WSR 08-10-048

PERMANENT RULES

DEPARTMENT OF

SOCIAL AND HEALTH SERVICES
(Health and Recovery Services Administration)

[ Filed May 1, 2008, 11:37 a.m. , effective June 1, 2008 ]


Effective Date of Rule: Thirty-one days after filing.

Purpose: The department is amending WAC 388-538-063 to meet requirements of the 2007-2009 state omnibus operating budget which provides for funding to add a mental health service component to the general assistance unemployable (GAU) medical care services care management project. GAU clients enrolled in a managed care plan in designated counties may receive mental health services and care coordination on a limited basis, subject to available funding from the legislature and an appropriate delivery system. The rule does not change the GAU scope of care and GAU medical/financial eligibility requirements.

Citation of Existing Rules Affected by this Order: Amending WAC 388-538-063.

Statutory Authority for Adoption: RCW 74.08.090.

Other Authority: 2007-2009 state omnibus operating budget (section 209 (13)-(14), chapter 522, Laws of 2007).

Adopted under notice filed as WSR 08-07-085 on March 19, 2008.

Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 1, Repealed 0.

Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 0, Repealed 0.

Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 1, Repealed 0.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: April 29, 2008.

Stephanie E. Schiller

Rules Coordinator

3952.3
AMENDATORY SECTION(Amending WSR 06-24-036, filed 11/30/06, effective 1/1/07)

WAC 388-538-063   ((Mandatory enrollment in managed care for GAU clients)) GAU clients residing in a designated mandatory managed care plan county.   (1) ((The purpose of this section is to describe the department's managed care requirement for general assistance unemployable (GAU) clients mandated by the Laws of 2003, chapter 25, section 209(15))) In Laws of 2007, chapter 522, section 209 (13) and (14), the legislature authorized the department to provide coverage of certain medical and mental health benefits to clients who:

(a) Receive medical care services (MCS) under the general assistance unemployable (GAU) program; and

(b) Reside in a county designated by the department as a mandatory managed care plan county.

(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 department-paid medical care,)) GAU clients who reside in a county designated by the department as a mandatory managed care plan county 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)) to receive department-paid medical care. A GAU client enrolled in an MCO plan under this section is defined as a GAU enrollee.

(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),)) The department ((will)) exempts a GAU client from mandatory enrollment in managed care ((or end an enrollee's enrollment in managed care in)):

(a) If the GAU client resides in a county that is not designated by the department as a mandatory MCO plan county; or

(b) In accordance with WAC 388-538-130(3) ((and 388-538-130(4))).

(6) The department ends a GAU enrollee's enrollment in managed care in accordance with WAC 388-538-130(4).

(7) On a case-by-case basis, the department may grant a GAU client's request for exemption from managed care or a GAU enrollee's request to end enrollment when, in the department'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))) (8) The department enrolls GAU clients in managed care effective on the earliest possible date, given the requirements of the enrollment system. The department does not enroll clients in managed care on a retroactive basis.

(((8))) (9) Managed care organizations (MCOs) that contract with the department to provide services ((for)) to GAU clients must meet the qualifications and requirements in WAC 388-538-067 and 388-538-095 (3)(a), (b), (c), and (d).

(((9))) (10) The department pays MCOs capitated premiums for GAU enrollees based on legislative allocations for the GAU program.

(((10))) (11) GAU enrollees are eligible for the scope of care as described in WAC 388-501-0060 for medical care services (MCS) programs. ((Other scope of care provisions that apply:))

(a) A ((client)) GAU enrollee 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) The department 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))

(d) A GAU enrollee may obtain:

(i) Emergency services in accordance with WAC 388-538-100; and

(ii) Mental health services in accordance with this section.

(((11))) (12) The department 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)) healthcare services that are:

(a) Provided by an MCO-contracted provider; or

(b) Authorized by the MCO and provided by nonparticipating providers.

(((12))) (13) The following services are not covered for GAU enrollees unless the MCO chooses to cover these services at no additional cost to the department:

(a) Services that are not medically necessary;

(b) Services not included in the medical care services scope of care, unless otherwise specified in this section;

(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))) (14) A provider may bill a GAU enrollee for noncovered services described in subsection (12) of this section, if the requirements of WAC 388-502-0160 and 388-538-095(5) are met.

(15) Mental health services and care coordination are available to GAU enrollees on a limited basis, subject to available funding from the legislature and an appropriate delivery system.

(16) A care coordinator (a person employed by the MCO or one of the MCO's subcontractors) provides care coordination to a GAU enrollee in order to improve access to mental health services. Care coordination may include brief, evidenced-based mental health services.

(17) To ensure a GAU enrollee receives appropriate mental health services and care coordination, the department requires the enrollee to complete at least one of the following assessments:

(a) A physical evaluation;

(b) A psychological evaluation;

(c) A mental health assessment completed through the client's local community mental health agency (CMHA) and/or other mental health agencies;

(d) A brief evaluation completed through the appropriate care coordinator located at a participating community health center (CHC);

(e) An evaluation by the client's primary care provider (PCP); or

(f) An evaluation completed by medical staff during an emergency room visit.

(18) A GAU enrollee who is screened positive for a mental health condition after completing one or more of the assessments described in subsection (17) of this section may receive one of the following levels of care:

(a) Level 1. Care provided by a care coordinator when it is determined that the GAU enrollee does not require Level 2 services. The care coordinator will provide the following, as determined appropriate and available:

(i) Evidenced-based behavioral health services and care coordination to facilitate receipt of other needed services.

(ii) Coordination with the PCP to provide medication management.

(iii) Referrals to other services as needed.

(iv) Coordination with consulting psychiatrist as necessary.

(b) Level 2. Care provided by a contracted provider when it is determined that the GAU enrollee requires services beyond Level 1 services. A care coordinator refers the GAU enrollee to the appropriate provider for services:

(i) A regional support network (RSN) contracted provider; or

(ii) A contractor-designated entity.

(19) Billing and reporting requirements and payment amounts for mental health services and care coordination provided to GAU enrollees are described in the contract between the MCO and the department.

(20) The total amount the department pays in any biennium for services provided pursuant to this section cannot exceed the amount appropriated by the legislature for that biennium. The department has the authority to take whatever actions necessary to ensure the department stays within the appropriation.

(21) Nothing in this section shall be construed as creating a legal entitlement to any GAU client for the receipt of any medical or mental health service by or through the department.

(22) An MCO may refer enrollees to the department's patient review and coordination (PRC) program according to WAC 388-501-0135.

(((14))) (23) The grievance and appeal process found in WAC 388-538-110 applies to GAU enrollees described in this section.

(((15))) (24) The hearing process found in chapter 388-02 WAC and WAC 388-538-112 applies to GAU enrollees described in this section.

[Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. 06-24-036, 388-538-063, filed 11/30/06, effective 1/1/07. Statutory Authority: RCW 74.08.090 and 74.09.522. 06-03-081, 388-538-063, filed 1/12/06, effective 2/12/06. 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.]

Washington State Code Reviser's Office