Original Notice.

     Preproposal statement of inquiry was filed as WSR 03-10-086.

     Title of Rule: Part 1 of 3, chapter 388-538 WAC, Managed care; amending WAC 388-538-050 Definitions, 388-538-060 Managed care and choice, 388-538-070 Managed care payment, and 388-538-095 Scope of care for managed care enrollees, and repealing WAC 388-538-080 Managed care exemptions.

     Purpose: To bring the managed care program into compliance with the federal Balanced Budget Act (BBA) of 1997. The department is also amending and adding definitions, updating incorrect cross-references and enrollment criteria, updating payment methodologies, consolidating exemptions listed in WAC 388-535-080 into 388-538-130, amending the scope of services to comply with the BBA, and adding information from the healthy options/state children's insurance program (SCHIP) contract about emergency services.

     Statutory Authority for Adoption: RCW 74.08.090, 74.09.522.

     Statute Being Implemented: RCW 74.09.080, 74.09.510, 74.09.522, 74.09.450, 42 C.F.R. 438.400 through 420.

     Summary: See Purpose above.

     Reasons Supporting Proposal: See Purpose above.

     Name of Agency Personnel Responsible for Drafting: Ann Myers, P.O. Box 45533, Olympia, WA 98504, (360) 725-1345; Implementation and Enforcement: Michael Paulson, P.O. Box 45530, Olympia, WA 98504, (360) 725-1641.

     Name of Proponent: Department of Social and Health Services, governmental.

     Rule is necessary because of federal law, 42 C.F.R. 438.400 through 420.

     Explanation of Rule, its Purpose, and Anticipated Effects: See Purpose above.

     The purpose is to meet federal requirements, update policies regarding payment methodology and enrollment criteria, and clarify existing policy.

     The anticipated effect is compliance with federal requirements and easier to understand rules.

     Proposal Changes the Following Existing Rules: This rule changes and adds to existing definitions, amends enrollment criteria, amends payment methodology, and further explains emergency services. WAC 388-538-080 will be repealed.

     No small business economic impact statement has been prepared under chapter 19.85 RCW. The department has analyzed the proposed rules, and, to the best of the department's knowledge, the businesses affected by the rule employ more than fifty employees. The affected businesses therefore do not meet the definition of a small business in RCW 19.85.020, and a statement is not required.

     RCW 34.05.328 applies to this rule adoption. The department has determined that while the proposed rule meets the definition of a "significant legislative rule," amended WAC 388-538-050 is exempt under RCW 34.05.328 (5)(b)(iii) because the amendments to this section are to comply with federal Balanced Budget Act requirements.

     WAC 388-538-060, 388-538-070, and 388-538-095 are amended to clarify policy and do not make significant changes to that policy. The department has analyzed the proposed amendments and concludes that the probable benefits are greater than the probable costs. A copy of the cost/benefit analysis memo is available from the department representative named above.

     Hearing Location: Blake Office Park (behind Goodyear Courtesy Tire), 4500 10th Avenue S.E., Rose Room, Lacey, WA 98503, on August 5, 2003, at 10:00 a.m.

     Assistance for Persons with Disabilities: Contact Fred Swenson, DSHS Rules Consultant, by July 15, 2003, phone (360) 664-6097, TTY (360) 664-6178, e-mail swensFH@dshs.wa.gov.

     Submit Written Comments to: Identify WAC Numbers, Department of Social and Health Services, Rules Coordinator, Rules and Policies Assistance Unit, delivered to 4500 10th Avenue S.E., Lacey, WA, mail to P.O. Box 45850, Olympia, WA 98504-5850, fax (360) 664-6185, or e-mail fernaax@dshs.wa.gov, by 5:00 p.m., August 5, 2003.

     Date of Intended Adoption: Not sooner than August 6, 2003.

June 23, 2003

Brian H. Lindgren, Manager

Rules and Policies Assistance Unit

     "Action" means:

     (1) The denial or limited authorization of a requested service, including the type or level of service;

     (2) The reduction, suspension, or termination of a previously authorized service;

     (3) The denial, in whole or in part, of payment for a service;

     (4) The failure to provide services in a timely manner, as defined by the state; or

     (5) The failure of an MCO to act within the timeframes provided in 42 C.F.R. 438.408(b).

     "Ancillary health services" means health services ordered by a provider, including but not limited to, laboratory services, radiology services, and physical therapy.

     "Appeal" means a ((formal)) request by a provider or covered enrollee for reconsideration of ((a decision such as a utilization review recommendation, a benefit payment, an administrative action, or a quality of care or service issue, with the goal of finding a mutually acceptable solution)) an action. The reconsideration includes independent review under RCW 48.43.535.

     "Assign" or "assignment" means that MAA selects a managed care organization (MCO) or primary care case management (PCCM) provider to serve a client who lives in a mandatory enrollment area and who has failed to select an MCO or PCCM provider.

     "Basic health (BH)" means the health care program authorized by chapter 70.47 RCW and administered by the health care authority (HCA). MAA considers basic health to be third-party coverage, however, this does not include basic health plus (BH+).

     (("Children's health insurance program (CHIP)" means the health insurance program authorized by Title XXI of the Social Security Act and administered by the department of social and health services (DSHS). This program also is referred to as the state children's health insurance program (SCHIP).))

     "Children with special health care needs" means children identified by the department of social and health services (DSHS) as having special health care needs. This includes:

     (1) Children designated as having special health care needs by the department of health (DOH) and served under the Title V program;

     (2) Children who meet disability criteria of Title 16 of the Social Security Act (SSA); and

     (3) Children who are in foster care or who are served under subsidized adoption.

     "Client" means an individual eligible for any medical program who is not enrolled with a managed care organization (MCO) or primary care case management (PCCM) provider. In this chapter, client refers to a person before the person is enrolled in managed care, while enrollee refers to an individual eligible for any medical program who is enrolled in managed care.

     (("Complaint" means an oral or written expression of dissatisfaction by an enrollee.))

     "Emergency medical condition" means a condition meeting the definition in ((42 U.S.C. 1396u-2 (b)(2)(C))) 42 C.F.R. 438.114(a).

     "Emergency services" means services as defined in ((42 U.S.C. 1396u-2 (b)(2)(B))) 42 C.F.R. 438.114(a).

     "End enrollment" means an enrollee is currently enrolled in managed care, either with a managed care organization (MCO) or with a primary care case management (PCCM) provider, and requests to discontinue enrollment and return to the fee-for-service delivery system for one of the reasons outlined in WAC 388-538-130. This is also referred to as "disenrollment."

     "Enrollee" means an individual eligible for any medical program who is enrolled in managed care through a (([managed])) managed care organization (MCO) or primary care case management (PCCM) provider that has a contract with the state.

     "Enrollees with ((chronic conditions)) special health care needs" means persons having chronic and disabling conditions, including persons with special health care needs that meet all of the following conditions:

     (1) Have a biologic, psychologic, or cognitive basis;

     (2) Have lasted or are virtually certain to last for at least one year; and

     (3) Produce one or more of the following conditions stemming from a disease:

     (a) Significant limitation in areas of physical, cognitive, or emotional function;

     (b) Dependency on medical or assistive devices to minimize limitation of function or activities; or

     (c) In addition, for children, any of the following:

     (i) Significant limitation in social growth or developmental function;

     (ii) Need for psychologic, educational, medical, or related services over and above the usual for the child's age; or

     (iii) Special ongoing treatments, such as medications, special diet, interventions, or accommodations at home or school.

     "Exemption" means a client, not currently enrolled in managed care, makes a preenrollment request to remain in the fee-for-service delivery system for one of the reasons outlined in WAC ((388-538-080)) 388-538-130.

     "Grievance" means an expression of dissatisfaction about any matter other than an action, as "action" is defined in this section.

     "Grievance system" means the overall system that includes grievances and appeals handled at the MCO level and access to the state fair hearing process.

     "Health care service" or "service" means a service or item provided for the prevention, cure, or treatment of an illness, injury, disease, or condition.

     "Healthy options contract or HO contract" means the agreement between the department of social and health services (DSHS) and a managed care organization (MCO) to provide prepaid contracted services to enrollees.

     "Healthy options program or HO program" means the medical assistance administration's (MAA) prepaid managed care health program for Medicaid-eligible clients and CHIP clients.

     "Managed care" means a comprehensive system of medical and health care delivery including preventive, primary, specialty, and ancillary health services. These services are provided either through a managed care organization (MCO) or primary care case management (PCCM) provider.

     "Managed care organization" or "MCO" means ((a health maintenance organization or health care service contractor)) an organization having a certificate of authority or certificate of registration from the office of insurance commissioner that contracts with the department of social and health services (DSHS) under a comprehensive risk contract to provide prepaid health care services to eligible medical assistance administration (MAA) clients under MAA's managed care programs.

     "Nonparticipating provider" means a person or entity that does not have a written agreement with a managed care organization (MCO) but that provides MCO-contracted health care services to managed care enrollees with the authorization of the MCO. The MCO is solely responsible for payment for MCO-contracted health care services that are authorized by the MCO and provided by nonparticipating providers.

     "Participating provider" means a person or entity with a written agreement with a managed care organization (MCO) to provide health care services to managed care enrollees. A participating provider must look solely to the MCO for payment for such services.

     "Primary care case management (PCCM)" means the health care management activities of a provider that contracts with the department to provide primary health care services and to arrange and coordinate other preventive, specialty, and ancillary health services.

     "Primary care provider (PCP)" means a person licensed or certified under Title 18 RCW including, but not limited to, a physician, an advanced registered nurse practitioner (ARNP), or a physician assistant who supervises, coordinates, and provides health services to a client or an enrollee, initiates referrals for specialist and ancillary care, and maintains the client's or enrollee's continuity of care.

     "Prior authorization (PA)" means a process by which enrollees or providers must request and receive MAA approval for services provided through MAA's fee-for-service program, or MCO approval for services provided through the MCO, for certain medical services, equipment, drugs, and supplies, based on medical necessity, before the services are provided to clients, as a precondition for provider reimbursement. Expedited prior authorization and limitation extension are forms of prior authorization. See WAC 388-501-0165.

     "Timely" - in relation to the provision of services, means an enrollee has the right to receive medically necessary health care ((without unreasonable delay)) as expeditiously as the enrollee's health condition requires. In relation to authorization of services and grievances and appeals, means in accordance with the Healthy Options (HO)/State Childrens Health Insurance Program (SCHIP) contract and the timeframes stated in this chapter.

[Statutory Authority: RCW 74.09.080, 74.08.510, [74.08.]522, 74.09.450, 1115 Waiver, 42 U.S.C. 1396. 02-01-075, § 388-538-050, filed 12/14/01, effective 1/14/02. Statutory Authority: RCW 74.08.090, 74.09.510 and [74.09.]522 and 1115 Federal Waiver, 42 U.S.C. 1396 (a), (e), (p), 42 U.S.C. 1396r-6(b), 42 U.S.C. 1396u-2. 00-04-080, § 388-538-050, filed 2/1/00, effective 3/3/00. Statutory Authority: RCW 74.08.090 and 1995 2nd sp.s. c 18. 95-18-046 (Order 3886), § 388-538-050, filed 8/29/95, effective 9/1/95. Statutory Authority: RCW 74.08.090. 93-17-039 (Order 3621), § 388-538-050, filed 8/11/93, effective 9/11/93.]

     (a) Is eligible for one of the medical programs for which clients must enroll in managed care;

     (b) Resides in an area, determined by the medical assistance administration (MAA), where clients must enroll in managed care;

     (c) Is not exempt from managed care enrollment as determined by MAA, consistent with WAC ((388-538-080)) 388-538-130, and any related fair hearing has been held and decided; and

     (d) Has not had managed care enrollment ended by MAA, consistent with WAC 388-538-130.

     (2) American Indian/Alaska Native (AI/AN) clients who meet the provisions of 25 U.S.C. 1603 (c)-(d) for federally-recognized tribal members and their descendants may choose one of the following:

     (a) Enrollment with a managed care organization (MCO) available in their area;

     (b) Enrollment with an Indian or tribal primary care case management (PCCM) provider available in their area; or

     (c) MAA's fee-for-service system.

     (3) A client may enroll with an MCO or PCCM provider by calling MAA's toll-free enrollment line or by sending a completed enrollment form to MAA.

     (a) Except as provided in subsection (2) of this section for clients who are AI/AN ((and in subsection (5) of this section for cross-county enrollment)), a client required to enroll in managed care must enroll with an MCO or PCCM provider available in the area where the client lives.

     (b) All family members must either enroll with the same MCO or enroll with PCCM providers.

     (c) Enrollees may request an MCO or PCCM provider change at any time.

     (d) When a client requests enrollment with an MCO or PCCM provider, MAA enrolls a client effective the earliest possible date given the requirements of MAA's enrollment system. MAA does not enroll clients retrospectively.

     (4) MAA assigns a client who does not choose an MCO or PCCM provider as follows:

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

     (b) If the client does not have family members enrolled with an MCO, and the client was enrolled in the last six months with an MCO or PCCM provider, the client is re-enrolled with the same MCO or PCCM provider;

     (c) If a client does not choose an MCO or a PCCM provider, but indicates a preference for a provider to serve as the client's primary case provider (PCP), MAA attempts to contact the client to complete the required choice. If MAA is not able to contact the client in a timely manner, MAA documents the attempted contacts and, using the best information available, assigns the client as follows. If the client's preferred PCP is:

     (i) Available with one MCO, MAA assigns the client in the MCO where the client's PCP provider is available. The MCO is responsible for PCP choice and assignment;

     (ii) Available only as a PCCM provider, MAA assigns the client to the preferred provider as the client's PCCM provider;

     (iii) Available with multiple MCOs or through an MCO and as a PCCM provider, MAA assigns the client to an MCO as described in (d) of this subsection;

     (iv) Not available through any MCO or as a PCCM provider, MAA assigns the client to an MCO or PCCM provider as described in (d) of this subsection.

     (d) If the client cannot be assigned according to (a), (b), or (c) of this subsection, MAA assigns the client as follows:

     (i) If an AI/AN client does not choose an MCO or PCCM provider, MAA assigns the client to a tribal PCCM provider if that client lives in a zip code served by a tribal PCCM provider. If there is no tribal PCCM provider in the client's area, the client continues to be served by MAA's fee-for-service system. A client assigned under this subsection may request to end enrollment at any time.

     (ii) If a non-AI/AN client does not choose an MCO or PCCM provider, MAA assigns the client to an MCO or PCCM provider available in the area where the client lives. The MCO is responsible for PCP choice and assignment. An MCO must meet the healthy options (HO) contract's access standards unless the MCO has been granted an exemption by MAA. The HO contract standards are as follows:

     (A) There must be two PCPs within ten miles for ninety percent of HO enrollees in urban areas and one PCP within twenty-five miles for ninety percent of HO enrollees in rural areas;

     (B) There must be two obstetrical providers within ten miles for ninety percent of HO enrollees in urban areas and one obstetrical provider within twenty-five miles for ninety percent of HO enrollees in rural areas;

     (C) There must be one hospital within twenty-five miles for ninety percent of HO enrollees in the contractor's service area;

     (D) There must be one pharmacy within ten miles for ninety percent of HO enrolles in urban areas and one pharmacy within twenty-five miles for ninety percent of HO enrollees in rural areas.

     (iii) MAA sends a written notice to each household of one or more clients who are assigned to an MCO or PCCM provider. The notice includes the name of the MCO or PCCM provider to which each client has been assigned, the effective date of enrollment, the date by which the client must respond in order to change MAA's assignment, and either the toll-free telephone number of:

     (A) The MCO for enrollees assigned to an MCO; or

     (B) MAA for enrollees assigned to a PCCM provider.

     (iv) An assigned client has at least thirty calendar days to contact MAA to change the MCO or PCCM provider assignment before enrollment is effective.

     (5) ((A client may enroll with a plan in an adjacent county when the client lives in an area, designated by MAA, where residents historically have traveled a relatively short distance across county lines to the nearest available practitioner.

     (6))) An MCO enrollee's selection of the enrollee's PCP or the enrollee's assignment to a PCP occurs as follows:

     (a) MCO enrollees may choose:

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

     (ii) Different PCPs or clinics participating with the same MCO for different family members.

     (b) The MCO assigns a PCP or clinic that meets the access standards set forth in subsection (4)(d)(ii) of this section if the enrollee does not choose a PCP or clinic;

     (c) MCO enrollees may change PCPs or clinics in an MCO ((at least once a year)) for any reason, ((and at any time for good cause)) with the change becoming effective no later than the beginning of the month following the enrollee's request; or

     (d) In accordance with this subsection, MCO enrollees may file ((an appeal)) a grievance with the MCO ((and/or a fair hearing request with the department of social and health services (DSHS))) and may change plans if the MCO denies an enrollee's request to change PCPs or clinics.

[Statutory Authority: RCW 74.09.080, 74.08.510, [74.08.]522, 74.09.450, 1115 Waiver, 42 U.S.C. 1396. 02-01-075, § 388-538-060, filed 12/14/01, effective 1/14/02. Statutory Authority: RCW 74.08.090, 74.09.510 and [74.09.]522 and 1115 Federal Waiver, 42 U.S.C. 1396 (a), (e), (p), 42 U.S.C. 1396r-6(b), 42 U.S.C. 1396u-2. 00-04-080, § 388-538-060, filed 2/1/00, effective 3/3/00. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057 and 74.08.090. 98-16-044, § 388-538-060, filed 7/31/98, effective 9/1/98. Statutory Authority: RCW 74.08.090 and 1995 2nd sp.s. c 18. 95-18-046 (Order 3886), § 388-538-060, filed 8/29/95, effective 9/1/95. Statutory Authority: RCW 74.08.090. 93-17-039 (Order 3621), § 388-538-060, filed 8/11/93, effective 9/11/93.]

     Reviser's note: The spelling error in the above section occurred in the copy filed by the agency and appears in the Register pursuant to the requirements of RCW 34.08.040.
AMENDATORY SECTION(Amending WSR 02-01-075, filed 12/14/01, effective 1/14/02)

WAC 388-538-070   Managed care payment.   (1) The medical assistance administration (MAA) pays managed care organizations (MCOs) monthly capitated premiums that:

     (a) Have been determined using generally accepted actuarial methods based on analyses of historical healthy options (HO) contractual rates and MCO experience in providing health care for the populations eligible for HO; and

     (b) Are paid based on legislative allocations for the HO program.

     (2) MAA pays primary care case management (PCCM) providers a monthly case management fee according to contracted terms and conditions.

     (3) MAA does not pay providers on a fee-for-service basis for services that are the MCO's responsibility under the HO contract, even if the MCO has not paid for the service for any reason. The MCO is solely responsible for payment of MCO-contracted health care services:

     (a) Provided by an MCO-contracted provider; or

     (b) That are authorized by the MCO and provided by nonparticipating providers.

     (4) MAA pays an additional monthly amount, known as an enhancement rate, to federally qualified health care centers (FQHC) and rural health clinics (RHC) for each client enrolled with MCOs through the FQHC or RHC. MCOs may contract with FQHCs and RHCs to provide services under HO. FQHCs and RHCs receive an enhancement rate from MAA on a per member, per month basis in addition to the negotiated payments they receive from the MCOs for services provided to MCO enrollees.

     (((a) MAA pays the enhancement rate only for the categories of service provided by the FQHC or RHC under the HO contact [contract]. MAA surveys each FQHC or RHC in order to identify the categories of services provided by the FQHC or RHC.

     (b) MAA bases the enhancement rate on both of the following:

     (i) The upper payment limit (UPL) for the county in which the FQHC or RHC is located; and

     (ii) An enhancement percentage.

     (c) MAA determines the UPL for each category of service based on MAA's historical fee-for-service (FFS) experience, adjusted for inflation and utilization changes.

     (d) MAA determines the enhancement percentage for HO enrollees as follows:

     (i) For FQHCs, the enhancement percentage is equal to the FQHC finalized audit period ratio. The "finalized audit period" is the latest reporting period for which the FQHC has a completed audit approved by, and settled with, MAA.

     (A) For a clinic with one finalized audit period, the ratio is equal to:

     (FQHC total costs) - (FFS reimbursements + HO reimbursements)/(FFS + HO reimbursements).

     (B) For a clinic with two finalized audit periods, the ratio is equal to the percentage change in the medical services encounter rate from one finalized audit period to the next. A "medical services encounter" is a face-to-face encounter between a physician or mid-level practitioner and a client to provide services for prevention, diagnosis, and/or treatment of illness or injury. A "medical services encounter rate" is the individualized rate MAA pays each FQHC to provide such services to clients, or the rate set by Medicare for each RHC for such services.

     (C) For FQHCs without a finalized audit, the enhancement percentage is the statewide weighted average of all the FQHCs' finalized audit period ratios. Weighting is based on the number of enrollees served by each FQHC.

     (ii) For RHCs, MAA applies the same enhancement percentage statewide.

     (A) On a given month, MAA determines the number of HO enrollees enrolled with each RHC that is located in the same county as an FQHC. This number is expressed as a percentage of the total number of RHC enrollees located in counties that have both FQHCs and RHCs.

     (B) For each county that has both an FQHC and an RHC, MAA multiplies the FQHC enhancement percentage, as determined under subsection (4)(d)(i) of this section, by the percentage obtained in section (4)(d)(ii)(A) of this section.

     (C) The sum of all these products is the weighted statewide RHC enhancement percentage.

     (iii) The HO enhancement percentage for FQHCs and RHCs is updated once a year.

     (e) For each category of service provided by the FQHC or RHC, MAA multiplies the UPL, as determined under subsection (4)(c) of this section, by the FQHC's or RHC's enhancement percentage. The sum of all these products is the enhancement rate for the individual FQHC or RHC.

     (f) To calculate the enhancement rate for FQHCs and RHCs that provide maternity and newborn delivery services, MAA applies each FQHC's or RHC's enhancement percentage to the delivery case rate (DCR), which is a one-time rate paid by MAA to the HO plan for each pregnant enrollee who gives birth.))

[Statutory Authority: RCW 74.09.080, 74.08.510, [74.08.]522, 74.09.450, 1115 Waiver, 42 U.S.C. 1396. 02-01-075, § 388-538-070, filed 12/14/01, effective 1/14/02. Statutory Authority: RCW 74.08.090, 74.09.510 and [74.09.]522 and 1115 Federal Waiver, 42 U.S.C. 1396 (a), (e), (p), 42 U.S.C. 1396r-6(b), 42 U.S.C. 1396u-2. 00-04-080, § 388-538-070, filed 2/1/00, effective 3/3/00. Statutory Authority: RCW 74.08.090. 96-24-073, § 388-538-070, filed 12/2/96, effective 1/2/97. Statutory Authority: RCW 74.08.090 and 1995 2nd sp.s. c 18. 95-18-046 (Order 3886), § 388-538-070, filed 8/29/95 effective 9/1/95. Statutory Authority: RCW 74.08.090. 93-17-039 (Order 3621), § 388-538-070, filed 8/11/93, effective 9/11/93.]

     (a) A client is entitled to timely access to medically necessary services as defined in WAC 388-500-0005.

     (b) The managed care organization (MCO) covers the services included in the healthy options (HO) contract for MCO enrollees. In addition, MCOs may, at their discretion, cover services not required under the HO contract.

     (c) The medical assistance administration (MAA) covers the medically necessary, covered categorically needy services not included in the HO contract for MCO enrollees.

     (d) MAA covers services on a fee-for-service basis for enrollees with a primary care case management (PCCM) provider. Except for emergencies, the PCCM provider must either provide the covered services needed by the enrollee or refer the enrollee to other providers who are contracted with MAA for covered services. The PCCM provider is responsible for instructing the enrollee regarding how to obtain the services that are referred by the PCCM provider. The services that require PCCM provider referral are described in the PCCM contract. MAA informs enrollees about the enrollee's program coverage, limitations to covered services, and how to obtain covered services.

     (e) MCO enrollees may obtain certain services from either a MCO provider or from a medical assistance provider with a DSHS core provider agreement without needing to obtain a referral from the PCP or MCO. These services are described in the HO contract, and are communicated to enrollees by MAA and MCOs as described in (f) of this subsection.

     (f) MAA sends each client written information about covered services when the client is required to enroll in managed care, and any time there is a change in covered services. This information describes covered services, which services are covered by MAA, and which services are covered by MCOs. In addition, MAA requires MCOs to provide new enrollees with written information about covered services.

     (2) For services covered by MAA through PCCM contracts for managed care:

     (a) MAA covers medically necessary ((covers)) services included in the categorically needy scope of care and rendered by providers with a current department of social and health services (DSHS) core provider agreement to provide the requested service;

     (b) MAA may require the PCCM provider to obtain authorization from MAA for coverage of nonemergency services;

     (c) The PCCM provider determines which services are medically necessary;

     (d) An enrollee may request a fair hearing for review of PCCM provider or MAA coverage decisions (see WAC 388-538-110); and

     (e) Services referred by the PCCM provider require an authorization number in order to receive payment from MAA.

     (3) For services covered by MAA through contracts with MCOs:

     (a) MAA requires the MCO to subcontract with a sufficient number of providers to deliver the scope of contracted services in a timely manner. Except for emergency services, MCOs provide covered services to enrollees through their participating providers;

     (b) MAA requires MCOs to provide new enrollees with written information about how enrollees may obtain covered services;

     (c) For nonemergency services, MCOs may require the enrollee to obtain a referral from the primary care provider (PCP), or the provider to obtain authorization from the MCO, according to the requirements of the HO contract;

     (d) MCOs and their providers determine which services are medically necessary given the enrollee's condition, according to the requirements included in the HO contract;

     (e) An enrollee may appeal an MCO ((coverage decisions)) action using the MCO's appeal process, as described in WAC 388-538-0110. After exhausting the MCO's appeal process, an enrollee may also request a department fair hearing for review of an MCO ((coverage decision)) action as described in ((chapter 388-02))WAC 388-538-112;

     (f) A managed care enrollee does not need a PCP referral to receive women's health care services, as described in RCW 48.42.100 from any women's health care provider participating with the MCO. Any covered services ordered and/or prescribed by the women's health care provider must meet the MCO's service authorization requirements for the specific service.

     (4) Unless the MCO chooses to cover these services, or an appeal or a fair hearing decision reverses an MCO or MAA denial, the following services are not covered:

     (a) For all managed care enrollees:

     (i) Services that are not medically necessary;

     (ii) Services not included in the categorically needy scope of services; and

     (iii) Services, other than a screening exam as described in WAC 388-538-100(3), received in a hospital emergency department for nonemergency medical conditions.

     (b) For MCO enrollees:

     (i) Services received from a participating specialist that require prior authorization from the MCO, but were not authorized by the MCO; and

     (ii) Services received from a nonparticipating provider that require prior authorization from the MCO that were not authorized by the MCO. All nonemergency services covered under the HO contract and received from nonparticipating providers require prior authorization from the MCO.

     (c) For PCCM enrollees, services that require a referral from the PCCM provider as described in the PCCM contract, but were not referred by the PCCM provider.

     (5) A provider may bill an enrollee for noncovered services as described in subsection (4) of this section, if the ((enrollee and provider sign an agreement)) requirements of WAC 388-502-0160 are met. The provider must give the original agreement to the enrollee and file a copy in the enrollee's record.

     (a) The agreement must state all of the following:

     (i) The specific service to be provided;

     (ii) That the service is not covered by either MAA or the MCO;

     (iii) An explanation of why the service is not covered by the MCO or MAA, such as:

     (A) The service is not medically necessary; or

     (B) The service is covered only when provided by a participating provider.

     (iv) The enrollee chooses to receive and pay for the service; and

     (v) Why the enrollee is choosing to pay for the service, such as:

     (A) The enrollee understands that the service is available at no cost from a provider participating with the MCO, but the enrollee chooses to pay for the service from a provider not participating with the MCO;

     (B) The MCO has not authorized emergency department services for nonemergency medical conditions and the enrollee chooses to pay for the emergency department's services rather than wait to receive services at no cost in a participating provider's office; or

     (C) The MCO or PCCM has determined that the service is not medically necessary and the enrollee chooses to pay for the service.

     (b) For limited English proficient enrollees, the agreement must be translated or interpreted into the enrollee's primary language to be valid and enforceable.

     (c) The agreement is void and unenforceable, and the enrollee is under no obligation to pay the provider, if the service is covered by MAA or the MCO as described in subsection (1) of this section, even if the provider is not paid for the covered service because the provider did not satisfy the payor's billing requirements.

[Statutory Authority: RCW 74.09.080, 74.08.510, [74.08.]522, 74.09.450, 1115 Waiver, 42 U.S.C. 1396. 02-01-075, § 388-538-095, filed 12/14/01, effective 1/14/02. Statutory Authority: RCW 74.08.090. 01-02-076, § 388-538-095, filed 12/29/00, effective 1/29/01. Statutory Authority: RCW 74.08.090, 74.09.510 and [74.09.]522 and 1115 Federal Waiver, 42 U.S.C. 1396 (a), (e), (p), 42 U.S.C. 1396r-6(b), 42 U.S.C. 1396u-2. 00-04-080, § 388-538-095, filed 2/1/00, effective 3/3/00. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057 and 74.08.090. 98-16-044, § 388-538-095, filed 7/31/98, effective 9/1/98. Statutory Authority: RCW 74.08.090 and 1995 2nd sp.s. c 18. 95-18-046 (Order 3886), § 388-538-095, filed 8/29/95, effective 9/1/95. Statutory Authority: RCW 74.08.090. 93-17-039 (Order 3621), § 388-538-095, filed 8/11/93, effective 9/11/93.]

     The following section of the Washington Administrative Code is repealed:

WAC 388-538-080

Managed care exemptions.

© Washington State Code Reviser's Office