WSR 18-08-035 PERMANENT RULES HEALTH CARE AUTHORITY [Filed March 27, 2018, 1:22 p.m., effective April 27, 2018] Effective Date of Rule: Thirty-one days after filing. Purpose: The agency is amending WAC 182-538-070 Payments to managed care organizations (MCO), to align language regarding enhancement payments for MCO enrollees assigned to federally qualified health centers and rural health clinics with the agency's rules found in chapters 182-548 and 182-549 WAC. Citation of Rules Affected by this Order: Amending WAC 182-538-070. Adopted under notice filed as WSR 18-04-088 on February 5, 2018. Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0. Number of Sections Adopted at the Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0. Number of Sections Adopted on the Agency's own Initiative: New 0, Amended 1, Repealed 0. Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 0, Repealed 0. Number of Sections Adopted using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 1, Repealed 0. Date Adopted: March 27, 2018. Wendy Barcus Rules Coordinator
AMENDATORY SECTION (Amending WSR 15-24-098, filed 12/1/15, effective 1/1/16)
WAC 182-538-070 Payments to managed care organizations (MCOs).
(1) The medicaid agency pays apple health managed care organizations (MCOs) monthly capitated premiums that:
(a) Have been developed 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 analysis of historical cost, rate information, or both; and
(e) Are paid based on legislative allocations.
(2) The MCO is solely responsible for payment of MCO-contracted health care services. The agency will not pay for a service that is the MCO's responsibility, even if the MCO has not paid the provider for the service.
(3) The agency pays an enhancement rate ((to federally qualified health care centers (FQHC) and rural health clinics (RHC))) for each 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)) a federally qualified health center (FQHC) or rural health clinic (RHC) according to chapters 182-548 and 182-549 WAC.
(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.
|