SOCIAL AND HEALTH SERVICES
(Health and Recovery Services Administration)
Effective Date of Rule: February 7, 2006.
Purpose: WAC 388-538-063 is being amended to remove incorrect authorization language.
Citation of Existing Rules Affected by this Order: Amending WAC 388-538-063.
Statutory Authority for Adoption: RCW 74.08.090, 74.09.035, 74.09.522.
Other Authority: ESSB 5404, Section 209(15), chapter 25, Laws of 2003 1st sp.s.
Under RCW 34.05.350 the agency for good cause finds that immediate adoption, amendment, or repeal of a rule is necessary for the preservation of the public health, safety, or general welfare, and that observing the time requirements of notice and opportunity to comment upon adoption of a permanent rule would be contrary to the public interest.
Reasons for this Finding: This emergency rule adoption is necessary while the permanent rule-making process is being completed. The current WAC incorrectly directs the client to receive authorization for services from the managed care organization (MCO) instead of the department. This incorrect language causes confusion and delays in the delivery of medically necessary services and results in the loss of due process rights for the enrollee. As the WAC now reads, enrollees must exhaust the MCO's appeal process before they can file a fair hearing. For GAU clients, the MCO does not have an appeal process because it is the department that approves or denies services. This creates a "catch twenty-two" for enrollees who have no redress through the MCO, but also cannot file a fair hearing request until the rule is corrected.
This continues the emergency rule that is currently in effect under WSR 05-21-027. The permanent rule has been adopted under WSR 06-03-081 and will supercede this emergency rule when the permanent rule becomes effective February 12, 2006. This emergency rule is necessary to cover the gap between the expiration of the current emergency rule (February 6) and the effective date of the permanent rule.
Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 1, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.
Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.
Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.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 0.
Date Adopted: January 25, 2006.
Andy Fernando, Manager
Rules and Policies Assistance Unit3559.2
(2) The only sections of chapter 388-538 WAC that apply to GAU clients described in this section are incorporated by reference into this section.
(3) To receive medical assistance administration (MAA) paid medical care, GAU clients must enroll in a managed care plan as required by WAC 388-505-0110(7) when they reside in a county designated as a mandatory managed care plan county.
(4) GAU clients are exempt from mandatory enrollment in managed care if they:
(a) Are American Indian or Alaska Native (AI/AN); and
(b) Meet the provisions of 25 U.S.C. 1603 (c)-(d) for federally recognized tribal members and their descendants.
(5) In addition to subsection (4), MAA will exempt a GAU client from mandatory enrollment in managed care or end an enrollee's enrollment in managed care in accordance with WAC 388-538-130(3) and 388-538-130(4).
(6) On a case-by-case basis, MAA may grant a GAU client's request for exemption from managed care or a GAU enrollee's request to end enrollment when, in MAA's judgment:
(a) The client or enrollee has a documented and verifiable medical condition; and
(b) Enrollment in managed care could cause an interruption of treatment that could jeopardize the client's or enrollee's life or health or ability to attain, maintain, or regain maximum function.
(7) MAA enrolls GAU clients in managed care effective on the earliest possible date, given the requirements of the enrollment system. MAA does not enroll clients in managed care on a retroactive basis.
(8) Managed care organizations (MCOs) that contract with MAA to provide services for GAU clients must meet the qualifications and requirements in WAC 388-538-067 and 388-538-095 (3)(a), (b), (c), and (d).
(9) MAA pays MCOs capitated premiums for GAU enrollees based on legislative allocations for the GAU program.
(10) GAU enrollees are eligible for the scope of care as described in WAC 388-529-0200 for medical care services (MCS). Other scope of care provisions that apply:
(a) A client is entitled to timely access to medically necessary services as defined in WAC 388-500-0005;
(b) MCOs cover the services included in the managed care contract for GAU enrollees. MCOs may, at their discretion, cover services not required under the MCO's contract for GAU enrollees;
(c) MAA pays providers on a fee-for-service basis for the medically necessary, covered medical care services not covered under the MCO's contract for GAU enrollees; and
Even if a service is covered by MAA on a
fee-for-service basis, it is the MCO, and not MAA, from whom a
GAU enrollee must obtain prior authorization before receiving
the service; and
(e))) A GAU enrollee may obtain emergency services in accordance with WAC 388-538-100.
(11) MAA does not pay providers on a fee-for-service basis for services covered under the MCO's contract for GAU enrollees, even if the MCO has not paid for the service, regardless of the reason. The MCO is solely responsible for payment of MCO-contracted health care services that are:
(a) Provided by an MCO-contracted provider; or
(b) Authorized by the MCO and provided by nonparticipating providers.
(12) The following services are not covered for GAU enrollees unless the MCO chooses to cover these services at no additional cost to MAA:
(a) Services that are not medically necessary;
(b) Services not included in the medical care services scope of care;
(c) Services, other than a screening exam as described in WAC 388-538-100(3), received in a hospital emergency department for nonemergency medical conditions; and
(d) Services received from a nonparticipating provider requiring prior authorization from the MCO that were not authorized by the MCO.
(13) A provider may bill a GAU enrollee for noncovered services described in subsection (12), if the requirements of WAC 388-502-0160 and 388-538-095(5) are met.
(14) The grievance and appeal process found in WAC 388-538-110 applies to GAU enrollees described in this section.
(15) The ((
fair)) hearing process found in chapter 388-02 WAC and WAC 388-538-112 applies to GAU enrollees described in
[Statutory Authority: RCW 74.08.090, 74.09.035, 74.09.522, and 2003 1st sp.s. c 25 § 209(15). 04-15-003, § 388-538-063, filed 7/7/04, effective 8/7/04.]