HEALTH CARE AUTHORITY

[Filed December 16, 2024, 8:13 a.m.]

Preproposal statement of inquiry was filed as WSR 23-23-182.

Title of Rule and Other Identifying Information: WAC 182-557-0200 Health home program—Eligibility.

Hearing Location(s): On January 22, 2025, at 10:00 a.m. The health care authority (HCA) holds public hearings virtually without a physical meeting place. To attend the virtual public hearing, you must register in advance https://us02web.zoom.us/webinar/register/WN_6bEgewjCTa6c66AYPfFGq.

If the link above opens with an error message, please try using a different browser. After registering, you will receive a confirmation email containing information about joining the public hearing.

Date of Intended Adoption: Not sooner than January 23, 2025.

Submit Written Comments to: HCA Rules Coordinator, P.O. Box 42716, Olympia, WA 98504-2716, email arc@hca.wa.gov, fax 360-586-9727, beginning December 17, 2024, 8:00 a.m., by January 22, 2025, by 11:59 p.m.

Assistance for Persons with Disabilities: Contact Johanna Larson, phone 360-725-1349, fax 360-586-9727, telecommunication relay service 711, email Johanna.Larson@hca.wa.gov, by January 3, 2025.

Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: HCA is amending this rule to clarify: (1) Which medicaid clients are eligible for the health home program; and (2) that people with third-party medical coverage are ineligible for this program.

Reasons Supporting Proposal: See purpose.

Statutory Authority for Adoption: RCW 41.05.021, 41.05.160.

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: Melinda Froud, P.O. Box 42716, Olympia, WA 98504-2716, 360-725-1408; Implementation and Enforcement: Christine Del Buono, P.O. Box 45502, Olympia, WA 98504-5502, 360-725-0832.

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.

Scope of exemption for rule proposal from Regulatory Fairness Act requirements:

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 proposed rule does not impose any costs on small businesses.

AMENDATORY SECTION(Amending WSR 17-24-111, filed 12/6/17, effective 1/6/18)

WAC 182-557-0200Health home program—Eligibility.

(1) To be eligible for the health home program, a client must:

(a) Be a recipient of categorically needy health care coverage or be eligible for services under an alternative benefits plan (ABP), as described in WAC 182-501-0060, through:

(i) Fee-for-service, including full dual eligible clients; or

(ii) An agency-contracted managed care organization.

(b) Have one or more chronic conditions as defined in WAC 182-557-0100; and

(c) Have a risk score of 1.5 or greater measured either with algorithms developed by the department of social and health services or the agency's clinical eligibility tool located at https://www.hca.wa.gov/assets/billers-and-providers/Clinical_Eligibility_Tool.xls.

(2) A person is ineligible to receive health home services when:

(a) The person ((has third-party coverage that provides comparable health care services; or))is enrolled in a third-party medical insurance plan. For purposes of this section, a medical insurance plan does not include plans that offer only dental, vision, pregnancy, or maternity care services.

(b) The person has a risk score of less than 1.0 for six consecutive months and has not received health home services.

(3) When the agency determines a client is eligible for health home services, the agency enrolls the client with a qualified health home in the coverage area where the client lives.

(a) The client may decline health home services or change to a different qualified health home or a different health home care coordinator.

(b) If the client chooses to participate in the health home program, a health home care coordinator will:

(i) Work with the participant to develop a health action plan that describes the participant's health goals and includes a plan for reaching those goals; and

(ii) Provide health home services at a level appropriate to the participant's needs.

(4) A participant who does not agree with a decision regarding health home services, including a decision regarding the client's eligibility to receive health home services, has the right to an administrative hearing as described in chapter 182-526 WAC.