WSR 05-08-122

PROPOSED RULES

DEPARTMENT OF

SOCIAL AND HEALTH SERVICES
(Health and Rehabilitative Services Administration)

[ Filed April 5, 2005, 4:20 p.m. ]

Original Notice.

Preproposal statement of inquiry was filed as WSR 04-05-085.

Title of Rule and Other Identifying Information: Amending WAC 388-865-0335 Consumer enrollment, and repealing WAC 388-865-0340 Consumer disenrollment.

Hearing Location(s): Blake Office Park East (behind Goodyear Courtesy Tire), Rose Room, 4500 10th Avenue S.E., Lacey, WA, on May 10, 2005, at 10:00 a.m.

Date of Intended Adoption: Not earlier than May 11, 2005.

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., May 10, 2005.

Assistance for Persons with Disabilities: Contact Andy Fernando, DSHS Rules Coordinator, by May 6, 2005, TTY (360) 664-6178 or (360) 664-6097.

Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: These rules implement the state's Medicaid 1915(b) waiver under the Social Security Act and Medicaid state plan to modify consumer enrollment provisions and repeal the consumer disenrollment provision.

Reasons Supporting Proposal: Implementation of these rules is necessary to maintain compliance with the Medicaid 1915(b) waiver and state plan provisions. The rule establishes the process by which consumers may be enrolled for Medicaid sponsored mental health benefits and repeals the provision for consumers to disenroll from the local service provider of record.

Statutory Authority for Adoption: RCW 71.24.035.

Statute Being Implemented: RCW 71.24.035.

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 and Implementation: C. H. Hank Balderrama, Olympia, Washington, (360) 902-0820; and Enforcement: Kellean Foster, Olympia, Washington, (360) 902-0795.

No small business economic impact statement has been prepared under chapter 19.85 RCW. This regulatory change affects prepaid inpatient health plans which are not small businesses.

A cost-benefit analysis is not required under RCW 34.05.328. Does not meet the definition of a significant rule under RCW 34.05.328.

March 30, 2005

Andy Fernando, Manager

Rules and Policies Assistance Unit

3472.4
AMENDATORY SECTION(Amending WSR 01-12-047, filed 5/31/01, effective 7/1/01)

WAC 388-865-0335   Consumer enrollment.   (1) DSHS enrolls a Medicaid recipient in a mental health prepaid inpatient health plan when the person resides in the contracted service area of the prepaid inpatient health plan. The assigned prepaid inpatient health plan is responsible to provide outpatient medically necessary state Medicaid plan approved services to Medicaid service recipients in the contracted service area and to assure inpatient medically necessary state Medicaid plan approved services are received;

(2) An enrolled Medicaid ((consumer)) service recipient who requests or receives medically necessary nonemergency community mental health rehabilitation services ((requests and receives)) may request and receive such service from the assigned mental health prepaid inpatient health plan through authorized providers only;

(3) An enrolled Medicaid ((consumer does not need to request disenrollment from the mental health division)) service recipient is automatically transferred from the assigned prepaid inpatient health plan when the recipient moves from the contracted service area of one mental health prepaid inpatient health plan to the contracted service area of another;

(4) Services to Medicaid recipients may be provided through alternative means if currently contracted authorized providers are not able to provide those services when:

(a) The services are state Medicaid plan approved services and are medically necessary for the Medicaid service recipient; and

(b) Services are or should be available to other Medicaid service recipients in the local mental health prepaid inpatient health plan; and

(c) The Medicaid service recipient has made reasonable attempts to utilize services through authorized providers; or

(d) The Medicaid service recipient has received a choice of providers and has made an informed decision to request medically necessary services through a provider outside the prepaid inpatient health plan provider network that has cultural or linguistic expertise or both needed to meet medical necessity that are not sufficient within the provider network; or

(e) The Medicaid service recipient has utilized the prepaid inpatient health plan grievance or appeal process and the state administrative hearing process, and a decision has been made in favor of the Medicaid service recipient that Medicaid plan approved services continue to be medically necessary.

[Statutory Authority: RCW 71.05.560, 71.24.035 (5)(c), 71.34.800, 9.41.047, 43.20B.020, and 43.20B.335. 01-12-047, 388-865-0335, filed 5/31/01, effective 7/1/01.]


REPEALER

     The following section of the Washington Administrative Code is repealed:
WAC 388-865-0340 Consumer disenrollment.

Washington State Code Reviser's Office