Original Notice.

Preproposal statement of inquiry was filed as WSR 99-01-167.

Title of Rule: Chapter 388-538 WAC, Managed care.

Purpose: To clarify changes made by the ESA/MAA review of all rules that possibly relate to TANF (temporary assistance to needy families) and CSOs (community service offices). To review the rules for compliance with the Governor's Executive Order 97-02.

Statutory Authority for Adoption: RCW 74.08.090, 74.09.510, and [74.09.]522, 1115 Federal Waiver, 42 U.S.C. 1396 (a), (e) and (p), 1396r-6(b), 1396u-2.

Statute Being Implemented: RCW 74.08.090, 74.09.510, and [74.09.]522, 1115 Federal Waiver, 42 U.S.C. 1396 (a), (e) and (p), 1396r-6(b), 1396u-2.

Summary: The rules have been rewritten to clarify changes made by the ESA/MAA review of all rules that possibly relate to TANF (temporary assistance to needy families) and CSOs (community service offices). The rewritten rules clarify healthy options enrollment criteria, payment methodology, the scope of care, and ending enrollment. New sections are added that establish eligibility criteria for basic health plan enrollees and cross-reference the children's health insurance program (CHIP). The rules have also been reviewed and rewritten to reflect current department policy and to clarify and simplify the language to meet the criteria in the Governor's Executive Order 97-02.

Reasons Supporting Proposal: To comply with the Governor's Executive Order 97-02. To ensure that current department policy and practice is reflected in rule.

Name of Agency Personnel Responsible for Drafting, Implementation and Enforcement: D. Andrea Davis, DPS/MCCM, 619 8th Avenue S.E., Olympia, WA 98501, (360) 586-4877.

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

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

Explanation of Rule, its Purpose, and Anticipated Effects: The rule as rewritten clarifies healthy options enrollment criteria, payment methodology, the scope of care, and ending enrollment. New sections are added that establish eligibility criteria for basic health plan enrollees and that cross-reference the children's health insurance program (CHIP). The amended rules clarify department policy, organizing and simplifying sections for clarity and ease of use.

Proposal Changes the Following Existing Rules: Amends rule listed in Title of Rule above to reflect current department policy and to clarify the language.

No small business economic impact statement has been prepared under chapter 19.85 RCW. The department has analyzed the proposed amendments and concludes that no new costs will be imposed on the small businesses affected by them.

RCW 34.05.328 applies to this rule adoption. The rule does meet the definition of a significant legislative rule, and the department has prepared a cost benefit analysis that can be obtained by contacting the person listed in Name of Agency Personnel above.

Hearing Location: Lacey Government Center (behind Tokyo Bento Restaurant), 1009 College Street S.E., Room 104-B, Lacey, WA 98503, on November 23, 1999, at 10:00 a.m.

Assistance for Persons with Disabilities: Contact Paige Wall by November 12, 1999, phone (360) 664-6094, TTY (360) 664-6178, e-mail wallpg@dshs.wa.gov.

Submit Written Comments to: Identify WAC Numbers, Paige Wall, DSHS Rules Coordinator, Rules and Policies Assistance Unit, P.O. Box 45850, Olympia, WA 98504-5850, fax (360) 664-6185, by November 23, 1999.

Date of Intended Adoption: November 24, 1999.

October 1, 1999

Marie Myerchin-Redifer, Manager

Rules and Policies Assistance Unit

((For the purpose of this chapter:

(1) "Emergency services" shall mean medical or other health services which are rendered for a medical condition (including emergency labor and delivery) manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in:

(a) Placing the patient's health in serious jeopardy;

(b) Serious impairment to bodily functions; or

(c) Serious dysfunction of any bodily organ or part.

(2) "Enrolled client" means a client eligible for Medicaid and receiving services from a health care plan or primary care case management provider who has a contract with the department.

(3) "Health care plan" or "plan" means an organization contracting with the department to provide managed care to the client by providing and/or paying for medical services covered by the department to an eligible enrolled client in exchange for a contracted rate or management fee.

(4))) The following definitions and abbreviations and those found in chapter 388-500-0005 WAC, Medical definitions, apply to this chapter. Defined words and phrases are bolded in the text.

"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.

"Basic health plan (BHP)" means the health care program authorized by title 70.47 RCW and administered by the health care authority (HCA).

"Children's health insurance program (CHIP)" means the health insurance program authorized by Title XXI of the Social Security Act and administered by the medical assistance administration (MAA)

"Client" means an individual eligible for any medical program who is not enrolled with a managed care plan or 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.

"End enrollment" means an enrollee is currently enrolled in HO 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 health care plan or primary care case management (PCCM) provider that has a contract with the state.

"Enrollees with chronic conditions" 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 is not currently enrolled in HO and makes a pre-enrollment request to remain in the fee-for-service delivery system for one of the reasons outlined in WAC 388-538-080.

"Health care plan" or "plan" means an organization contracted with the department of social and health services (DSHS) to provide managed care to MAA clients.

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

"Healthy options contract or HO contract" means the agreement between the department of social and health services and a health care plan to provide the contracted services to enrollees.

"Healthy options program or HO program" means medical assistance administration's managed care health program for Medicaid-eligible clients.

"Managed care" means a comprehensive system of medical and health care delivery including preventive, primary, specialty, and ancillary health services((.  Managed care involves having clients enrolled:

(a) With or assigned to a primary care provider;

(b) With or assigned to a plan; or

(c) With an independent provider, who is responsible for arranging or delivering all contracted medical care.

(5) "Persons with special health care needs" means persons having ongoing health conditions that:

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

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

(c) Produce one or more of the following sequelae:

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

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

(iii) In addition for children:

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

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

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

(6) "Primary care provider (PCP)" means a provider who has responsibility for supervising, coordinating, and providing initial and primary care to clients, initiating referrals for specialist care, and maintaining the continuity of patient care.  A primary care provider shall be either:

(a) A physician, who meets the criteria under WAC 388-87-007;

(b) An advanced registered nurse practitioner (ARNP), who meets the criteria under WAC 388-87-007; or

(c) A licensed physician assistant.

(7) "Primary care case management (PCCM)" means a model of health care where a physician, ARNP, physician assistant, community/migrant health center, health department, or clinic agrees to provide primary health care services and to arrange and coordinate other preventative, specialty, and ancillary health care in exchange for a contracted payment for each client managed.  

(8) "Timely provision of services" means a client has the right to receive medically necessary health care without unreasonable delay)).

"Participating provider" means a person or entity with a written agreement with a plan to provide health care services to managed care enrollees.

"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, and 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.

"Timely" - in relation to the provision of services, means an enrollee has the right to receive medically necessary health care according to timeline standards in the healthy options contract.

[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.]

(1) A client is required to enroll in ((the department's "healthy options" (HO) managed care when that client:

(a) Is eligible for one of the medical programs subject to mandatory enrollment as determined by the department;

(b) Resides in one of the department's contracted managed care service areas;

(c) Is not exempted by the department per WAC 388-538-080; and

(d) Is not removed from HO enrollment by the department per WAC 388-538-130.

(2) American Indians or Alaskan Natives (AI/AN) are those individuals meeting the provisions of 25 U.S.C. 1603 (c)-(d) as of April 30, 1998 (printed format available from the Government Printing Office, Washington, DC).  They have the following options:

(a) Enrolling with an HO primary care case manager (PCCM), which include Indian health service direct-care clinics, clinics operated by tribes, and urban Indian health centers; or

(b) Voluntarily selecting an HO contracted managed care plan; or

(c) Requesting an exemption from enrollment in managed care based solely on their status as an AI/AN.

(3) An AI/AN who does not make a choice under subsection (2) of this section will be assigned to an HO PCCM if the client lives in a PCCM area.  HO PCCMs are described in subsection (2)(a) of this section.  A client who is assigned under this subsection is entitled to request and obtain removal from the PCCM assignment at any time.

(4) A client who is a Medicare beneficiary is not currently eligible to enroll with an HO managed care plan.

(5) Except for clients who are AI/AN, if the client does not choose an HO managed care plan, the department assigns the client to a HO plan in the client's area.

(6) The client will be given an opportunity to select a primary care provider from their HO managed care plan's available providers.

(7) If the client does not choose a primary care provider (PCP), the plan assigns the client a PCP.

(8) A client may change their PCP once a year for any reason.  For more frequent PCP changes, the client must notify the plan of the request and a reason showing good cause.  If the plan denies the change, the client may:

(a) Appeal to the plan; or

(b) Ask the department for a fair hearing; or

(c) Appeal to the plan and request a fair hearing from the department)) HO when that client meets all of the following conditions:

(a) Is eligible for one of the medical programs for which clients must enroll in HO as described in the HO contract;

(b) Resides in an area, determined by MAA, where clients must enroll in HO;

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

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

(2) American Indian/Alaskan 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) Enroll with an HO plan available in their area;

(b) Enroll with an HO Indian or tribal PCCM provider available in their area; or

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

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

(a) Except as provided in subsection (2) of this section for AI/AN and in subsection (5) of this section for cross-county enrollment, a client required to enroll in HO must enroll with a plan available in the area where the client lives.

(b) Family members must enroll with the same plan.

(c) Enrollees may request a plan change at any time.

(d) When a client requests enrollment with a plan 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 a plan or PCCM provider as follows:

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

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

(c) If a client does not choose a plan or PCCM provider but chooses a provider, MAA attempts to contact the client by phone to obtain the client's plan or PCCM provider choice. If MAA is not able to contact the client, MAA attempts to determine whether the client's chosen provider is with a plan, and, if so, assigns the client to that plan;

(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 a plan, MAA assigns the client to a PCCM provider if that client lives in a zip code served by a PCCM provider. If there is no PCCM provider in the client's area, the client will remain fee-for-service. A client assigned under this subsection may request to end enrollment according to WAC 388-538-130 (2)(b) at any time.

(ii) If a non-AI/AN client does not choose a plan, MAA assigns a plan available in the area where the client lives. A plan must have at least one PCP available within twenty-five miles of the zip code in which the client lies for the plan to be considered available.

(iii) MAA sends a written notice to each household of one or more clients who are assigned to a plan or PCCM provider. The notice includes the name of the plan or PCCM provider to which each client has been assigned, toll-free contact phone numbers for the plan or PCCM provider and MAA, the effective date of enrollment, and the date by which the client must respond.

(iv) An assigned client has at least thirty calendar days to contact MAA to change the plan or PCCM provider 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) PCP choice or assignment occurs as follows:

(a) Enrollees may choose:

(i) A PCP or clinic that is in their plan and accepting new enrollees; or

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

(b) The plan assigns a PCP or clinic within reasonable proximity to the enrollee's home if the enrollee does not choose one;

(c) Enrollees may change PCPs or clinics in a plan at least once a year for any reason, and at any time for good cause; or

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

[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.]

(1) Certain children and pregnant women who are enrolled in the BHP (chapter 70.47 RCW) are eligible for Medicaid under pediatric and maternity expansion provisions of the Social Security Act. MAA determines Medicaid eligibility for BHP enrollee children and pregnant women.

(2) The administrative rules and regulations that apply to HO enrollees also apply to Medicaid eligible BHP enrollees, except as follows:

(a) The process for enrolling in HO described in WAC 388-538-060(3) does not apply since enrollment is through the health care authority, the state agency that administers the BHP;

(b) American Native/Native Alaskan (AI/AN) clients cannot choose fee-for-service or PCCM as described in WAC 388-538-060(2) under BHP. They must enroll with a BHP health care plan;

(c) If a Medicaid eligible BHP enrollee does not choose a plan within ninety days, the enrollee is transferred from BHP to HO and is assigned to a plan as described in WAC 388-538-060 (4)(c).

[]

(1) Children eligible for the children's health insurance program (CHIP), a non-Medicaid medical program, may be enrolled in managed care as described in chapter 388-542 WAC.

(2) With the exception of the following sections, the sections in this chapter apply to CHIP clients enrolled in managed care:

(a) WAC 388-538-060 does not apply to CHIP. The enrollment and choice provisions for CHIP clients are included in chapter 388-542 WAC.

(b) WAC 388-538-065 does not apply to CHIP since CHIP eligible clients cannot enroll in managed care through the BHP.

(c) WAC 388-538-080 and 388-538-130 do not apply to CHIP. Chapter 388-542 WAC includes the provisions for exceptions to managed care enrollment for CHIP clients.

[]

((The department shall pay for managed care as follows:

(1) Under a capitated system:

(a) A set rate to a plan for contracted health care provided to the client; and

(b) The plan has one year from the date services are provided to an SSI client to submit claims:

(i) To the department to be considered towards meeting the stop-loss deductible; and

(ii) For the department to make payments to the plan once the deductible is satisfied.

(2) Under a PCCM model in which the contract is between the department and the health care provider, a monthly management fee in addition to a fee for covered services provided to the client;

(3) Under a PCCM model in which the contract is between the department and a plan, a monthly management fee to the plan to be divided between the plan and the primary care provider, in addition to a fee to the health care provider for covered services provided to the client)) MAA pays plans a monthly capitated premium according to contracted terms and conditions.

(2) MAA pays 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 plan's responsibility under the HO contract, even if the plan has not paid for the service for any reason.

(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 plans through the FQHC or RHC. Plans may contract with FQHCs and RHCs to provide services under HO. FQHCs and RHCs receive an enhancement rate from MAA in addition to the negotiated payments they receive from the plans for services provided to enrollees. MAA pays the enhancement rate to supplement the plan payment to ensure full reimbursement of the FQHC and RHC reasonable costs.

(a) MAA pays the enhancement rate only for the categories of service provided by the FQHC or RHC under the HO contact. 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 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) - (Fee-for-service 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, the by 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 74.08.090.  96-24-073, § 388-538-070, filed 12/2/96, effective ½/97.  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.]

Reviser's note: The typographical 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 98-16-044, filed 7/31/98, effective 9/1/98)

WAC 388-538-080
Healthy options ((managed care)) exemptions.

(1) Only a client or ((their)) a client's representative (RCW 7.70.065) may request an exemption from HO enrollment ((to a healthy options (HO) managed care plan)).  "Exemption" means the client is excused from mandatory enrollment when ((they have not yet enrolled with)) the client has not yet chosen or been assigned to ((an HO)) a plan or PCCM provider.  If a client asks for an exemption((, they are)) prior to the enrollment effective date, the client is not enrolled until ((the department)) MAA approves or denies the request and any related fair hearing is held and decided.

(2) MAA exempts a client ((is exempted)) from mandatory enrollment in ((an HO managed care)) a plan ((if)) or with a PCCM provider if any of the following apply:

(a) Based on ((the department's)) MAA's evaluation of objective medical evidence, all of the following are met:

(i) The client has multiple, complex, or severe medical ((diagnoses)) diagnosis; ((and))

(ii) The client's established provider is not with any available managed care plan; ((and))

(iii) There is a written treatment plan; ((and))

(iv) The treatment plan requires frequent change or monitoring; and

(v) Disruption of client's care would be harmful; or

(b) Prior to enrollment, the client scheduled a surgery with a provider not available to the client in ((an HO managed care plan (or after enrollment it is discovered that the provider is not in the client's current plan))) a plan and the surgery is scheduled within the first thirty days of enrollment; or

(c) The client is ((an)) AI/AN as specified in WAC 388-538-060(2) and requests exemption; or

(d) The client has private insurance under a managed care arrangement; or

(e) The client has BHP; or

(f) The client has CHAMPUS; or

(g) The client requests enrollment in the same plan with which the client has private insurance under any arrangement; or

(h) On a case-by-case basis, the client presents evidence that the HO program does not provide medically necessary care ((which)) that is reasonably available and accessible as offered to the client.  MAA considers that medically necessary care is not ((considered)) reasonably available and accessible when ((the client)) any of the following apply:

(i) The client is homeless or is expected to live in temporary housing for less than one hundred twenty days from the date the client requests the exemption; ((or))

(ii) The client is limited English speaking or hearing impaired((,)) and the client can communicate with a provider who communicates in the client's language or in American Sign Language and is not in an HO ((managed care)) plan ((who speaks in the client's language)); ((or))

(iii) The client is pregnant and wishes to continue her established course of prenatal care with an obstetrical provider who is not available to her through a plan;

(iv) The client shows that travel to ((a Medicaid HO provider)) an HO PCP is unreasonable when compared to travel to a non-HO ((Medicaid provider)) PCP.  This is shown when any of the following transportation situations apply to the client ((has)):

(A) ((To travel)) It is over twenty-five miles one-way to the nearest ((managed care)) HO PCP who is accepting ((clients)) enrollees, and the current PCP is closer and not in an available ((HO managed care)) plan; ((or))

(B) ((A)) The travel time ((of)) is over forty-five minutes one-way to the nearest HO ((managed care)) PCP who is accepting ((clients)) enrollees, ((when)) and the travel time to the current PCP, who is not in an available ((HO managed care)) plan, is less; ((or))

(C) Other transportation difficulties ((making)) make it unreasonable to get primary medical services under ((managed care)) HO; or

(((iv) Is pregnant and wishes to continue her established course of prenatal care with an obstetrical provider who is not available to her through an HO plan (or, after enrollment, when the established provider becomes unavailable through HO during the course of treatment); or))

(v) ((Presents)) Other evidence is presented that exemption is appropriate based on ((their)) the client's circumstances, as evaluated by ((the department)) MAA.

(3) MAA exempts the ((client's period of exemption is limited by the department to)) client for the time period the circumstances or conditions that ((caused)) led to the exemption are expected to exist. If the request is approved for a limited time, the client is notified of the time limitation and the process for renewing the exemption.

(4) The client ((remains exempt)) is not enrolled as provided in subsection (1) of this section and receives timely notice by telephone or in writing when ((their)) MAA approves or denies the client's exemption request ((is denied.  The department's)). If initial denial notice was by telephone, then MAA gives the reasons for the denial ((are given)) in writing before requiring the client ((is required)) to enroll in HO.  The written notice to the client contains all of the following:

(a) The action ((the department)) MAA intends to take, including enrollment information;

(b) The reason(s) for the intended action;

(c) The specific rule or regulation supporting the action;

(d) The client's right to request a fair hearing, including the circumstances under which the fee-for-service status ((is continuing)) continues, if a hearing is requested; and

(e) A ((full)) translation into the client's primary language when the client has limited English proficiency.

[Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057 and 74.08.090.  98-16-044, § 388-538-080, filed 7/31/98, effective 9/1/98.  Statutory Authority: RCW 74.08.090.  96-24-074, § 388-538-080, filed 12/2/96, effective 1/1/97.  Statutory Authority: RCW 74.08.090 and 1995 2nd sp.s. c 18.  95-18-046 (Order 3886), § 388-538-080, filed 8/29/95 effective 9/1/95.  Statutory Authority: RCW 74.08.090.  93-17-039 (Order 3621), § 388-538-080, filed 8/11/93, effective 9/11/93.]

(1) A ((client in the healthy options (HO))) managed care ((program)) enrollee is eligible for the categorically needy scope of medical care as described in WAC 388-529-0100.  ((Those covered services not provided by the HO contracted plan are provided through the department's on fee-for-service basis.))

(a) A client is entitled to medically necessary services. The HO contract includes the definition of medically necessary as well as utilization management requirements in the quality improvement program standards for how plans and their participating providers determine medical necessity.

(b) The plan covers the services included in the HO contract for plan enrollees. In addition, plans may cover services not required under the HO contract.

(c) MAA covers the categorically needy services not included in the HO contract for plan enrollees.

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

(e) 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 described covered services, which services are covered by MAA, and which services are covered by plans. In addition, MAA requires plans to provide new enrollees with written information about covered services.

(f) MAA covers services on a fee-for-service basis for clients enrolled with a PCCM provider. Except for emergencies, a client's PCCM provider must refer the client for most services not provided by the PCCM provider. The services that require PCCM provider referral are described in the PCCM contract. MAA requires PCCM providers to inform enrollees about covered services and how to obtain them.

(2) For services covered by MAA for managed care enrollees:

(a) MAA covers services rendered by providers with a current DSHS core provider agreement to provide the requested service;

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

(c) MAA determines which services are medically necessary; and

(d) An enrollee may request a fair hearing for review of MAA coverage decisions.

(3) For services covered by plans:

(a) MAA requires plans to contract with a sufficient number of providers, as determined by MAA, to deliver the scope of services contracted with the plan. Except for emergency services, plans provide covered services to enrollees through their participating providers;

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

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

(d) Plans 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 plan coverage decisions using the plan's appeal process, as described in WAC 388-538-0110. An enrollee may also request a fair hearing for review of a plan coverage decision as described in chapter 388-08 WAC; and

(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 plan. Any covered services ordered and/or prescribed by the women's health care provider must meet the plan's service authorization requirements for the specific service.

(4) Unless the plan chooses to cover these services, or an appeal or a fair hearing decision reverses a 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 plan enrollees:

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

(ii) Services received from a nonparticipating provider that require prior authorization from the plan that were not authorized by the plan. All nonemergency services received from nonparticipating providers require prior authorization from the plan.

(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) In order to be held financially responsible for noncovered services as described in subsection (4) of this section, an enrollee must have consented in writing to pay for services prior to receiving services. In order for the consent to be valid for limited-English proficient enrollees, the consent must be translated or interpreted into the enrollee's primary language.

(a) The written consent form must be approved by MAA and include all of the following:

(i) A description of the specific service the enrollee is agreeing to pay for;

(ii) A statement that the service is not covered by MAA or the plan;

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

(A) The service is not medically necessary; or

(B) The service is covered only when a participating provider provides it.

(iv) A statement that the enrollee chooses to receive the service;

(v) A statement that the enrollee agrees to pay for the service; and

(vi) A statement explaining 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 plan, but the enrollee chooses to pay for the service from a provider not participating with the plan;

(B) The plan 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 in a participating provider's office; or

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

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

[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.]

(1) ((The department shall exempt emergencies and emergency transportation services from routine medical care authorization procedures of)) A managed care enrollee may obtain emergency services, as defined in 42 U.S.C. 1396u-2(b), for emergency medical conditions as defined in 42 U.S.C. 1396u-2(c) in any hospital emergency department. These definitions differ from the emergency services definition that applies to services covered under MAA's fee-for-service programs (42 U.S.C. 447.53(4)).

(a) The plan covers emergency services for plan enrolles.

(b) MAA covers emergency services for PCCM enrollees.

(2) Emergency services for emergency medical conditions do not require prior authorization by the plan, PCP, PCCM provider, or MAA.

(3) An enrollee who requests emergency services is entitled to receive an exam to determine if the enrollee has an emergency medical condition.

(((2) A client shall not be responsible for determining if an emergency exists or for the cost of such determination.  For nonemergency conditions, hospital reimbursement for PCCM under WAC 388-87-072(4) shall be limited to a medical evaluation fee as established by the department.

(3) In a medical emergency, the client shall not be financially responsible for covered managed care services provided.

(4) When an emergency does not exist, and the client's PCP does not authorize services, the client shall be financially responsible for further services received only when the client is informed and agrees, in writing, to the responsibility before receiving the services as described under WAC 388-87-010.))

[Statutory Authority: RCW 74.08.090 and 1995 2nd sp.s. c 18.  95-18-046 (Order 3886), § 388-538-100, filed 8/29/95, effective 9/1/95.  Statutory Authority: RCW 74.08.090.  95-04-033 (Order 3826), § 388-538-100, filed 1/24/95, effective 2/1/95; 93-17-039 (Order 3621), § 388-538-100, filed 8/11/93, effective 9/11/93.]

(1) A ((client aggrieved by a decision of a managed care contractor or the department shall have the right to a fair hearing as required under WAC 388-81-040.

(2) A client enrolled in a plan:

(a) Shall exhaust a plan's grievance procedure before requesting a fair hearing, except as provided in subsection (3) of this section;

(b) Shall receive a written decision containing the following information:

(i) Action the plan intends to take;

(ii) Reasons for the intended action;

(iii) The specific information supporting the action;

(iv) Client's right to request a fair hearing;

(v) Full translation into the primary language of the limited English proficient recipient.

(c) May request a fair hearing when a:

(i) Grievance decision is adverse;

(ii) Plan does not respond in writing within thirty days from the date the client requests the grievance.

(3) The client may request a fair hearing at the same time a grievance is filed when:

(a) The plan denies medical care that a client indicates is urgently needed and the client requests a grievance in writing; or

(b) The subject matter of the grievance is one for which a client has a fair hearing right under chapters 34.05 RCW, 388-08 WAC, or this chapter.

(4) The managed care contractor shall advise a client of the client's right to request a fair hearing at the time the contractor notifies the client of the grievance decision)) managed care enrollee has the right to voice a complaint or appeal a plan, PCP or provider decision.

(2) To ensure the rights of enrollees are protected, MAA approves each plan's complaint and appeal process annually or whenever the plan makes a change to the process.

(3) MAA requires plans to inform enrollees in writing within fifteen days of enrollment about their rights and how to use the plan's complaint and appeal processes. MAA requires plans to obtain MAA approval of all written information sent to enrollees.

(4) Enrollees may request assistance from the plan when using the plan's complaint and appeals processes.

(5) An enrollee who complains to a plan is entitled to a written or verbal response from the plan within the timeline in the plan's MAA-approved complaint process.

(6) An enrollee who appeals a plan, PCP, or provider decision is entitled to all of the following:

(a) A review of the decision being appealed. The review must be conducted by a plan representative who was not involved in the decision under appeal;

(b) Continuation of the service already being received and which is under appeal, until a final decision is made;

(c) A written decision from the plan, usually within thirty days, in the enrollee's primary language. The plan does not need to translate the decision if an enrollee with limited English proficiency prefers correspondence in English, and the plan documents the enrollee's preference. The notice must clearly explain all of the following:

(i) The decision and any action the plan intends to take;

(ii) The reason for the decision;

(iii) The specific information that supports the plan's decision; and

(iv) Any further appeal or fair hearing rights available to the enrollee, including the enrollee's right to continue receiving the service under appeal until a final decision is made.

(d) An expedited decision when it is necessary to meet an existing or anticipated acute or urgent medical need.

(7) The plan's medical director or designee reviews all appeals and requests for fair hearings when the issues involve medical necessity.

[Statutory Authority: RCW 74.08.090.  97-04-004, § 388-538-110, filed 1/24/97, effective 2/24/97.  Statutory Authority: RCW 74.08.090 and 1995 2nd sp.s. c 18.  95-18-046 (Order 3886), § 388-538-110, filed 8/29/95, effective 9/1/95.  Statutory Authority: RCW 74.08.090.  94-04-038 (Order 3701), § 388-538-110, filed 1/26/94, effective 2/26/94; 93-17-039 (Order 3621), § 388-538-110, filed 8/11/93, effective 9/11/93.]

(1) ((The client enrolled in)) A managed care ((shall have)) plan enrollee has the right to a timely referral for a second opinion ((by another physician or specialist)) when:

(a) ((When the client)) The enrollee needs more information ((as to the medical necessity of medical)) about treatment recommended by the ((PCP)) provider or plan; or

(b) ((If the client)) The enrollee believes the ((PCP)) plan is not authorizing medically necessary care.

(2) ((If the client is enrolled in a plan, the second opinion physician or specialist shall be a participating provider in the plan.  If the client is enrolled with a PCCM, which does not involve a plan, the client shall have the right to a second opinion by another provider or specialist, who is a medical assistance provider)) A managed care plan enrollee has a right to a second opinion from a primary or specialty care physician who is participating in the existing plan network. At the plan's discretion, a clinically appropriate nonparticipating provider who is agreed upon the plan and the enrollee may provide the second opinion.

(3) ((When medically necessary, the client shall be promptly referred to:

(a) Another participating physician or specialist of a plan, when enrolled in a plan; or

(b) Another provider or specialist when enrolled under PCCM, which does not involve a plan)) PCCM provider enrollees have a right to a timely referral for a second opinion by another provider who has a core provider agreement with MAA.

[Statutory Authority: RCW 74.08.090 and 1995 2nd sp.s. c 18.  95-18-046 (Order 3886), § 388-538-120, filed 8/29/95, effective 9/1/95.  Statutory Authority: RCW 74.08.090.  93-17-039 (Order 3621), § 388-538-120, filed 8/11/93, effective 9/11/93.]

(1) ((Only the department has authority to remove a client from the healthy options (HO) program, but requests for removal can be made by the client, their)) An enrollee, the enrollee's representative as defined in RCW 7.70.065, or ((by the client's HO)) plan may request MAA to end enrollment. Only MAA has authority to remove an enrollee from the HO program.  Pending ((the department's)) MAA's final decision, the ((client)) enrollee remains enrolled unless staying in HO ((managed care)) would adversely affect the ((client's)) enrollee's health status.

(2) ((The department may remove a client from)) MAA ends enrollment in HO when the ((client)) enrollee meets any of the following:

(a) Is no longer eligible for a medical program subject to enrollment; or

(b) Requests to be removed from HO((, and the department approves)) according to ((the same criteria given in)) WAC 388-538-080 ((())(2)(a)(c)(h), Exemption(())), and MAA approves the request; ((or))

(c) ((Is)) Becomes a Medicare beneficiary;

(d) Is scheduled for a surgery with a provider not available to the enrollee in the enrollee's current plan and the surgery is scheduled to be performed within the first thirty days of enrollment;

(e) Is pregnant and requests to continue her established course of prenatal care with an obstetrical provider who is not available through her current plan;

(f) Notifies MAA of private insurance under a managed care arrangement;

(g) Notifies MAA of BHP coverage;

(h) Notifies MAA of CHAMPUS coverage;

(i) Notifies MAA of private insurance with the same plan as the enrollee's current HO plan under any arrangement; or

(j) Asks to be taken out of the current plan in order to stay with the enrollee's established provider but is willing to enroll in the established provider's plan. MAA reviews subsection (2)(b), (d), and (e) in this section when reviewing a request to end a client's enrollment per this subsection. MAA's decisions on those requests include all of the following:

(i) The decision is given verbally or in writing; and

(ii) Verbal and written notices include the reason for the decision and information on hearings so the enrollee may appeal the decision; and

(iii) If the request to end enrollment is approved, it may be effective back to the beginning of the current month; and

(iv) If the request to end enrollment is denied, and the enrollee requests a hearing; the enrollee remains enrolled in te plan until the hearing decision is made as provided in subsection (1) of this section.

(3) ((The department may remove a client from HO plan enrollment when the client's HO plan substantiates in writing, to the department's satisfaction that:

(a) The client's behavior is inconsistent with the HO plan's rules and regulations, such as intentional misconduct; and

(b) After medical review and treatment interventions, the client's behavior continues to prevent the provider from safely or prudently providing medical care to the client; and

(c) The client received written notice from their HO plan of the plan's intent to request the client's removal.  The plan's notice to the client must include the client's right to use the plan's appeal process to review the plan's request and the client's right to use the department fair hearing process.

The requirement that the plan notify the client is waived if the client's conduct presents the threat of imminent harm to others)) MAA ends enrollment for the period of time the circumstances or conditions that led to ending the enrollment are expected to exist. If the request to end enrollment is approved for a limited time, the client is notified of the time limitation and the process for renewing the exemption.

(4) ((Within thirty days of receiving the plan)) MAA does not approve an enrollee's request to ((remove a client from HO enrollment, a decision is made by the department. Before a decision is made an attempt is made by the department to contact the client and learn the client's perspective.  If the plan's request to remove the client from HO)) end enrollment ((is approved, the client will be given advance and adequate notice including hearing rights information (ten days in advance of the effective date of the removal))) solely to pay for services received but not authorized by the plan.

(5) ((An HO plan's request to remove a client from HO enrollment will not be approved when it is solely due to an adverse change in the client's health or the cost of meeting the client's needs)) The enrollee remains in HO as provided in subsection (1) of this section and receives timely notice by telephone or in writing when MAA approves or denies the enrollee's request to end enrollment. Except as provided in subsection (2)(j) of this section, MAA gives the reasons for a denial in writing. The written denial notice to the enrollee contains all of the following:

(a) The action MAA intends to take;

(b) The reason(s) for the intended action;

(c) The specific rule or regulation supporting the action;

(d) The enrollee's right to request a fair hearing; and

(e) A translation into the enrollee's primary language when the enrollee has limited English proficiency.

(6) MAA may end an enrollee's enrollment in a plan when the enrollee's plan substantiates in writing, to MAA's satisfaction, that:

(a) The enrollee's behavior is inconsistent with the plan's rules and regulations, such as intentional misconduct; and

(b) After the plan has provided:

(i) Clinically appropriate evaluation(s) to determine whether there is a treatable problem contributing to the enrollee's behavior; and

(ii) If so, has provided clinically appropriate referral(s) and treatment(s), but the enrollee's behavior continues to prevent the provider from safely or prudently providing medical care to the enrollee; and

(c) The enrollee received written notice from the plan of the plan's intent to request the enrollee's removal, unless MAA has waived the requirement for the plan because the enrollee's conduct presents the threat of imminent harm to others. The plan's notice to the enrollee must include all of the following:

(i) The enrollee's right to use the plan's appeal process to review the plan's request to end the enrollee's enrollment; and

(ii) The enrollee's right to use the department fair hearing process.

(7) MAA makes a decision to remove an enrollee from enrollment with a plan within thirty days of receiving the plan's request to do so. Before making a decision, MAA attempts to contact the enrollee and learn the enrollee's perspective. If MAA approves the plan's request to remove the enrollee, MAA sends a notice which includes hearing rights information, at least ten days in advance of the effective date that enrollment will end.

(8) MAA does not approve a plan's request to remove an enrollee from HO when the request is solely due to an adverse change in te enrollee's health or the cost of meeting the enrollee's needs.

[Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057 and 74.08.090.  98-16-044, § 388-538-130, 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), § 388-538-130, filed 8/29/95, effective 9/1/95.  Statutory Authority: RCW 74.08.090.  93-17-039 (Order 3621), § 388-538-130, filed 8/11/93, effective 9/11/93.]

((The department shall require:))

(1) ((A plan to appoint a medical director or designee who:

(a) Shall be responsible for the plan's quality assurance program and shall review all plan grievances; and

(b) Furnishes MAA with a copy of all grievances and a plan's response to such grievances.

(2) A PCCM not involving a plan to provide adequate documentation for quality assurance review.

(3) A plan or PCCM to have in place a method)) In order to assure that managed care enrollees receive appropriate access to quality health care and services, MAA does all of the following:

(a) Requires plans to have a fully operational quality assurance system that meets a comprehensive set of quality improvement program (QIP) standards.

(b) Monitors plan performance through on-site visits and other audits, and requires corrective action for deficiencies that are found.

(c) Requires plans to report annually on standardized clinical performance measures that are specified in the contract with MAA, and requires corrective action for substandard performance.

(d) Contracts with a professional review organization to conduct independent external review studies of selected health care and service delivery.

(e) Conducts enrollee satisfaction surveys.

(f) Annually publishes plan performance on certain clinical measures and enrollee satisfaction surveys and makes reports of site monitoring visits available upon request.

(2) MAA requires plans to have a method to assure consideration of the unique needs of ((persons with special health care needs as defined in WAC 388-538-050 and to assist with)) enrollees with chronic conditions. The method includes:

(a) Early identification ((of persons with special health care needs));

(b) Timely access to health care; and

(c) Coordination of health service delivery and community linkages.

(((4) The department shall conduct outreach of various types to accommodate the unique communication needs of some members of the populations served.

(5) The department shall ensure that clients are given the most important relevant information and a variety of ways to enroll or request exemptions and disenrollments.

(6) The plan or PCCM shall make reasonable and appropriate accommodations as required under the Americans with Disabilities Act (ADA) for clients who have a mental, physical, or sensory impairment or another limitation which affects the clients' abilities to understand written notices and/or other types of communications.))

[Statutory Authority: RCW 74.08.090 and 1995 2nd sp.s. c 18.  95-18-046 (Order 3886), § 388-538-140, filed 8/29/95, effective 9/1/95.  Statutory Authority: RCW 74.08.090.  93-17-039 (Order 3621), § 388-538-140, filed 8/11/93, effective 9/11/93.]

     The following sections of the Washington Administrative Code are repealed:

WAC 388-538-001	Purpose.
WAC 388-538-090	Client's choice of primary care provider.
WAC 388-538-150	Managed care medical audit.

© Washington State Code Reviser's Office