PERMANENT RULES
(Medicaid Program)
Effective Date of Rule: July 1, 2013.
Purpose: In accordance with the federal Patient Protection and Affordable Care Act (PPACA), Section 2703, and Washington SSB 5394, these rules are necessary to implement adoption of health homes and within them, advance the practice of chronic care management to improve health outcomes and reduce unnecessary costs. The agency is changing the title of this chapter to health homes.
Citation of Existing Rules Affected by this Order: Amending WAC 182-557-0050, 182-557-0100, 182-557-0200, 182-557-0300, and 182-557-0400.
Statutory Authority for Adoption: RCW 41.05.021; chapter 316, Laws of 2011 (SSB 5394).
Adopted under notice filed as WSR 13-03-089 on January 15, 2013.
Changes Other than Editing from Proposed to Adopted Version: WAC 182-557-0050 Health home -- General.
(1) The agency's health home program provides
patient-centered care to beneficiaries at high risk for high
health costs and poor health outcomes. Health home services
consist of six care coordination activities that include
providing education to the beneficiary in self-managing his or
her condition and navigating the health care system. who:
(a) Have a least one chronic condition as defined in WAC 182-557-0100;
(b) Be at risk of a second chronic condition with a minimum predictive risk score of 1.5; and
(c) Are at risk for high health costs, avoidable admissions to institutional care settings, and poor health outcomes.
(2) Health homes offers: six care coordination activities
to assist the beneficiary in self-managing his or her
condition and navigating the health care system:
(a) Comprehensive or intensive care management, including
but not limited to, assessing participant's readiness for
self-management, and promote promoting self-management
skills;, coordinating interventions tailored to meet the
beneficiary's needs, and facilitating improved outcomes and
appropriate use of health care services;
(b) Care coordination and health promotion to support
coordination across sytems of care and beneficiaries'
participation in their care;
(c) Comprehensive transitional care between care settings, including, but not limited to, after discharge from an inpatient facility (hospital, rehabilitative, psychiatric, skilled nursing, substance use disorder treatment or residential habilitation setting);
(d) Individual and family support services to provide health promotion, education, training and coordination of covered services for beneficiaries and their support network;
(e) Referrals to community and support services; and
(f) Use of health information technology (HIT) to link
services between the health home and the beneficiaries'
providers.
(3) The agency's health home program does not:
(a) Change the scope of services available to for which a
beneficiary is eligible under medicare or a Title XIX medicaid
program;
(b) Interfere with the relationship between a beneficiary and his or her chosen agency-enrolled provider(s);
(c) Duplicate case management activities available to a
beneficiary in the beneficiary's community or by is receiving
from other providers or programs; or
WAC 182-557-0100 Health home program--Definitions.
Covered services - The medicare and medicaid covered services that will be coordinated as part of health home program activities.
Full dual eligible - For the purpose of this chapter,
means individuals who are enrolled in medicare parts A and B,
and who are eligible for, and reeiving, medicaid and no other
comprehensive private and public health coverage an individual
who receives qualified medicare beneficiary coverage or
specified low-income medicare beneficiary coverage and
categorically needy health care coverage.
HIPAA (Health Insurance Portability and Accountability Act of 1996) - The agency struck this proposed definition.
Participation - An agreement by the beneficiary to
participate in health home services as demonstrated by the
health action plan. A beneficiary's agreement to a health
action plan which constitutes an agreement by the beneficiary
to participate in health home services.
"PRISM" or "Predictive Risk Intelligence SysteM" - A DSHS-secure web-based predictive modeling and clinical decision support tool. This tool provides a unified view of medical, behavioral health, and long-term care service data that is refreshed on a regular basis. PRISM provides prospective medical risk scores that are a measure of expected medical costs in the next twelve months based on the patient's disease profile and pharmacy utilization.
"Self-management" - With guidance from a health home care coordinator or health home care team, the concept of the beneficiary being the driver of his or her own health through the process of:
| • | Identification of health care conditions; |
| • | Health action planning; |
| • | Education; |
| • | Monitoring to ensure progress towards achievement of health action goals; |
| • | Active involvement of the beneficiary in the decision-making process with the health home care coordinator or health home care team. |
(1) To participate in the health home program, a beneficiary must:
(a) Be a recipient of categorically needy health care
coverage, aged, blind, disabled assistance program; or
(b) A recipient of temporary assistance for needy families (TANF); or
(c) (b) A full dually eligible for medicare and medicaid
services; and
(i) Have one or more chronic condition(s) as defined in
WAC 182-557-0100 and the at risk of developing another as
determined by a PRISM risk score of 1.5 or greater; and
(ii) Be identified through predictive modeling as being
high rish [risk] for high medical costs and poor health
outcomes as a result of needing medical treatment for chronic
condition(s); and
(iii) Agree to participate in a health home program.
(2) A beneficiary participating in the health home program must not be:
(a) Eligible for third-party coverage that provides comparable care management services or requires administrative controls that would duplicate or interfere with the agency's health home program; or
(b) Receiving services through another health system that health home services would duplicate.
(3) Using data provided by the department of social and
health services (DSHS), the agency identifies beneficiaries
who are potential participants of health home services. A
beneficiary who meets the participation requirements in this
section will:
(a) Be served by a qualified health home based on the
coverage area in which the beneficiary resides Beneficiaries
who are eligible for health home services will be enrolled
with a qualified health home; and
(b) Be contacted for an assessment and participation in
the program May decline enrollment or change to a different
plan if he or she chooses to;.
(c) Work with a care coordinator to develop a health
action plan that details the beneficiary's health goals and a
plan for achievement of those goals; and
(d) Will receive health home services at a level appropriate to the beneficiary's needs.
(4) A participant who does not agree with a decision
regarding health home services has the right to an
administrative hearing as described in chapter 182-526 WAC. A
beneficiary who meets the participation requirements in this
section will:
(a) Receive services from a qualified health home that contracts with the agency to provide health home services in the coverage area in which the beneficiary resides;
(b) Work with a care coordinator employed by or contracting with a qualified health home provider to develop a health action plan that details the beneficiary's health goals and a plan for achievement of those goals; and
(c) Receive additional health home services at a level appropriate to the beneficiary's needs.
(5) A participant who does not agree with a decision regarding health home services, including a decision regarding the beneficiary's eligibility to participate in health home services, has the right to an administrative hearing as described in chapter 182-526 WAC.
WAC 182-557-0300 Health home services--Confidentiality and
data sharing
(1) Qualified health home contractors must meet comply
with the confidentiality and data sharing requirements that
apply to clients eligible under medicare and Title XIX
medicaid programs and as specified in the health home
contract.
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 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 5, 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 5, Repealed 0.
Date Adopted: May 22, 2013.
Kevin M. Sullivan
Rules Coordinator
OTS-5235.4
AMENDATORY SECTION(Amending WSR 11-14-075, filed 6/30/11,
effective 7/1/11)
WAC 182-557-0050
((Chronic care management program))
Health home--General.
(((1) The department's chronic care
management program:
(a) Offers care management and coordination activities for medical assistance clients determined to be at risk for high medical costs;
(b) Provides education, training, and/or coordination of services for program participants through statewide care management (SCM) and local care management (LCM) providers contracted with DSHS;
(c) Assists program participants in improving self-management skills and improving health outcomes; and
(d) Reduces medical costs by educating clients to better utilize health care services.
(2) The department's chronic care management program does not:
(a) Change the scope of services available to a client eligible under a Title XIX medicaid program;
(b) Interfere with the relationship between a participant (client) and the client's chosen department-enrolled provider(s);
(c) Duplicate case management activities available to a client in the client's community; or
(d) Substitute for established activities that are available to a client and provided by programs administered through other DSHS divisions or state agencies.
(3) Chronic care management program services provided by a statewide care management (SCM) contractor and a local care management (LCM) contractor must meet:
(a) The conditions of the contract between DSHS and the contractor; and
(b) Applicable state and federal requirements.
(4) The SCM contractor uses a predictive modeling program to review DSHS claims, and eligibility data to identify clients eligible to participate in the chronic care management program.)) (1) The agency's health home program provides patient-centered care to beneficiaries who:
(a) Have a least one chronic condition as defined in WAC 182-557-0100;
(b) Be at risk of a second chronic condition with a minimum predictive risk score of 1.5; and
(c) Are at risk for high health costs, avoidable admissions to institutional care settings, and poor health outcomes.
(2) Health homes offer six care coordination activities to assist the beneficiary in self-managing his or her condition and navigating the health care system:
(a) Comprehensive or intensive care management including, but not limited to, assessing participant's readiness for self-management, promoting self-management skills, coordinating interventions tailored to meet the beneficiary's needs, and facilitating improved outcomes and appropriate use of health care services;
(b) Care coordination and health promotion;
(c) Comprehensive transitional care between care settings including, but not limited to, after discharge from an inpatient facility (hospital, rehabilitative, psychiatric, skilled nursing, substance use disorder treatment or residential habilitation setting);
(d) Individual and family support services to provide health promotion, education, training and coordination of covered services for beneficiaries and their support network;
(e) Referrals to community and support services; and
(f) Use of health information technology (HIT) to link services between the health home and beneficiaries' providers.
(3) The agency's health home program does not:
(a) Change the scope of services for which a beneficiary is eligible under medicare or a Title XIX medicaid program;
(b) Interfere with the relationship between a beneficiary and his or her chosen agency-enrolled provider(s);
(c) Duplicate case management activities the beneficiary is receiving from other providers or programs; or
(d) Substitute for established activities that are available through programs administered through the agency or other state agencies.
(4) Qualified health home providers must:
(a) Contract with the agency to provide services under this chapter to eligible beneficiaries;
(b) Accept the terms and conditions in the agency's contract;
(c) Be able to meet the network and quality standards established by the agency;
(d) Accept the rates established by the agency; and
(e) Comply with all applicable state and federal requirements.
(5) The agency reserves the right to not contract with any otherwise qualified health home provider.
[11-14-075, recodified as § 182-557-0050, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500, 74.09.520, and 2007 c 259, § 4. 07-20-048, § 388-557-0050, filed 9/26/07, effective 11/1/07.]
(("Chronic care management program services" are services
provided by DSHS-contracted organizations to clients with
multiple health, behavioral, and social needs in order to
improve care coordination, client education, and client
self-management skills.
"Evidence-based health care practice" means a clinical approach to practicing medicine based on the clinician's awareness of evidence and the strength of that evidence to support the management of a disease treatment process.
"Local care management program" or "LCM program" means a comprehensive care management program and medical home program for medical assistance clients (participants) that serves a specific geographical area of the state.
"Local care management (LCM) contractor" means an entity or group of entities that contracts with DSHS to provide chronic care management program services to eligible participants (clients).
"Medical home" means an approach to providing health care services in a high-quality and cost-effective manner that is accessible, family-centered, comprehensive, continuous, coordinated, compassionate, and culturally competent.
"Participant" means a medical assistance client who has been contacted by an SCM or LCM, and has agreed to participate in the chronic care management program.
"Predictive modeling" means using historical medical claims data to predict future utilization of medical services.
"Self-management" means, with guidance from a health care team, the concept of a medical assistance client being the "driver" of their own health care to improve their health care outcome through:
• Education;
• Monitoring;
• Adherence to evidence-based guidelines; and
• Active involvement in the decision-making process with the team.
"Statewide care management program" or "SCM program" means a comprehensive care management program for clients that serves all areas of the state not served by a local care management (LCM) program.
"Statewide care management (SCM) contractor" means an entity that contracts with DSHS to provide chronic care management program services to eligible medical assistance clients (participants). The SCM contractor provides client identification and referral to appropriate local care management (LCM) programs through predictive modeling.)) Agency - See WAC 182-500-0010.
Beneficiary - A person who is eligible for health home services. See WAC 182-557-0200.
Chronic condition - A condition that, in combination with the beneficiary's risk score, determines eligibility for health home services. The chronic conditions covered are mental health conditions, substance use disorders, asthma, diabetes, heart disease, cancer, cerebrovascular disease, coronary artery disease, dementia or Alzheimer's disease, intellectual disability or disease, HIV/AIDS, renal failure, chronic respiratory conditions, neurological disease, gastrointestinal, hematological and musculoskeletal conditions.
Contractor - The entity providing covered services under contract with the agency.
Coverage area(s) - Predetermined geographical area(s) composed of specific counties that will facilitate a phased-in implementation of health homes.
Covered services - The medicare and medicaid covered services that will be coordinated as part of health home program activities.
DSHS - The department of social and health services.
Full dual eligible - For the purpose of this chapter, means an individual who receives qualified medicare beneficiary coverage or specified low-income medicare beneficiary coverage and categorically needy health care coverage.
Health action plan - A beneficiary-prioritized plan identifying what the beneficiary plans to do to improve their health and/or self-management of health conditions.
Health home - An entity composed of community based providers, qualified and contracted by the agency to provide health home services to eligible beneficiaries.
Medicaid - See WAC 182-500-0070.
Participation - A beneficiary's agreement to a health action plan which constitutes an agreement by the beneficiary to participate in health home services.
Predictive modeling - Using historical medical claims data to predict future utilization of health care services.
PRISM or Predictive Risk Intelligence SysteM - A DSHS-secure web-based predictive modeling and clinical decision support tool. This tool provides a unified view of medical, behavioral health, and long-term care service data that is refreshed on a regular basis. PRISM provides prospective medical risk scores that are a measure of expected medical costs in the next twelve months based on the patient's disease profile and pharmacy utilization.
Risk score - A measure of expected cost risk in the next twelve months based on the beneficiary's disease profiles, medical care utilization, and pharmacy utilization.
Self-management - With guidance from a health home care coordinator or health home care team, the concept of the beneficiary being the driver of his or her own health through the process of:
• Identification of health care conditions;
• Health action planning;
• Education;
• Monitoring to ensure progress towards achievement of health action goals; and
• Active involvement of the beneficiary in the decision-making process with the health home care coordinator or health home care team.
[11-14-075, recodified as § 182-557-0100, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500, 74.09.520, and 2007 c 259, § 4. 07-20-048, § 388-557-0100, filed 9/26/07, effective 11/1/07.]
(a) Be a recipient of the supplemental security income (SSI) program or general assistance with expedited medical categorically needy (GAX) program;
(b) Be identified through predictive modeling as being high risk for high medical costs as a result of needing medical treatment for multiple conditions; and
(c) Agree to participate in the program.
(2) A client participating in the chronic care management program must not be:
(a) Receiving medicare benefits;
(b) Residing in an institution, as defined in WAC 388-500-0005, for more than thirty days;
(c) Eligible for third party coverage that provides care management services or requires administrative controls that would duplicate or interfere with the department's chronic care management program;
(d) Enrolled with a managed care organization (MCO) plan contracted with DSHS;
(e) Currently receiving long term care services; or
(f) Receiving case management services that chronic care management program services would duplicate.
(3) Using data provided by DSHS, the statewide care management (SCM) contractor identifies medical assistance clients who are potential participants for chronic care management program services. A client who meets the participation requirements in this section:
(a) Will be served by the SCM program or a local care management (LCM) program, based on the geographical area of the state the client resides.
(b) Will be contacted by an SCM or LCM care manager for an assessment and enrollment in the program;
(c) Will not be enrolled unless the client specifically agrees to the enrollment;
(d) May request disenrollment at any time. Disenrollment is effective the first day of the following month; and
(e) May request reenrollment at any time. Reenrollment is effective the first day of the following month.
(4) A participating client who subsequently enrolls in a DSHS voluntary managed care program is no longer eligible for chronic care management program services.
(5) A client who meets the eligibility and enrollment criteria for participation in the chronic care management services program:
(a) Is eligible to participate for six months from the date of enrollment provided the client continues to meet eligibility and enrollment criteria; and
(b) May participate for additional six-month participation periods if both the department and the SCM or LCM contractor determine that the participant's self-management skills and health care outcome would benefit.
(6) A client who does not agree with a decision regarding chronic care management program services has a right to a hearing under chapter 388-02 WAC.)) (1) To participate in the health home program, a beneficiary must:
(a) Be a recipient of categorically needy health care coverage; or
(b) A full dual eligible; and
(i) Have one or more chronic condition(s) as defined in WAC 182-557-0100 and at risk of developing another as determined by a PRISM risk score of 1.5 or greater; and
(ii) Agree to participate in a health home program.
(2) A beneficiary participating in the health home program must not be:
(a) Eligible for third-party coverage that provides comparable care management services or requires administrative controls that would duplicate or interfere with the agency's health home program; or
(b) Receiving services through another health system that health home services would duplicate.
(3) Using data provided by the department of social and health services (DSHS), the agency identifies beneficiaries who are potential participants of health home services.
(a) Beneficiaries who are eligible for health homes will be enrolled with a qualified health home; and
(b) May decline enrollment or change to a different plan if he or she chooses to.
(4) A beneficiary who meets the participation requirements in this section will:
(a) Receive services from a qualified health home that contracts with the agency to provide health home services in the coverage area in which the beneficiary resides;
(b) Work with a care coordinator employed by or contracting with a qualified health home provider to develop a health action plan that details the beneficiary's health goals and a plan for achievement of those goals; and
(c) Receive additional health home services at a level appropriate to the beneficiary's needs.
(5) A participant who does not agree with a decision regarding health home services, including a decision regarding the beneficiary's eligibility to participate in health home services, has the right to an administrative hearing as described in chapter 182-526 WAC.
[11-14-075, recodified as § 182-557-0200, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500, 74.09.520, and 2007 c 259, § 4. 07-20-048, § 388-557-0200, filed 9/26/07, effective 11/1/07.]
(2) DSHS shares health care data with SCM and LCM contractors under the provisions of RCW 70.02.050 and the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
(3) DSHS requires SCM and LCM contractors to monitor and evaluate participant activities and provide to the department:
(a) Any client information collected; and
(b) Any data compiled as the result of the program.)) (1) Qualified health home contractors must comply with the confidentiality and data sharing requirements that apply to clients eligible under medicare and Title XIX medicaid programs and as specified in the health home contract.
(2) The agency and the department of social and health services (DSHS) share health care data with qualified health home contractors under the provisions of RCW 70.02.050 and the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
(3) The agency requires qualified health home contractors to monitor and evaluate participant activities and report to the agency as required by the health home contract.
[11-14-075, recodified as § 182-557-0300, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500, 74.09.520, and 2007 c 259, § 4. 07-20-048, § 388-557-0300, filed 9/26/07, effective 11/1/07.]
[11-14-075, recodified as § 182-557-0400, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500, 74.09.520, and 2007 c 259, § 4. 07-20-048, § 388-557-0400, filed 9/26/07, effective 11/1/07.]