WSR 05-17-154

PERMANENT RULES

DEPARTMENT OF

SOCIAL AND HEALTH SERVICES
(Health and Recovery Services Administration)

[ Filed August 22, 2005, 4:19 p.m. , effective September 22, 2005 ]


Purpose: To amend WAC 388-865-0335 and 388-865-0340 to repeal provisions that allow consumer disenrollment from a regional support network in accordance with the federal waiver of provisions at Section 1915(b) of the Social Security Act as approved by the Centers for Medicare and Medicaid Services.

Citation of Existing Rules Affected by this Order: Repealing WAC 388-865-0340; and amending WAC 388-865-0335.

Statutory Authority for Adoption: RCW 71.24.035.

Adopted under notice filed as WSR 05-08-122 on April 5, 2005.

Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 1, Repealed 1; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 0, Repealed 0.

Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 1, Repealed 1.

Date Adopted: August 17, 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