WSR 17-20-006 PERMANENT RULES DEPARTMENT OF SOCIAL AND HEALTH SERVICES (Behavioral Health Administration) [Filed September 21, 2017, 3:57 p.m., effective October 22, 2017] Effective Date of Rule: Thirty-one days after filing. Purpose: The department is amending rules about grievances, appeals, and hearings in chapter 388-877 WAC to align with the Centers for Medicare and Medicaid Services (CMS) amended federal rules in 42 C.F.R. 438 Subpart F that govern the grievance and appeals system for medicaid managed care. States must comply with these federal rule amendments by July 1, 2017. The new definitions, time frames, and alignment of certain processes for appeals and grievances will provide individuals with a more streamlined and manageable grievance and appeals process, and will allow behavioral health agencies and behavioral health organizations to further align rules applicable to private health insurance and group health plans that apply across the market. The department is limiting amendments to bringing the rules into compliance with federal rules and making necessary edits to change names and terms and clarify language without changing the rule's effect. When these rules become effective, they will supersede emergency rules filed as WSR 17-14-094 that went into effect July 1, 2017. Citation of Rules Affected by this Order: Amending WAC 388-877-0654, 388-877-0655, 388-877-0660, 388-877-0665, 388-877-0670, 388-877-0675, and 388-877-0680.
Other Authority: 42 C.F.R. 438 Subpart F, as amended in 81 Fed. Reg. 27498, May 6, 2016. Adopted under notice filed as WSR 17-11-068 on May 17, 2017. Changes Other than Editing from Proposed to Adopted Version:
WAC 388-877-0654(4) … behavioral health ombuds services described in under … lowest possible level before and during …
WAC 388-877-0654 new (5) In handling grievances and appeals, each BHO and behavioral health agency must give individuals any reasonable assistance in completing forms and taking other procedural steps related to a grievance or appeal. This includes, but is not limited to, auxiliary aids and services, upon request, such as providing interpreter services and toll-free numbers that have adequate TTY/TTD and interpreter capability.
WAC 388-877-0655(2) new (f) For a resident of a rural area with only one BHO, the denial of an individual's request to exercise their right to obtain services outside the network;
WAC 388-877-0655(2) new (g) The denial of an individual's request to dispute a financial liability, including cost sharing, copayments, premiums, deductibles, coinsurance, and other enrollee financial liabilities.
WAC 388-877-0660(2) … grievances or expressions of dissatisfaction.
WAC 388-877-0660 (5) and (6) … The grievance cannot does not progress to a hearing …
WAC 388-877-0660 (7)(f) … decision as expeditiously as the individual's health condition requires, and no longer than …
WAC 388-877-0660 (8)(c)(i) … Neither were not involved … nor are subordinates a subordinate of any …
WAC 388-877-0660 (8)(d) … the individual's interest. The BHO must:
(i) Make reasonable efforts to give the individual prompt oral notice of the delay; and
(ii) Within two calendar days, give the individual written notice of the reason for the decision to extend the time frame and inform the individual of the right to file a grievance if the individual disagrees with that decision;
WAC 388-877-0660 (8)(e) and 388-877-0665 (1)(a) … which includes requirements requires that each notice: (i) Is Be written …
WAC 388-877-0665(3) … timely manner, or when the BHO does not act within the grievance and appeal system time frames as identified within this chapter, it is considered an adverse benefit determination. In these cases, the BHO sends a formal notice of adverse benefit determination, which includes the individual's right to request an administrative hearing. When the BHO does not act within the grievance and appeal system time frames as identified within this chapter, it is considered exhaustion of the appeals process and the individual has a right to request an administrative hearing.
WAC 388-877-0670(2) … must file an appeal and receive a notice of the resolution from the BHO exhaust the appeals process before …
WAC 388-877-0670 (4)(a) … evidence and testimony and make legal …
WAC 388-877-0670 (4)(b) … Provide the individual opportunity, … to examine the individual's clinical record, including examining new or …
WAC 388-877-0670 (5)(a) … Neither were not involved … nor are subordinates a subordinate of any …
WAC 388-877-0670(6) … An oral filing of a standard an appeal …
WAC 388-877-0670 (6)(c) … resolution as expeditiously as the individual's health requires, and no longer … The BHO must:
(i) Make reasonable efforts to give the individual prompt oral notice of the delay; and
(ii) Within two calendar days, give the individual written notice of the reason for the decision to extend the time frame and inform the individual of the right to file a grievance if the individual disagrees with that decision.
WAC 388-877-0670(7) … An oral filing of a standard an appeal …
WAC 388-877-0670(8) … health provider believes feels that …
WAC 388-877-0670 (8)(b)(ii) … resolution as expeditiously as the individual's health condition requires, and no longer …
WAC 388-877-0670 (9)(b)(i) … of the hearing or if the individual is asking for an expedited hearing.
WAC 388-877-0670 (9)(c) … which includes requirements requires that each notice: (i) Be Is written …
WAC 388-877-0675(4) If an individual requests an expedited administrative hearing, the expedited hearing must be requested within ten calendar days from the date on the notice of the resolution or notice of determination or the individual's behavioral health provider believes that the time taken for a standard administrative hearing could seriously jeopardize the individual's life, physical or mental health, or ability to attain, maintain, or regain maximum function, an expedited hearing may be requested …
WAC 388-877-0675(7) … of this section. Recovery of the cost of medicaid services is limited to the first sixty days of services after the department or the office of administrative hearings (OAH) receives an administrative hearing request. See RCW 74.09.741. 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 7, Repealed 0. Number of Sections Adopted at the 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 7, Repealed 0. Date Adopted: September 19, 2017. Katherine I. Vasquez Rules Coordinator
Reviser's note: The material contained in this filing exceeded the page-count limitations of WAC 1-21-040 for appearance in this issue of the Register. It will appear in the 17-21 issue of the Register. |