WSR 17-07-087 PERMANENT RULES HEALTH CARE AUTHORITY (Washington Apple Health) [Filed March 20, 2017, 10:59 a.m., effective April 20, 2017] Effective Date of Rule: Thirty-one days after filing.
Purpose: The agency is amending these rules because it is delegating third-party activities to managed care organizations.
Citation of Existing Rules Affected by this Order: Amending WAC 182-538A-130 and 182-538A-190.
Adopted under notice filed as WSR 17-04-054 on January 27, 2017.
Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.
Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.
Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.
Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 2, Repealed 0.
Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 2, Repealed 0.
Date Adopted: March 20, 2017.
Wendy Barcus
Rules Coordinator
AMENDATORY SECTION (Amending WSR 16-05-051, filed 2/11/16, effective 4/1/16)
WAC 182-538A-130 Exemptions and ending enrollment in fully integrated managed care (FIMC).
(1) Fully integrated managed care (FIMC) and behavioral health services only (BHSO) are mandatory for individuals residing in FIMC regional service areas.
(2) The medicaid agency enrolls a client ((into)) residing in an FIMC regional service area in either FIMC or BHSO, depending on the client's eligibility, in accordance with WAC 182-538A-060.
(((2) WAC 182-538A-060 applies to disenrollment and choice.
(3) A client may end enrollment in FIMC if:
(a) The client has comparable coverage; or
(b) The client's request to end enrollment is approved by the agency under one of the following circumstances:
(i) The enrollee moves out of the FIMC regional service area;
(ii) Medically necessary care is unavailable from the MCO including, but not limited to, when:
(A) The MCO does not, because of moral or religious objections, deliver the service the enrollee seeks; or
(B) The enrollee needs related services performed at the same time and not all related services are available within the network and the enrollee's primary care provider or another provider determines receiving the services separately would subject the enrollee to unnecessary risk.)) (3) The agency may end enrollment of an enrollee in FIMC or authorize an exemption of a client from enrollment in FIMC according to the rules in WAC 182-538-130.
(4) If ((an enrollee)) the agency authorizes a request to end((s)) enrollment ((in)) of an enrollee in FIMC or authorizes exemption of a client from enrollment in FIMC based on WAC 182-538-130, the ((agency enrolls the)) enrollee ((in BHSO if the enrollee)) is required to enroll in BHSO if eligible.
AMENDATORY SECTION (Amending WSR 16-05-051, filed 2/11/16, effective 4/1/16)
WAC 182-538A-190 Behavioral health services only (BHSO).
This section applies to enrollees receiving behavioral health services only (BHSO) under the fully integrated managed care (FIMC) medicaid contract.
(1) The medicaid agency requires eligible clients in FIMC regional service areas to enroll in the BHSO program.
(2) A BHSO enrollee in an FIMC regional service area may change managed care organizations (MCOs) but may not disenroll from the BHSO program.
(3) For BHSO enrollees, the MCO covers the behavioral health benefit included in the FIMC medicaid contract.
(4) WAC 182-538-110 applies to BHSO enrollees in FIMC regional service areas.
(5) The agency assigns the BHSO enrollee to an MCO available in the area where the client resides.
(6) A BHSO enrollee may change MCOs for any reason with the change becoming effective according to the agency's managed care policy.
(((7) The agency ends enrollment in BHSO managed care when the enrollee becomes eligible for any third-party health care coverage comparable to BHSO.))
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