HEALTH CARE AUTHORITY

(Washington Apple Health)

This chapter governs services provided under the Washington apple health managed care contracts. Washington apple health managed care services are available through either a managed care organization (MCO) or primary care case management (PCCM) provider.

The following definitions and abbreviations and those found in chapter 182-500 WAC, Medical definitions, apply to this chapter. ((References to managed care in this chapter do not apply to mental health managed care administered under chapter 388-865 WAC.))

(((1))) (a) The denial or limited authorization of a requested service, including the type or level of service;

(((2))) (b) The reduction, suspension, or termination of a previously authorized service;

(((3))) (c) The denial, in whole or in part, of payment for a service;

(((4))) (d) The failure to provide services in a timely manner, as defined by the state; or

(((5))) (e) The failure of a managed care organization (MCO) to act within the time frames provided in 42 C.F.R. 438.408(b).

"Agency" - See WAC 182-500-0010.

"Appeal" means a request by an enrollee or provider with written permission of an enrollee for reconsideration of an action.

"Assign" or "assignment" means the agency selects an MCO ((or primary care case management (PCCM) provider)) to serve a client who has not selected an MCO ((or PCCM provider)).

"Auto enrollment" means the agency has automatically enrolled a client into an MCO in the client's area of residence.

"Client" means, for the purposes of this chapter, an individual eligible for any ((medical assistance)) Washington apple health program, including managed care programs, but who is not enrolled with an MCO or PCCM provider. ((In this chapter, "client" refers to a person before he or she is enrolled in managed care, while "enrollee" refers to an individual eligible for any medical assistance program who is enrolled in managed care.))

"Disenrollment" - See "end enrollment."

"Emergency medical condition" means a condition meeting the definition in 42 C.F.R. 438.114(a).

"Emergency services" means services defined in 42 C.F.R. 438.114(a).

"End enrollment" means ending the enrollment of an enrollee for one of the reasons outlined in WAC 182-538-130.

"Enrollee" means an individual eligible for any ((medical assistance)) Washington apple health program enrolled in managed care with an MCO or PCCM provider that has a contract with the state.

"Enrollee's representative" means ((an individual)) a person with a legal right or written authorization from the enrollee to act on behalf of the enrollee in making decisions.

"Enrollees with special health care needs" means enrollees having chronic and disabling conditions and the conditions:

(((1))) (a) Have a biologic, psychologic, or cognitive basis;

(((2))) (b) Have lasted or are virtually certain to last for at least one year; and

(((3))) (c) Produce one or more of the following conditions stemming from a disease:

(((a))) (i) Significant limitation in areas of physical, cognitive, or emotional function;

(((b))) (ii) Dependency on medical or assistive devices to minimize limitation of function or activities; or

(((c))) (iii) In addition, for children, any of the following:

(((i))) (A) Significant limitation in social growth or developmental function;

(((ii))) (B) Need for psychological, educational, medical, or related services over and above the usual for the child's age; or

(((iii))) (C) Special ongoing treatments, such as medications, special diet, interventions, or accommodations at home or school.

"Exemption" means agency approval of a client's preenrollment request to remain in the fee-for-service delivery system for one of the reasons outlined in WAC 182-538-130.

"Grievance" means an expression of dissatisfaction about any matter other than an action, as "action" is defined in this section.

"Grievance system" means the overall system that includes grievances and appeals handled at the MCO level and access to the agency's hearing process.

"Health care service" or "service" means a service or item provided for the prevention, cure, or treatment of an illness, injury, disease, or condition.

"Managed care" means a comprehensive health care delivery system that includes preventive, primary, specialty, and ancillary services. These services are provided through either an MCO or PCCM provider.

"Managed care contract" means the agreement between the agency and an MCO to provide prepaid contracted services to enrollees.

"Managed care organization" or "MCO" means an organization having a certificate of authority or certificate of registration from the office of insurance commissioner that contracts with the agency under a comprehensive risk contract to provide prepaid health care services to ((eligible clients)) enrollees under the agency's managed care programs.

"Mandatory enrollment" means the agency's requirement that a client enroll in managed care.

"Mandatory service area" means a service area in which eligible clients are required to enroll in an MCO.

"Nonparticipating provider" means a ((health care provider that does not have a written agreement with an MCO but that provides MCO-contracted health care services to managed care enrollees with the MCO's authorization)) person, health care provider, practitioner, facility, or entity acting within their scope of practice and licensure that:

(b) Does not have a written agreement with the managed care organization (MCO) to participate in the MCO's provider network.

"Participating provider" means a ((health care provider with a written agreement with an MCO to provide health care services to the MCO's managed care enrollees. A participating provider must look solely to the MCO for payment for such services)) person, health care provider, practitioner, or entity acting within their scope of practice and licensure with a written agreement with the MCO to provide services to enrollees.

"Primary care case management" or "PCCM" means the health care management activities of a provider that contracts with the agency to provide primary health care services and to arrange and coordinate other preventive, specialty, and ancillary health services.

"Primary care provider" or "PCP" means a person licensed or certified under Title 18 RCW including, but not limited to, a physician, an advanced registered nurse practitioner (ARNP), naturopath, or a physician assistant who supervises, coordinates, and provides health services to a client or an enrollee, initiates referrals for specialist and ancillary care, and maintains the client's or enrollee's continuity of care.

"Timely" ((means in relation to)) concerning the provision of services, means an enrollee has the right to receive medically necessary health care as expeditiously as the enrollee's health condition requires. ((In relation to)) Concerning authorization of services and grievances and appeals, "timely" means according to the agency's managed care program contracts and the time frames stated in this chapter.

(1) ((This chapter does not apply to the subsidized basic health program found in chapters 182-24 and 182-22 WAC unless allowed by specific program rule.

(2))) Except as provided in subsection (((3))) (2) of this section, the medicaid agency requires a client to enroll in managed care when that client:

(a) Is eligible for one of the ((medical assistance)) Washington apple health programs for which enrollment is mandatory;

(b) Resides in an area where enrollment is mandatory; and

(c) Is not exempt from managed care enrollment or the agency has not ended the client's managed care enrollment, consistent with WAC 182-538-130((, and any related hearing has been held and decided)).

(((3))) (2) American Indian and Alaska native (AI/AN) clients ((who meet the provisions of 25 U.S.C. 1603 (c)-(d) for federally recognized tribal members)) and their descendants may choose one of the following:

(a) Enrollment with a managed care organization (MCO) available in their area;

(b) Enrollment with ((an Indian or tribal primary care case management (PCCM) provider)) a PCCM provider through a tribal clinic or urban Indian center available in their area; or

(c) The agency's fee-for-service system.

(((4))) (3) To enroll with an MCO or PCCM provider, a client may:

(a) Enroll online via the Washington Healthplanfinder at https://www.wahealthplanfinder.org;

(b) Call the agency's toll-free enrollment line at 800-562-3022;

(((b))) (c) Go to the ProviderOne client portal at https://www.waproviderone.org/client and follow the instructions;

(d) Mail a postage-paid completed managed care enrollment form (HCA 13-862) to the agency's unit responsible for managed care enrollment; or

(((c))) (e) Fax the managed care enrollment form (HCA 13-862) to the agency at the number located on the enrollment form.

(((5))) (4) A client must enroll with an MCO ((provider)) available in the area where the client resides.

(((6) All family members of an enrollee placed in the patient review and coordination (PRC) program under WAC 182-501-0135 must enroll with the same MCO but may enroll in a different MCO than the family member placed in the PRC program.)) (5) All family members will be enrolled with the same MCO, except family members of an enrollee placed in the patient review and coordination (PRC) program under WAC 182-501-0135 need not enroll in the same MCO as the family member placed in the PRC program.

(7) When a client requests enrollment with an MCO or PCCM provider, the agency enrolls a client effective the earliest possible date given the requirements of the agency's enrollment system. ((The agency does not enroll clients retrospectively.))

(8) The agency assigns a client who does not choose an MCO ((or PCCM provider)) as follows:

(a) ((If the client has a family member or family members enrolled with an MCO, the client is enrolled with that MCO;

(b))) If the client ((does not have a family member or family members enrolled with an MCO that is currently under contract with the agency, and the client was previously)) was enrolled with ((the)) an MCO or PCCM provider((, and the agency can identify the previous enrollment)) within the previous six months, the client is reenrolled with the same MCO ((or PCCM provider));

(c) If the client cannot be assigned according to (a) or (b) of this subsection, the agency assigns the client as follows:

(i) ((If an AI or AN client does not choose an MCO or PCCM provider, the agency assigns the client to a tribal PCCM provider if that client resides in a zip code served by a tribal PCCM provider. If there is no tribal PCCM provider in the client's area, the client continues to be served by the agency's fee-for-service system. A client assigned under this subsection may request to end enrollment at any time.

(ii))) If a client who is not AI or AN does not choose an MCO ((provider)), the agency assigns the client to an MCO available in the area where the client resides. The MCO is responsible for primary care provider (PCP) choice and assignment.

(((iii))) (ii) For clients who are ((new recipients)) newly eligible or who have had a break in eligibility of ((greater than two)) more than six months, the agency sends a written notice to each household of one or more clients who are assigned to an MCO ((or PCCM provider)). The assigned client has ten calendar days to contact the agency to change the MCO ((or PCCM provider)) assignment before enrollment is effective. The notice includes ((the)):

(B) The toll-free number and name of the MCO ((or PCCM provider)) to which each client has been assigned((,));

(C) The effective date of enrollment((,)); and

(D) The date by which the client must respond in order to change the assignment((, and the toll-free telephone number of either:

(iii) If the client has a break in eligibility of less than ((two)) six months, the client will be automatically reenrolled with his or her previous MCO ((or PCCM provider)) and no notice will be sent.

(9) ((The agency:

(b))) Upon request, the agency will assist clients in identifying an MCO with which their provider participates.

(10) An MCO enrollee's selection of a PCP or assignment to a PCP occurs as follows:

(a) An MCO enrollee may choose:

(i) A PCP or clinic that is in the enrollee's MCO and accepting new enrollees; or

(ii) A different PCP or clinic participating with the enrollee's MCO for different family members.

(b) The MCO assigns a PCP or clinic that meets the access standards set forth in the relevant managed care contract if the enrollee does not choose a PCP or clinic.

(c) An MCO enrollee may change PCPs or clinics in an MCO for any reason, with the change becoming effective no later than the beginning of the month following the enrollee's request.

(d) An MCO enrollee may file a grievance with the MCO if the MCO does not approve an enrollee's request to change PCPs or clinics.

(e) MCO enrollees required to participate in the agency's PRC program may be limited in their right to change PCPs (see WAC ((388-501-0135)) 182-501-0135).

(2) The agency reserves the right not to contract with any otherwise qualified MCO.)) (1) A managed care organization (MCO) must meet the following qualifications to be eligible to contract with the medicaid agency:

A ((provider may contract with the agency as a)) primary care case management (PCCM) ((provider to coordinate health care services to eligible clients under the agency's managed care program. The PCCM)) provider or the individual providers in a PCCM group or clinic must:

(1) Have a core provider agreement with the medicaid agency;

(2) Be a recognized urban Indian health center or tribal clinic;

(3) Accept the terms and conditions of the agency's PCCM contract;

(4) Be able to meet the quality standards established by the agency; and

(5) Accept ((PCCM)) the case management rate((s published)) paid by the agency.

(1) The medicaid agency pays apple health managed care organizations (MCOs) monthly capitated premiums that:

(a) Have been developed ((in accordance with)) using generally accepted actuarial principles and practices;

(b) Are appropriate for the populations to be covered and the services to be furnished under the MCO contract;

(c) Have been certified by actuaries who meet the qualification standards established by the American Academy of Actuaries and follow the practice standards established by the Actuarial Standards Board;

(d) Are based on ((historical)) analysis of ((financial)) historical cost ((and/or)), rate information, or both; and

(e) Are paid based on legislative allocations.

(2) ((The agency pays primary care case management (PCCM) providers a monthly case management fee according to contracted terms and conditions.

(3))) The MCO is solely responsible for payment of MCO-contracted health care services. The agency ((does)) will not pay ((providers under the fee-for-service system)) for a service that is the MCO's responsibility, even if the MCO has not paid the provider for the service ((for any reason. The MCO is solely responsible for payment of MCO-contracted health care services)).

(((4))) (3) The agency pays an enhancement rate to federally qualified health care centers (FQHC) and rural health clinics (RHC) for each ((client enrolled with MCOs through)) MCO enrollee assigned to the FQHC or RHC. The enhancement rate from the agency is in addition to the negotiated payments FQHCs and RHCs receive from the MCOs for services provided to MCO enrollees. To ensure that the appropriate amounts are paid to each FQHC or RHC, the agency performs an annual reconciliation of the enhancement payments with the FQHC or RHC.

(((5))) (4) The agency pays MCOs a delivery case rate, separate from the capitation payment, when an enrollee delivers a child(ren) and the MCO pays for any part of labor and delivery.

(1) The medicaid agency pays PCCM providers a monthly case management fee according to contracted terms and conditions.

(2) The agency pays PCCM providers for health care services under the fee-for-service health care delivery system.

(1) A managed care enrollee((s are)) is eligible for the scope of services ((as described)) in WAC 182-501-0060 for categorically needy clients.

(a) ((A client is entitled to timely access to medically necessary services as defined in WAC 182-500-0070.

(b))) The managed care organization (MCO) covers the services included in the ((MCO)) contract for ((MCO)) its enrollees.

(i) MCOs may, at their discretion, cover ((additional)) services not required under the MCO contract. ((However,))

(ii) The agency ((may not)) cannot require the MCO to cover any ((additional)) services outside the scope of services ((negotiated)) in the MCO's contract with the agency.

(((c))) (b) The agency covers ((medically necessary)) services ((described)) identified as covered for categorically needy clients in WAC 182-501-0060 and described in WAC 182-501-0065 that are excluded from coverage in the MCO contract.

(4) Unless the MCO chooses to cover these services, or an appeal, or a hearing decision reverses an MCO or agency denial,)) (2) The following services are not covered by the MCO:

(a) ((For all managed care enrollees:

(i))) Services that are not medically necessary as defined in WAC 182-500-0070.

(((ii))) (b) Services not included in the categorically needy scope of services.

(((iii))) (c) Services((, other than a screening exam as described in WAC 182-538-100(3),)) received in a hospital emergency department for nonemergency medical conditions, except for a screening exam as described in WAC 182-538-100.

(i))) (d) Services received from a participating ((specialist)) provider that require prior authorization from the MCO, but were not authorized by the MCO.

(e) All nonemergency services covered under the MCO contract and received from nonparticipating providers ((require)) that were not prior ((authorization from)) authorized by the MCO.

(5))) (3) A provider may bill an enrollee for noncovered services as described in subsection (((4))) (2) of this section, if the requirements of WAC 182-502-0160 are met.

(1) A primary care case management (PCCM) enrollee is eligible for the scope of services in WAC 182-501-0060 and 182-501-0065. An enrollee is entitled to timely access to covered services that are medically necessary.

(a) The agency covers services through the fee-for-service system for enrollees with a primary care case management (PCCM) provider. Except for emergencies, the PCCM provider must either provide the covered services or refer the enrollee to other providers who are contracted with the agency for covered services. The PCCM provider is responsible for explaining to the enrollee how to obtain the services for which the PCCM provider is referring the enrollee. Services that require PCCM provider referral are described in the PCCM contract.

(b) The agency sends each enrollee written information about covered services when the client enrolls in managed care and when there is a change in covered services. This information describes covered services, which services are covered by the agency, and how to access services through the PCCM provider.

(2) For services covered by the agency through PCCM contracts for managed care:

(a) The agency covers medically necessary services included in the categorically needy scope of care and furnished by providers who have a current core provider agreement with the agency to provide the requested service;

(b) The agency may require the PCCM provider to obtain authorization from the agency for coverage of nonemergency services;

(c) The PCCM provider determines which services are medically necessary;

(d) Services referred by the PCCM provider require an authorization number to receive payment from the agency; and

(e) An enrollee may request a hearing for review of PCCM provider or agency coverage decisions (see WAC 182-538-110).

(3) The following services are not covered:

(a) Services that are not medically necessary as defined in WAC 182-500-0070.

(b) Services not included in the categorically needy scope of services.

(c) Services, other than a screening exam as described in WAC 182-538-100(3), received in a hospital emergency department for nonemergency medical conditions.

(d) Services that require a referral from the PCCM provider as described in the PCCM contract, but were not referred by the PCCM provider.

(1) A managed care enrollee may obtain emergency services((,)) for emergency medical conditions from any qualified medicaid provider.

(a) The managed care organization (MCO) covers emergency services for MCO enrollees.

(b) The agency covers emergency services for primary care case management (PCCM) enrollees.

(2) Emergency services for emergency medical conditions do not require prior authorization by the MCO, primary care provider (PCP), PCCM provider, or the agency.

(3) MCOs must cover all emergency services provided to an enrollee by a provider who is qualified to furnish medicaid services, without regard to whether the provider is a participating or nonparticipating provider.

(4) An enrollee who requests emergency services ((is entitled to)) may receive an exam to determine if the enrollee has an emergency medical condition. What constitutes an emergency medical condition may not be limited on the basis of diagnosis or symptoms.

(5) The MCO must cover emergency services provided to an enrollee when:

(a) The enrollee had an emergency medical condition, including cases in which the absence of immediate medical attention would not have had the outcomes specified in the definition of an emergency medical condition; and

(b) The plan provider or other MCO representative instructs the enrollee to seek emergency services.

(6) In any disagreement between a hospital and the MCO about whether the enrollee is stable enough for discharge or transfer, or whether the medical benefits of an unstabilized transfer outweigh the risks, the judgment of the attending physician(s) actually caring for the enrollee at the treating facility prevails.

(7) Under 42 C.F.R. 438.114, the enrollee's MCO must cover and pay for:

(a) Emergency services provided to enrollees by an emergency room provider, hospital or fiscal agent outside the managed care system; and

(b) Any screening and treatment the enrollee requires ((subsequent to)) after the provision of the emergency services.

(b) If the MCO or the final order as defined in chapter 182-526 WAC reverses a decision to deny authorization of services, and the enrollee received the disputed services while the appeal was pending, the MCO must pay for those services.)) (1) This section contains information about the grievance system for managed care organization (MCO) enrollees. See WAC 182-538-111 for information about PCCM enrollees.

(1) This section contains information about the ((grievance system)) administrative hearing process for primary care case management (PCCM) enrollees((, which includes grievances and appeals)). See WAC 182-538-110 for information about the grievance system for managed care organization (MCO) enrollees.

(2) ((A PCCM enrollee may voice a grievance or file an appeal, either orally or in writing. PCCM enrollees use the agency's grievance and appeal processes.

(c) The appeal process for PCCM enrollees follows that described in chapter 182-526 WAC. Where a conflict exists, the requirements in this chapter take precedence.)) PCCM enrollees follow the same administrative hearing rules and processes as fee-for-service clients under chapter 182-526 WAC.

(8) Upon request, the agency may exempt the client or end enrollment for the period of time the circumstances or conditions described in subsection (7) of this section are expected to exist. The agency may periodically review those circumstances or conditions to determine if they continue to exist. If the agency approves the request for a limited time, the client or enrollee is notified in writing or by telephone of the time limitation, the process for renewing the exemption or the ending of enrollment.)) (1) The agency exempts a client from enrollment or end enrollment from mandatory managed care when any of the following apply:

(1) To assure that managed care enrollees receive quality health care services, the agency requires managed care organizations (MCOs) to comply with quality improvement standards detailed in the agency's managed care contract. MCO's must:

(a) Have a clearly defined quality organizational structure and operation, including a fully operational quality assessment, measurement, and improvement program;

(b) Have effective means to detect over and ((under utilization)) underutilization of services;

(c) Maintain a system for provider and practitioner credentialing and recredentialing;

(d) Ensure that MCO subcontracts and the delegation of MCO responsibilities ((are in accordance)) align with ((the)) agency standards ((and regulations));

(e) Ensure MCO oversight of delegated entities responsible for any delegated activity to include:

(i) A delegation agreement with each entity describing the responsibilities of the MCO and the entity;

(ii) Evaluation of the entity ((prior to)) before delegation;

(iii) An annual evaluation of the entity; and

(iv) Evaluation or regular reports and follow-up on issues ((out of compliance)) that are not compliant with the delegation agreement or the agency's managed care contract specifications.

(f) Cooperate with an agency-contracted, qualified independent external quality review organization (EQRO) conducting review activities as described in 42 C.F.R. 438.358;

(g) Have an effective mechanism to assess the quality and appropriateness of care furnished to enrollees with special health care needs;

(h) Assess and develop individualized treatment plans for enrollees with special health care needs which ensure integration of clinical and nonclinical disciplines and services in the overall plan of care;

(i) Submit annual reports to the agency on performance measures as specified by the agency;

(j) Maintain a health information system that:

(i) Collects, analyzes, integrates, and reports data as requested by the agency;

(ii) Provides information on utilization, grievances and appeals, enrollees ending enrollment for reasons other than the loss of medicaid eligibility, and other areas as defined by the agency;

(iii) Collects data on enrollees, providers, and services provided to enrollees through an encounter data system, in a standardized format as specified by the agency; and

(iv) Ensures data received from providers is adequate and complete by verifying the accuracy and timeliness of reported data and screening the data for completeness, logic, and consistency.

(k) Conduct performance improvement projects designed to achieve significant improvement, sustained over time, in clinical care outcomes and services, and that involve the following:

(i) Measuring performance using objective quality indicators;

(ii) Implementing system changes to achieve improvement in service quality;

(iii) Evaluating the effectiveness of system changes;

(iv) Planning and initiating activities for increasing or sustaining performance improvement;

(v) Reporting each project status and the results as requested by the agency; and

(vi) Completing each performance improvement project timely so as to generally allow aggregate information to produce new quality of care information every year.

(l) Ensure enrollee access to health care services;

(m) Ensure continuity and coordination of enrollee care; ((and))

(n) Maintain and monitor availability of health care services for enrollees;

(p) Obtain and maintain national committee on quality assurance (NCQA) accreditation.

(2) The agency may:

(a) Impose intermediate sanctions ((in accordance with)) under 42 C.F.R. 438.700 and corrective action for substandard rates of clinical performance measures and for deficiencies found in audits and on-site visits;

(b) Require corrective action for findings for noncompliance with any contractual state or federal requirements; and

(c) Impose sanctions for noncompliance with any contractual, state, or federal requirements not corrected.

(1) Unless otherwise stated in this section, all of the provisions of chapter 182-538 WAC apply to apple health foster care (AHFC).

(2) The following sections of chapter 182-538 WAC do not apply to AHFC:

(a) WAC 182-538-068;

(b) WAC 182-538-071;

(c) WAC 182-538-096; and

(d) WAC 182-538-111.

(3) Enrollment in AHFC is voluntary for eligible individuals. The agency will enroll eligible individuals in the single MCO that serves children and youth in foster care and adoption support, and young adult alumni of the foster care system.

(a) The agency will not enroll a client in AHFC or will end an enrollee's enrollment in AHFC when the client has, or becomes eligible for, TRICARE or any other third-party health care coverage that would:

(i) Require the agency to either exempt the client from enrollment in managed care; or

(ii) End the enrollee's enrollment in managed care.

(b) An AHFC enrollee may request exemption from enrollment or termination of enrollment in AHFC without cause if the client is in the adoption support or young adult alumni programs under WAC 182-538-130.

(4) In addition to the scope of medical care services in WAC 182-538-095, AHFC coordinates health care services for enrollees with the department of social and health services community mental health system and other health care systems as needed.

(5) The agency sends written information about covered services when the individual becomes eligible to enroll in AHFC and at any time there is a change in covered services. In addition, the agency requires MCOs to provide new enrollees with written information about:

(a) Covered services;

(b) The right to grievances and appeals through the MCO; and

(c) Hearings through the agency.