HEALTH CARE AUTHORITY

[Filed May 12, 2021, 8:25 a.m., effective June 12, 2021]

Effective Date of Rule: Thirty-one days after filing.

Purpose: The new rule establishes when the agency disenrolls health home enrollees for cause and aligns with agency policy.

Citation of Rules Affected by this Order: New WAC 182-557-0500.

Statutory Authority for Adoption: RCW 41.05.021, 41.05.160.

Adopted under notice filed as WSR 21-06-086 on March 2, 2021.

Changes Other than Editing from Proposed to Adopted Version:

Proposed/Adopted	WAC Subsection	Reason
WAC 182-557-0500 (1)(c)
Proposed	(c) Health homes requesting disenrollment must provide documentation of any reasonable modifications attempted or made in light of a client's special needs, disability, or behavioral health condition.	The rule now requires a client's assessment and more detail about what must be considered for reasonable modifications. The agency made these revisions to clarify the standard of review it uses to permit involuntary disenrollment.
Adopted	(c) Health homes requesting disenrollment must provide a client's assessment with any reasonable modifications attempted or made of policies, practices, procedures, or the provision of auxiliary aids or services, based on available evidence, in light of a client's special needs, disability, or behavioral health condition.

Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

Number of Sections Adopted at the Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

Number of Sections Adopted on the Agency's own Initiative: New 0, Amended 0, Repealed 0.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 1, Repealed 0.

Number of Sections Adopted using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 1, Repealed 0.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: May 12, 2021.

WAC 182-557-0500Involuntary disenrollment from a health home.

(1) Involuntary disenrollment for health and safety concerns. If a qualified health home or care coordinator believes there are unresolved health or safety concerns with a health home client, the medicaid agency reviews the health home's written request for involuntary disenrollment of the client from the health home program.

(a) Concerns about health and safety include, but are not limited to:

(i) Inappropriate or threatening behavior, such as inappropriate sexual or physical behavior;

(ii) Illegal or criminal activity;

(iii) Harassment; or

(iv) Environmental hazards, such as methamphetamine laboratories, dangerous animals, poor sanitation, or an unsafe home structure.

(b) The agency does not approve requests to end enrollment that are solely due to uncooperative or disruptive behavior resulting from a client's special needs, disability, or behavioral health condition, except when continued enrollment in the health home seriously impairs the health home's ability to furnish services to the client or other clients.

(c) Health homes requesting disenrollment must provide a client's assessment with any reasonable modifications attempted or made of policies, practices, procedures, or the provision of auxiliary aids or services, based on available evidence, in light of a client's special needs, disability, or behavioral health condition.

(d) A client's involuntary disenrollment is for one year, beginning on the first day of the month following the date on the notice of involuntary disenrollment.

(2) Disenrollment request. The agency grants a request from a qualified health home to involuntarily disenroll a client when the request is submitted to the agency in writing and includes documentation for the agency to determine that the criteria under subsection (1) of this section is met.

(3) Client notification and appeal rights. The agency notifies the qualified health home of the agency's decision within ten business days. If the request is approved, the agency sends a written notice of involuntary disenrollment to the client. The notice includes:

(a) The client's administrative hearing rights as described in chapter 182-526 WAC;

(b) The specific factual basis for disenrolling the client;

(c) The applicable provision under subsection (1) of this section, and any other applicable rule on which the disenrollment is based; and

(d) Any other information required by WAC 182-518-0005.

(4) Reenrollment. The agency may reenroll a client with a qualified health home within one year if:

(a) All of the concerns that led to the involuntary disenrollment are resolved; and

(b) The client continues to meet the health home eligibility criteria in this chapter.