WSR 05-16-084

PROPOSED RULES

DEPARTMENT OF

SOCIAL AND HEALTH SERVICES
(Aging and Disability Services Administration)

[ Filed August 1, 2005, 4:30 p.m. ]

Original Notice.

Preproposal statement of inquiry was filed as WSR 05-06-082.

Title of Rule and Other Identifying Information: Adopting new WAC 388-106-0720 through 388-106-0740, Medicare/Medicaid integration program (MMIP) services; and amending WAC 388-106-0015 What long-term care services does the department provide?

Hearing Location(s): Blake Office Park East, Rose Room, 4500 10th Avenue S.E., Lacey, WA 98503 (one block north of the intersection of Pacific Avenue S.E. and Alhadeff Lane, behind Goodyear Tire. A map or directions are available at http://www1.dshs.wa.gov/msa/rpau/docket.html or by calling (360) 664-6097), on September 6, 2005, at 10:00 a.m.

Date of Intended Adoption: Not earlier than September 7, 2005.

Submit Written Comments to: DSHS Rules Coordinator, P.O. Box 45850, Olympia, WA 98504, delivery 4500 10th Avenue S.E., Lacey, WA 98503, e-mail fernaax@dshs.wa.gov, fax (360) 664-6185, by 5:00 p.m., September 6, 2005.

Assistance for Persons with Disabilities: Contact Stephanie Schiller, DSHS Rules Consultant, by September 2, 2005, TTY (360) 664-6178 or (360) 664-6097 or by e-mail at schilse@dshs.wa.gov.

Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: The purpose of the rules are to add eligibility criteria and guidance for implementation of the Medicare/Medicaid integration project (MMIP), a new and innovative managed care program in the state of Washington that will combine long-term care and medical services under one coordinated service delivery model and capitated payment structure, thereby improving client outcomes through increased coordination, while better managing Medicaid expenditures.

Reasons Supporting Proposal: See above.

Statutory Authority for Adoption: RCW 74.08.090.

Statute Being Implemented: RCW 74.08.090, 42 C.F.R. 441.302(a); Social Security Act section 1915(c) waiver rules; 42 C.F.R. 438.

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, Implementation and Enforcement: Brooke Buckingham, P.O. Box 45600, Olympia, WA 98504-5600, (360) 725-3213.

No small business economic impact statement has been prepared under chapter 19.85 RCW. The department has analyzed the proposed rules and determined that no new costs will be imposed on small businesses or nonprofit organizations.

A cost-benefit analysis is not required under RCW 34.05.328. Exempt per RCW 34.05.328 (5)(b)(vii), "Rules of the department of social and health services relating only to client medical or financial eligibility..."

July 28, 2005

Andy Fernando, Manager

Rules and Policies Assistance Unit

3570.4MEDICARE/MEDICAID INTEGRATION PROGRAM (MMIP) SERVICES
NEW SECTION
WAC 388-106-0720   What services may I receive under MMIP?   (1) Once you are determined eligible, your care plan could include, but is not limited to, any of the following long-term care services:

(a) Care coordination;

(b) Personal care services in your own home or in a residential facility;

(c) Home Health Aide;

(d) Adult Day Services;

(e) Environmental Modifications;

(f) Personal Emergency Response System (PERS);

(g) Skilled Nursing;

(h) Specialized Medical Equipment and Supplies;

(i) Home Delivered Meals;

(j) Residential care;

(k) Nursing facility care.

(2) The care plan may also include, but is not limited to, the following medical services:

(a) Primary medical care;

(b) Restorative therapies, including speech, occupational, and physical therapy;

(c) Nursing Services;

(d) Durable medical equipment (e.g., wheelchair);

(e) Pharmaceutical products;

(f) Immunizations and vaccinations;

(g) Vision Care;

(h) Emergency room visits and inpatient hospital stays. The care plan may also include other services determined necessary by the interdisciplinary team to improve and maintain your overall health status.

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NEW SECTION
WAC 388-106-0725   Am I eligible for MMIP services?   To qualify for Medicaid-funded MMIP services, you must:

(1) Be age sixty-five or older;

(2) Live within the designated MMIP service area;

(3) Be eligible for Medicare (Parts A and B);

(4) Be eligible for Medicaid-funded medical and/or long-term care services.

(a) To be eligible to receive long-term care services under this program, you must meet functional eligibility for one of the long-term care programs per WAC 388-106-0210(2), WAC 388-106-0310(4), or WAC 388-106-0355(1) and financial eligibility for noninstitutional categorically needy, or institutional categorically needy as described in chapter 388-513 WAC and WAC 388-515-1505.

(b) Ongoing functional and financial eligibility for long-term care services will be determined at least annually by the state.

(c) If you are determined not eligible for long-term care services, you may be eligible to receive medical services under MMIP; and

(5) Not be enrolled in any other medical coverage plan that purchases services on a prepaid basis (e.g., prepaid health plan).

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NEW SECTION
WAC 388-106-0730   How do I pay for MMIP services?   Depending on your income and resources, you may be required to pay for part of your MMIP services. The department's financial worker will determine what amount, if any, you must contribute toward the cost of your care.

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NEW SECTION
WAC 388-106-0735   How do I disenroll from MMIP?   You may choose to disenroll from MMIP for any reason at any time. See WAC 388-538-061 for additional information on ending enrollment in MMIP.

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NEW SECTION
WAC 388-106-0740   What is the fair hearing process for enrollee appeals of managed care organization actions?   See WAC 388-538-112 for additional information about the fair hearing process.

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3583.1
AMENDATORY SECTION(Amending WSR 05-11-082, filed 5/17/05, effective 6/17/05)

WAC 388-106-0015   What long-term care services does the department provide?   The department provides long-term care services through programs that are designed to help you remain in the community. These programs offer an alternative to nursing home care (which is described in WAC 388-106-0350 through 388-106-0360). You may receive services from any of the following:

(1) Medical personal care (MPC) is a Medicaid state plan program authorized under RCW 74.09.520. Clients eligible for this program may receive personal care in their own home or in a residential facility.

(2) Community options program entry system (COPES) is a Medicaid waiver program authorized under RCW 74.39A.030. Clients eligible for this program may receive personal care in their own home or in a residential facility.

(3) Medically needy residential waiver (MNRW) is a Medicaid waiver program authorized under RCW 74.39.041. Clients eligible for this program may receive personal care in a residential facility.

(4) Medically needy in-home waiver (MNIW) is a Medicaid waiver program authorized under RCW 74.09.700. Clients eligible for this program may receive personal care in their own home.

(5) Chore is a state-only funded program authorized under RCW 74.39A.110. Grandfathered clients may receive assistance with personal care in their own home.

(6) Volunteer chore is a state-funded program that provides volunteer assistance with household tasks to eligible clients.

(7) Program of all-inclusive care for the elderly (PACE) is a Medicaid/Medicare managed care program authorized under 42 CFR 460.2. Clients eligible for this program may receive personal care and medical services in their own home, in residential facilities, and in adult day health centers.

(8) Adult day health is a supervised daytime program providing skilled nursing and rehabilitative therapy services in addition to core services outlined in WAC 388-106-0800.

(9) Adult day care is a supervised daytime program providing core services, as defined under WAC 388-106-0800.

(10) GAU-funded residential care is a state-funded program authorized under WAC 388-400-0025. Clients eligible for this program may receive personal care services in an adult family home or an adult residential care facility.

(11) Residential care discharge allowance is a service that helps eligible clients to establish or resume living in their own home.

(12) Private duty nursing is a Medicaid service that provides an alternative to institutionalization in a hospital or nursing facility setting. Clients eligible for this program may receive at least four continuous hours of skilled nursing care on a day to day basis in their own home.

(13) Senior Citizens Services Act (SCSA) is a program authorized under chapter 74.38 RCW. Clients eligible for this program may receive community-based services as defined in RCW 74.38.040.

(14) Respite program is a program authorized under RCW 74.41.040 and WAC 388-106-1200. This program provides relief care for unpaid family or other caregivers of adults with a functional disability.

(15) Programs for persons with developmental disabilities are discussed in chapter 388-825 through 388-853 WAC.

(16) Nursing facility.

(17) Medicare/Medicaid Integration Project (MMIP) is a DSHS prepaid managed care program, authorized under 42 CFR Part 438, that integrates medical and long-term care services for clients who are sixty-five years of age or older and eligible for Medicare (Parts A and B) and Medicaid.

[Statutory Authority: RCW 74.08.090, 74.09.520. 05-11-082, 388-106-0015, filed 5/17/05, effective 6/17/05.]

Washington State Code Reviser's Office