/03. 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, § 388-538-050, 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, § 388-538-050, 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.]

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

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

     (c) Is not exempt from managed care enrollment as determined by MAA, consistent with WAC 388-538-130, and any related fair hearing has been held and decided; and

     (d) Has not had 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) Enrollment with a managed care organization (MCO) available in their area;

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

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

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

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

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

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

     (d) When a client requests enrollment with 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 an MCO or PCCM provider as follows:

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

     (b) If the client does not have family members enrolled with an MCO that is currently under contract with DSHS, and the client was previously enrolled ((in the last six months with an)) with the MCO or PCCM provider, and DSHS can identify the previous enrollment, the client is reenrolled with the same MCO or PCCM provider;

     (c) If a client does not choose an MCO or a PCCM provider, but indicates a preference for a provider to serve as the client's primary ((case)) care provider (PCP), MAA attempts to contact the client to complete the required choice. If MAA is not able to contact the client in a timely manner, MAA documents the attempted contacts and, using the best information available, assigns the client 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 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 continues to be served by MAA's fee-for-service system. A client assigned under this subsection may request to end enrollment at any time.

     (ii) If a non-AI/AN client does not choose an MCO or PCCM provider, MAA assigns the client to an MCO or PCCM provider available in the area where the client lives. 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 enrollees in urban areas and one pharmacy within twenty-five miles for ninety percent of HO enrollees in rural areas)).

     (iii) For clients who are new to medical assistance or who have had a break in eligibility of greater than two months, MAA sends a written notice to each household of one or more clients who are assigned to an MCO or PCCM provider. The assigned client has ten calendar days to contact MAA to change the MCO or PCCM provider assignment before enrollment is effective. The notice includes the name of the MCO or PCCM provider to which each client has been assigned, the effective date of enrollment, the date by which the client must respond in order to change MAA's assignment, and ((either)) the toll-free telephone number of either:

     (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 MCO or PCCM provider assignment before enrollment is effective)) If the client has a break in eligibility of less than two months, the client will be automatically re-enrolled with his or her previous MCO or PCCM provider and no notice will be sent.

     (5) 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 the enrollee's MCO and accepting new enrollees; or

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

     (b) The MCO assigns a PCP or clinic that meets the access standards set forth in ((subsection (4)(d)(ii) of this section)) the relevant managed care contract if the enrollee does not choose a PCP or clinic;

     (c) MCO enrollees may change PCPs or clinics in an MCO for any reason, with the change becoming effective no later than the beginning of the month following the enrollee's request; or

     (d) In accordance with this subsection, MCO enrollees may file a grievance with the MCO and may change plans if the MCO denies an enrollee's request to change PCPs or clinics.

[Statutory Authority: RCW 74.08.090, 74.09.522. 03-18-109, § 388-538-060, filed 9/2/03, effective 10/3/03. 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, § 388-538-060, 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, § 388-538-060, 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) Unless otherwise stated in this section, all of the provisions of chapter 388-538 WAC apply to clients enrolled in WMIP and MMIP.

     (3) The following sections of chapter 388-538 WAC do not apply to WMIP enrollees or MMIP enrollees:

     (a) WAC 388-538-060. However, WAC 388-538-060(5), describing enrollees' ability to choose their PCP, does apply to WMIP enrollees and MMIP enrollees;

     (b) WAC 388-538-063;

     (c) WAC 388-538-065;

     (d) WAC 388-538-068; and

     (e) WAC 388-538-130. However, WAC 388-538-130(3) and WAC 388-538-130(4), describing the process used when MAA receives a request from an MCO to remove an enrollee from enrollment in managed care, do apply to WMIP enrollees and MMIP enrollees. Also, WAC 388-538-130(9), describing the MCO's ability to refer enrollees to MAA's "Patient Review and Restriction" program, does apply to WMIP enrollees and MMIP enrollees.

     (4) The process for enrollment of WMIP and MMIP clients is as follows:

     (a) For WMIP, MAA automatically enrolls clients, with the exception of American Indian/Alaska Natives and clients eligible for both Medicare and Medicaid, when they:

     (i) Are aged, blind, or disabled;

     (ii) Are twenty-one years of age or older; and

     (iii) Receive medical assistance.

     (b) For MMIP, clients are eligible to voluntarily enroll when they:

     (i) Are sixty-five years of age or older; and

     (ii) Receive Medicare and/or Medicaid.

     (c) American Indian/Alaska Native (AI/AN) clients who meet the eligibility criteria in (a) or (b) of this subsection may voluntarily enroll or end enrollment in WMIP or MMIP at any time.

     (d) MAA will not enroll a client in WMIP or MMIP, or will end an enrollee's enrollment in WMIP or MMIP when the client has, or becomes eligible for, CHAMPUS/TRICARE or any other accessible third-party health care coverage that would require exemption or involuntary disenrollment from managed care.

     (e) Clients enrolled in WMIP or MMIP may end enrollment from the MCO at any time without cause. The client may then re-enroll at any time with the MCO. MAA ends enrollment for clients prospectively to the first of the month following request to end enrollment.

     (f) On a case-by-case basis, MAA may retroactively end enrollment from WMIP and MMIP when, in MAA's judgment:

     (i) The client or enrollee has a documented and verifiable medical condition; and

     (ii) Enrollment in managed care could cause an interruption of on-going treatment that could jeopardize the client's or enrollee's life or health or ability to attain, maintain, or regain maximum function.

     (5) In addition to the scope of medical care described in WAC 388-538-095, the following services are also included in the MCO contract for WMIP and MMIP enrollees:

     (a) For WMIP enrollees - mental health, chemical dependency treatment, and long-term care services; and

     (b) For MMIP enrollees - long-term care services.

     (6) MAA sends each client written information about covered services when the client is eligible to enroll in WMIP or MMIP, and any time there is a change in covered services. In addition, MAA requires MCOs to provide new enrollees with written information about covered services.

[]

© Washington State Code Reviser's Office