PDFWAC 182-538-067

Qualifications to become a managed care organization (MCO) in integrated managed care.

(1) To provide physical or behavioral health services under the apple health IMC contract, a managed care organization (MCO) must:
(a) Contract with the agency; and
(b) Contract with an agency-contracted behavioral health administrative service organization (BH-ASO) that maintains an adequate provider network to deliver services to clients in IMC regional service areas.
(2) An MCO must meet the following qualifications to be eligible to contract with the agency:
(a) Have a certificate of registration from the Washington state office of the insurance commissioner (OIC) that allows the MCO to provide health care services under a risk-based contract;
(b) Accept the terms and conditions of the agency's managed care contract;
(c) Meet the network and quality standards established by the agency; and
(d) Pass a readiness review, including an on-site visit conducted by the agency.
(3)(a) The agency may from time to time conduct a procurement for new apple health MCOs or to reduce or expand the use of existing apple health MCOs.
(b) The agency may conduct a procurement when the agency determines in its sole discretion there is a need to:
(i) Expand or reduce current MCO contracts;
(ii) Enhance current MCO provider networks; or
(iii) Establish new contracts for integrated managed care in one or more regional services areas; or
(iv) Adjust the program to ensure adherence to state and federal law.
(c) In accordance with RCW 74.09.522 and 74.09.871, the agency will give significant weight to the following factors in any procurement process:
(i) Demonstrated commitment to, and experience in, serving low-income populations;
(ii) Demonstrated commitment to, and experience in, serving persons who have mental illness, substance use disorders, or co-occurring disorders;
(iii) Demonstrated commitment to, and experience with, partnerships with county and municipal criminal justice systems, housing services, and other critical support services necessary to achieve the outcomes established in RCW 70.320.020, 71.24.435, and 71.36.025;
(iv) Recognition that meeting enrollees' physical and behavioral health care needs is a shared responsibility of contracted behavioral health administrative services organizations, MCOs, service providers, the state, and communities;
(v) Consideration of past and current performance and participation in other state or federal behavioral health programs as a contractor;
(vi) Quality of services provided to enrollees under previous contracts with the state of Washington or other states;
(vii) Accessibility, including appropriate utilization, of services offered to enrollees;
(viii) Demonstrated capability to perform contracted services, including the ability to supply an adequate provider network; and
(ix) The ability to meet any other requirements established by the agency.
(d) The agency may define and consider additional factors as part of any procurement including, but not limited to:
(i) Timely processing of, and payments to, providers in the MCO networks, including reconciliation of outstanding payments; and
(ii) The optimal number of MCOs per regional services area, based on population and in the manner that the agency determines most beneficial for the program, clients, and providers.
(4) The agency reserves the right not to contract with any otherwise qualified MCO.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 20-20-011, § 182-538-067, filed 9/24/20, effective 10/25/20. Statutory Authority: RCW 41.05.021, 41.05.160, 2019 c 325, 2014 c 225, and 2018 c 201. WSR 19-24-063, § 182-538-067, filed 11/27/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-24-098, § 182-538-067, filed 12/1/15, effective 1/1/16. Statutory Authority: RCW 41.05.021, 42 C.F.R. 438. WSR 13-02-010, § 182-538-067, filed 12/19/12, effective 2/1/13. WSR 11-14-075, recodified as § 182-538-067, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.09.522. WSR 08-15-110, § 388-538-067, filed 7/18/08, effective 8/18/08; WSR 06-03-081, § 388-538-067, filed 1/12/06, effective 2/12/06. Statutory Authority: RCW 74.08.090, 74.09.522, 2003 E1 c 25 § 201(4), 2004 c 276 § 201(4), 42 U.S.C. 1396N (section 1915 (b) and (c) of the Social Security Act of 1924). WSR 05-01-066, § 388-538-067, filed 12/8/04, effective 1/8/05. Statutory Authority: RCW 74.08.090, 74.09.522. WSR 03-18-112, § 388-538-067, filed 9/2/03, effective 10/3/03. Statutory Authority: RCW 74.09.080, RCW 74.08.510, [74.08.]522, 74.09.450, 1115 Waiver, 42 U.S.C. 1396. WSR 02-01-075, § 388-538-067, filed 12/14/01, effective 1/14/02.]