HEALTH CARE AUTHORITY

[Filed March 15, 2019, 10:34 a.m.]

Preproposal statement of inquiry was filed as WSR 19-03-088.

Title of Rule and Other Identifying Information: WAC 182-538A-060 Fully integrated managed care and choice and 182-538A-130 Exemptions and ending enrollment in fully integrated managed care (FIMC).

Hearing Location(s): On April 23, 2019, at 10:00 a.m., at the Health Care Authority (HCA), Cherry Street Plaza, Pear Conference Room 107, 626 8th Avenue, Olympia, WA 98504. Metered public parking is available street side around building. A map is available at https://www.hca.wa.gov/assets/program/Driving-parking-checkin-instructions.pdf or directions can be obtained by calling 360-725-1000.

Date of Intended Adoption: Not sooner than April 24, 2019.

Submit Written Comments to: HCA Rules Coordinator, P.O. Box 42716, Olympia, WA 98504-2716, email arc@hca.wa.gov, fax 360-586-9727, by April 19, 2019.

Assistance for Persons with Disabilities: Contact Amber Lougheed, phone 360-725-1349, fax 360-586-9727, telecommunication relay services 711, email amber.lougheed@hca.wa.gov, by April 19, 2019.

Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: The agency is amending WAC 182-538A-060 Fully integrated managed care and choice and 182-538A-130 Exemptions and ending enrollment in fully integrated managed care (FIMC), to remove language indicating that enrollment in a behavioral health services managed care organization is mandatory for American Indian and Alaska Native clients and their descendants or add language to stipulate there is no mandatory enrollment, whichever is appropriate.

Reasons Supporting Proposal: See purpose.

Statutory Authority for Adoption: RCW 41.05.021, 41.05.160, and 74.09.873.

Statute Being Implemented: RCW 41.05.021, 41.05.160.

Rule is not necessitated by federal law, federal or state court decision.

Name of Proponent: HCA, governmental.

Name of Agency Personnel Responsible for Drafting: Jason Crabbe, P.O. Box 42716, Olympia, WA 98504-2716, 360-725-9563; Implementation and Enforcement: Greg Sandoz, P.O. Box 45502, Olympia, WA 98504-5502, 360-725-1624.

A school district fiscal impact statement is not required under RCW 28A.305.135.

A cost-benefit analysis is not required under RCW 34.05.328. RCW 34.05.328 does not apply to HCA rules unless requested by the joint administrative rules review committee or applied voluntarily.

The proposed rule does not impose more-than-minor costs on businesses. Following is a summary of the agency's analysis showing how costs were calculated. The changes to the proposed rules apply to clients so they do not impose any costs on businesses.

AMENDATORY SECTION(Amending WSR 16-05-051, filed 2/11/16, effective 4/1/16)

WAC 182-538A-060Fully integrated managed care and choice.

(1) Except as provided in subsection (2) of this section, the medicaid agency requires a client to enroll in a fully integrated managed care (FIMC) managed care organization (MCO) when that client:

(a) Is eligible;

(b) Resides in a mandatory enrollment FIMC regional service area; and

(2)(a) American Indian and Alaska native (AI/AN) clients and their descendants may choose one of the following:

(i) Enrollment with an FIMC MCO available in their regional service area;

(ii) Enrollment with a primary care case management (PCCM) provider through a tribal clinic or urban Indian center available in their area, which includes ((mandatory)) enrollment into a behavioral health services only (BHSO) MCO; or

(iii) The agency's fee-for-service system((, which includes mandatory enrollment into a BHSO MCO)).

(b) To enroll with an FIMC MCO or PCCM provider, an AI/AN client may:

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

(ii) ((Mail or fax the following to the agency's unit responsible for FIMC enrollment:

(A) Form HCA 13-664; or

(B) Form HCA 13-862 found online at https://www.hca.wa.gov/medicaid/forms/pages/index.aspx.

(iii))) Enroll online through the Washington Healthplanfinder at https://www.wahealthplanfinder.org; or

(((iv)))(iii) Go to the ProviderOne client portal at https://www.waproviderone.org/client and follow the prompts.

(3) A client must enroll with an FIMC MCO available in the regional service area where the client resides.

(4) The agency enrolls all family members with the same FIMC MCO, if available.

(5) If a family member is enrolled in the patient review and coordination (PRC) program, that family member must follow the rules in WAC 182-501-0135.

(6) When a client requests enrollment with an FIMC MCO or PCCM provider, the agency enrolls a client effective the first day of the current month a client becomes eligible.

(7) To enroll with an FIMC MCO, a client may:

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

(b) ((Mail or fax the following to the agency's unit responsible for FIMC enrollment:

(i) Form HCA 13-664; or

(ii) Form HCA 13-862 found online at https://www.hca.wa.gov/medicaid/forms/pages/index.aspx.

(c))) Enroll online through the Washington Healthplanfinder at https://www.wahealthplanfinder.org; or

(((d)))(c) Go to the ProviderOne client portal at https://www.waproviderone.org/client and follow the prompts.

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

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

(b) If the client has a family member or members enrolled with a PCCM provider, the client is enrolled with that PCCM provider;

(i) The agency identifies the prior MCO and the program is available; and

(ii) The client does not have a family member enrolled with an agency-contracted MCO or PCCM provider.

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

(e) If the client cannot be assigned according to (a), (b), (c), or (d) of this subsection, the agency assigns the client according to agency policy.

(9) An FIMC enrollee's selection of a primary care provider (PCP) or assignment to a PCP occurs as follows:

(a) An FIMC enrollee may choose:

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

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

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

(c) An FIMC enrollee may change PCPs or clinics for any reason, provided the PCP or clinic is within the enrollee's FIMC MCO's provider network and accepting new enrollees.

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

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

AMENDATORY SECTION(Amending WSR 17-07-087, filed 3/20/17, effective 4/20/17)

WAC 182-538A-130Exemptions 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 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.

(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 the agency authorizes a request to end enrollment of an enrollee in FIMC or authorizes exemption of a client from enrollment in FIMC based on WAC 182-538-130, the enrollee is required to enroll in BHSO if eligible.

(5) American Indian and Alaska native (AI/AN) clients and their descendants are exempt from mandatory enrollment in FIMC. See WAC 182-538A-060(2) for coverage options for AI/AN clients.