Purpose: The rules clarify existing managed care rules; revise WAC 388-538-060 to remove language regarding contract access standards; to simplify enrollment process; and adopt rules for the Washington Medicaid integration partnership (WMIP) and the Medicare/Medicaid integration program (MMIP).

     Citation of Existing Rules Affected by this Order: Amending WAC 388-538-050, 388-538-060, 388-538-065, 388-538-067, 388-538-070, 388-538-095, 388-538-112, and 388-538-120.

     Statutory Authority for Adoption: RCW 74.08.090.

     Other Authority: RCW 74.09.522, ESSB 5404, section 201(4), chapter 25, Laws of 2003, section 201(4), chapter 276, Laws of 2004, 42 USC 1396N (section 1915 (b) and (c) of the Social Security Act of 1924).

      Adopted under notice filed as WSR 04-21-057 and 04-21-058 on October 18, 2004.

     Changes Other than Editing from Proposed to Adopted Version: The following changes, other than editing, were made to the rule as a result of comments of received:

AMENDED SECTION:

WAC 388-538-050 Definitions, new language added at the adopted rule is double underlined.

The word "contracts" was added to the definition below and the "s" was removed from the word program.

     "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 program contracts and the time frames stated in this chapter.

Added the words "is designed to integrate" instead of "integrates."

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

NEW SECTION: Added language at adoption is double underlined, deleted language is lined through.

WAC 388-538-061 Managed care provided through the Washington Medicaid Integration Partnership (WMIP) or Medicare/Medicaid Integration Program (MMIP)

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

     (a) Enrollment in WMIP and MMIP is voluntary, subject to program limitations in subsection (b) and (c) of this section.

     (ab) 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 categorically needy medical assistance.

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

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

     (ii) Receive Medicare and/or Medicaid.

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

     (de) 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.

     (ef) A clients or enrolleed in WMIP or MMIP or the client's or enrollee's representative 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, except as provided in subsection (g) of this section.

     (fg) Clients may request that MAA retroactively end enrollment from WMIP and MMIP. 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 WMIP and MMIP are designed to include the following services:

     (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. This notice informs the client about the right to disenroll and how to do so.

     A final cost-benefit analysis is available by contacting Alison Robbins, MAA Care Coordinator, Medical Assistance Administration, P.O. Box 45530, Olympia, WA 98504-5530, phone (360) 725-1634, fax (360) 753-7315, e-mail robbiaa@dshs.wa.gov. No changes were made. The preliminary cost-benefit analysis will be final.

     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 1, 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 6, 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 1, Amended 6, Repealed 0.

     Date Adopted: December 3, 2004.

Brian H. Lindgren, Manager

Rules and Policies Assistance Unit

     Reviser's note: The material contained in this filing exceeded the page-count limitations of WAC 1-21-040 for appearance in this issue of the Register. It will appear in the 05-02 issue of the Register.

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