WSR 11-23-072

EMERGENCY RULES

HEALTH CARE AUTHORITY


(Medicaid Program)

[ Filed November 15, 2011, 10:25 a.m. , effective November 15, 2011, 10:25 a.m. ]


Effective Date of Rule: Immediately.

Purpose: In meeting the requirements of E2SHB 2082, the agency is amending WAC 182-538-063 to replace General assistance -- Unemployable with medical care services program. The new incapacity-based medical care services program became effective November 1, 2011, under WSR 11-22-052.

Citation of Existing Rules Affected by this Order: Amending WAC 182-538-063.

Statutory Authority for Adoption: RCW 41.05.021, 74.09.035.

Other Authority: Chapter 36, Laws of 2011 (ESSHB [E2SHB] 2082).

Under RCW 34.05.350 the agency for good cause finds that state or federal law or federal rule or a federal deadline for state receipt of federal funds requires immediate adoption of a rule.

Reasons for this Finding: See Purpose statement above.

Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 1, Repealed 0.

Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 0, Repealed 0.

Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 1, Repealed 0.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: November 14, 2011.

Kevin M. Sullivan

Rules Coordinator

OTS-4473.1


AMENDATORY SECTION(Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)

WAC 182-538-063   ((GAU)) MCS clients residing in a designated mandatory managed care plan county.   (1) 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)) Are eligible for medical care services (MCS) under ((the general assistance unemployable (GAU) program)) WAC 182-508-0005; and

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

(2) The only sections of chapter ((388-538)) 182-538 WAC that apply to ((GAU)) MCS clients described in this section are incorporated by reference into this section.

(3) ((GAU)) MCS 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))) 182-508-0001 to receive ((department-paid)) agency-paid medical care. ((A GAU)) An MCS client enrolled in an MCO plan under this section is defined as ((a GAU)) an MCS enrollee.

(4) ((GAU)) MCS clients are exempt from mandatory enrollment in managed care if they are American Indian or Alaska Native (AI/AN) and meet the provisions of 25 U.S.C. 1603 (c)-(d) for federally recognized tribal members and their descendants.

(5) The ((department)) agency exempts ((a GAU)) an MCS client from mandatory enrollment in managed care:

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

(b) In accordance with WAC ((388-538-130)) 182-538-130(3).

(6) The ((department)) agency ends ((a GAU)) an MCS enrollee's enrollment in managed care in accordance with WAC ((388-538-130)) 182-538-130(4).

(7) On a case-by-case basis, the ((department)) agency may grant ((a GAU)) an MCS client's request for exemption from managed care or ((a GAU)) an MCS enrollee's request to end enrollment when, in the ((department's)) agency'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.

(8) The ((department)) agency enrolls ((GAU)) MCS clients in managed care effective on the earliest possible date, given the requirements of the enrollment system. The ((department)) agency does not enroll clients in managed care on a retroactive basis.

(9) Managed care organizations (MCOs) that contract with the ((department)) agency to provide services to ((GAU)) MCS clients must meet the qualifications and requirements in WAC ((388-538-067)) 182-538-067 and ((388-538-095)) 182-538-095 (3)(a), (b), (c), and (d).

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

(11) ((GAU)) MCS enrollees are eligible for the scope of care as described in WAC ((388-501-0060)) 182-501-0060 for medical care services (MCS) programs.

(a) ((A GAU)) An MCS enrollee is entitled to timely access to medically necessary services as defined in WAC ((388-500-0005)) 182-500-0070;

(b) MCOs cover the services included in the managed care contract for ((GAU)) MCS enrollees. MCOs may, at their discretion, cover services not required under the MCO's contract for ((GAU)) MCS enrollees;

(c) The ((department)) agency 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)) MCS enrollees;

(d) ((A GAU)) An MCS enrollee may obtain:

(i) Emergency services in accordance with WAC ((388-538-100)) 182-538-100; and

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

(12) The ((department)) agency does not pay providers on a fee-for-service basis for services covered under the MCO's contract for ((GAU)) MCS 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 healthcare services that are:

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

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

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

(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)) 182-538-100(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.

(14) A provider may bill ((a GAU)) an MCS enrollee for noncovered services described in subsection (12) of this section, if the requirements of WAC ((388-502-0160)) 182-502-0160 and ((388-538-095)) 182-538-095(5) are met.

(15) Mental health services and care coordination are available to ((GAU)) MCS 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)) an MCS 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)) an MCS enrollee receives appropriate mental health services and care coordination, the ((department)) agency 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)) An MCS 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)) MCS 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)) MCS enrollee requires services beyond Level 1 services. A care coordinator refers the ((GAU)) MCS 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)) MCS enrollees are described in the contract between the MCO and the ((department)) agency.

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

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

(22) An MCO may refer enrollees to the ((department's)) agency's patient review and coordination (PRC) program according to WAC ((388-501-0135)) 182-501-0135.

(23) The grievance and appeal process found in WAC ((388-538-110)) 182-538-110 applies to ((GAU)) MCS enrollees described in this section.

(24) The hearing process found in chapter ((388-02)) 182-526 WAC and WAC ((388-538-112)) 182-538-112 applies to ((GAU)) MCS enrollees described in this section.

[11-14-075, recodified as 182-538-063, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 2007 c 522 209 (13)-(14). 08-10-048, 388-538-063, filed 5/1/08, effective 6/1/08. 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