HEALTH CARE AUTHORITY

(Washington Apple Health)

(1) The agency's health home program provides patient-centered care to ((beneficiaries)) participants who:

(a) Have ((a)) at least one chronic condition as defined in WAC 182-557-0100; and

(b) ((Be)) Are at risk of a second chronic condition ((with)) as evidenced by 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) The health home((s)) program offers six care coordination activities to assist ((the beneficiary)) participants in self-managing ((his or her)) their conditions 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)) participant'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)) participants 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')) participants' providers.

(3) The agency's health home program does not:

(a) Change the scope of services for which a ((beneficiary)) participant is eligible under medicare or a Title XIX medicaid program;

(b) Interfere with the relationship between a ((beneficiary)) participant and his or her chosen agency-enrolled provider(s);

(c) Duplicate case management activities the ((beneficiary)) participant is receiving from other providers or programs; or

(d) Substitute for established activities that are available through other programs administered ((through)) by 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)) participants;

(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.

The following terms and definitions ((apply to the health home program:)) and those found in chapter 182-500 WAC apply to this chapter:

Agency - See WAC 182-500-0010.

Chronic condition - ((A condition that, in combination with the beneficiary's risk score, determines eligibility for health home services. The chronic conditions covered are)) Means 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.

Coverage area(((s))) - ((Predetermined)) Means a geographical area(((s))) composed of ((specific counties that will facilitate a phased-in implementation of health homes.

DSHS - The department of social and health services.)) one or more counties within Washington state. The map of the coverage areas and the list of the qualified health homes is available on the agency's web site at: http://www.hca.wa.gov/medicaid/health_homes/Pages/index.aspx.

Full dual eligible - For the purpose of this chapter, means ((an individual)) a fee-for-service client 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.)) Means a plan that lists the participant's goals to improve and self-manage their health conditions and steps needed to reach those goals.

Medicaid - See WAC 182-500-0070.

• Active involvement of the beneficiary in the decision-making process with the health home care coordinator or health home care team.)) Participant - Means a client who has agreed to receive health home services under the requirements of this chapter.

(1) To ((participate in)) be eligible for the health home program, a ((beneficiary)) client must:

(a) Be a recipient of categorically needy health care coverage((; or

(i))) through:

(b) 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

(d) Agree to participate in a health home program.

(2) A ((beneficiary participating in the health home program must not be:

(a) Eligible for)) person is ineligible to receive health home services when the person has third-party coverage that provides comparable health 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)) information provided by the department of social and health services (DSHS), the agency identifies ((beneficiaries)) clients who are ((potential participants of)) eligible for health home services.

(((a) Beneficiaries who are)) (4) When the agency determines a client is eligible for health home((s will be enrolled with a qualified health home; and

(b))) services, the agency enrolls the client with a qualified health home in the coverage area where the client lives.

(a) The client may decline ((enrollment)) health home services or change to a different ((plan if he or she chooses to.

(b) Work with a care coordinator employed by or contracting with a qualified health home provider to)) qualified health home or a different health home care coordinator.

(i) Work with the participant to develop a health action plan that ((details)) describes the ((beneficiary's)) participant's health goals and includes a plan for ((achievement of)) reaching those goals; and

(((c) Receive additional)) (ii) Provide health home services at a level appropriate to the ((beneficiary's)) participant's needs.

(5) A participant who does not agree with a decision regarding health home services, including a decision regarding the ((beneficiary's)) client's eligibility to ((participate in)) receive health home services, has the right to an administrative hearing as described in chapter 182-526 WAC.

The agency uses eight steps to calculate a person's risk score.

(1) Step 1. Collect paid claims and health plan encounter data. The agency obtains a set of paid fee-for-service claims and managed care encounters for a client.

(a) For clients age seventeen and younger, the agency uses all paid claims and encounters within the last twenty-four months.

(b) For clients age eighteen and older, the agency uses all paid claims and encounters within the last fifteen months.

(i) The claims and encounters include the international classification of diseases (ICD) diagnosis codes and national drug codes (NDC) submitted by health care providers. These are used in steps 2 and 3 to create a set of risk categories.

(ii) The agency uses two algorithms developed by the University of San Diego:

(A) Chronic illness and disability payment system (CDPS) which assigns ICD diagnosis codes to CDPS risk categories (see Table 6 in Steps to Calculate a Medical Expenditure Risk Score located at http://www.hca.wa.gov/medicaid/health_homes/Documents/calculate_medical_expenditure_risk.pdf); and

(B) Medical Rx (MRx) which assigns NDCs to MRx risk categories (see Table 7 in Steps to Calculate a Medical Expenditure Risk Score located at http://www.hca.wa.gov/medicaid/health_homes/Documents/calculate_medical_expenditure_risk.pdf).

(2) Step 2. Group ICD diagnosis codes into chronic illness and disability payment system risk categories.

(a) To group ICD diagnosis codes into the CDPS risk categories (see Table 1 in (b) of this subsection), the agency uses an ICD diagnosis code to CDPS risk categories crosswalk in subsection (1)(b)(ii)(A) of this section. Each of the ICD diagnosis codes listed is assigned to one risk category. If an ICD diagnosis code is not listed in the crosswalk it does not map to a risk category that is used in the calculation of the risk score.

(b) Table 1. Titles of Chronic Illness and Disability Payment System Risk Categories

(3) Step 3. Group national drug codes (NDCs) into MRx risk categories.

(a) To group the NDC codes into MRx risk categories (see Table 2 in (b) of this subsection), the agency uses a NDC code to MRx risk categories crosswalk in subsection (1)(b)(ii)(B) of this section.

(b) Table 2. Titles of Medicaid Rx Risk Categories

(4) Step 4. Remove duplicate risk categories. After mapping all diagnosis and drug codes to the risk categories, the agency eliminates duplicates of each client's risk categories so that there is only one occurrence of any risk category for each client.

(5) Step 5. Select the highest CDPS risk category within a disease group.

(a) The agency organizes CPDS risk categories into risk category groups of different intensity levels. The high risk category in each group is used in the calculation of the risk score. The lower level risk categories are eliminated from further calculations.

(b) Table 3. Chronic Disease Payment System Risk Category Groups

(6) Step 6. Determine age/gender category.

(a) For each client, the agency selects the appropriate age/gender category. The eleven categories are listed in Table 4 in (b) of this subsection. The categories for ages below five and above sixty-five are gender neutral.

(b) Table 4. Age/Gender Categories

(7) Step 7. Apply risk weights.

(a) The agency assigns each risk category and age/gender category a weight. The weight comes from either the model for clients who are age seventeen and younger or from the model for clients age eighteen and older.

(b) In each model there are three types of weights.

(i) Age/gender – Weights that correspond to the age/gender category of a client.

(ii) CDPS – Weights that correspond to fifty-eight of the CDPS risk categories.

(iii) MRx – Weights that correspond to forty-five of the MRx risk categories.

(c) Table 5. Risk Score Weights

(8) Step 8. Sum risk weights to obtain the risk score.

After obtaining the weights that correspond to a client's age/gender category and set of risk categories, the agency takes a sum of the values of all of the weights. This sum is the risk score for a client.

(1) Qualified health homes ((contractors)) must comply with the confidentiality and data sharing requirements that apply to ((clients)) participants 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 homes ((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 homes ((contractors)) to monitor and evaluate participant activities and report to the agency as required by the health home contract.

(1) Qualified health homes must have a grievances and appeals process in place that complies with the requirements of this section and must maintain records of all grievances and appeals.

(a) This section contains information about the grievance system for fee-for-service clients, including full dual eligible clients, for health home services. These participants must follow the process in chapter 182-526 WAC for appeals.

(b) Participants who are enrolled in an agency-contracted managed care organization must follow the process in WAC 182-538-110 to file a grievance or an appeal for health home services.

(2) Grievance process.

(a) Only a participant or the participant's authorized representative may file a grievance with the qualified health home orally or in writing. A health home care coordinator may not file a grievance for the participant unless the participant gives the health home care coordinator written consent to act on the participant's behalf.

(b) The qualified health home must:

(i) Accept, document, record, and process grievances that it receives from the participant, the participant's representative, or the agency;

(ii) Acknowledge receipt of each grievance, either orally or in writing, within two business days of receiving the grievance;

(iii) Assist the participant with all grievance processes;

(iv) Cooperate with any representative authorized in writing by the participant;

(v) Ensure that decision makers on grievances were not involved in the activity or decision being grieved, or any review of that activity or decision by qualified health home staff;

(vi) Consider all information submitted by the participant or the participant's authorized representative;

(vii) Investigate and resolve all grievances;

(viii) Complete the disposition of a grievance and notice to the affected parties as quickly as the participant's health condition requires, but no later than forty-five calendar days from receipt of the grievance;

(ix) Notify the participant, either orally or in writing, of the disposition of grievances within five business days of determination. Notification must be in writing if the grievance is related to a quality of care issue.

(3) Appeal process.

(a) The qualified health home must give the participant written notice of an action.

(b) The written notice must:

(i) State what action the qualified health home intends to take and the effective date of the action;

(ii) Explain the specific facts and reasons for the decision to take the intended action;

(iii) Explain the specific rule or rules that support the decision, or the specific change in federal or state law that requires the action;

(iv) Explain the participant's right to appeal the action according to chapter 182-526 WAC;

(v) State that the participant must request a hearing within ninety calendar days from the date that the notice of action is mailed.

(c) The qualified health home must send the written notice to the participant no later than ten days before the date of action. The written notice may be sent by the qualified health home no later than the date of the action it describes only if:

(i) The qualified health home has factual information confirming the death of a participant; or

(ii) The qualified health home receives a written statement signed by a participant that:

(A) The participant no longer wishes to receive health home services; or

(B) Provides information that requires termination or reduction of health home services and which indicates that the participant understands that supplying the information will result in health home services being ended or reduced.

(d) A health home care coordinator may not file an appeal for the participant.

(e) If the agency receives a request to appeal an action of the qualified health home, the agency will provide the qualified health home notice of the request.

(f) The agency will process the participant's appeal in accordance with chapter 182-526 WAC.

(g) Continued coverage. If a participant appeals an action by a qualified health home, the participant's health home services will continue consistent with WAC 182-504-0130.

(h) Reinstated coverage. If the agency ends or changes the participant's qualified health home coverage without advance notice, the agency will reinstate coverage consistent with WAC 182-504-0135.

(i) If the participant requests a hearing, the qualified health home must provide to the agency and the participant, upon request, and within three working days, all documentation related to the appeal.

(j) The qualified health home is an independent party and is responsible for its own representation in any administrative hearing, subsequent review process, and judicial proceedings.

(k) If a final order, as defined in WAC 182-526-0010, requires a qualified health home to provide the participant health home services that were not provided while the appeal was pending, the qualified health home must authorize or provide the participant those health home services promptly. A qualified health home cannot seek further review of a final order issued in a participant's administrative appeal of an action taken by the qualified health home.

Only an agency-contracted qualified health home may bill and be paid for providing health home services described in this chapter. Billing requirements and payment methodology are described in the contract between the agency and the ((contractor)) qualified health home.