WASHINGTON STATE REGISTER

WSR 06-03-081

PERMANENT RULES

DEPARTMENT OF

SOCIAL AND HEALTH SERVICES
(Health and Recovery Services Administration)

[ Filed January 12, 2006, 4:33 p.m. , effective February 12, 2006 ]

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

аааааPurpose:

Х Change all references of "Medical Assistance Administration (MAA)" to "the department";

Х Add a definition for "enrollees representative";

Х Clarify where in the department to send a completed enrollment form;

Х Add the requirement of being a "recognized urban Indian Health Center or tribal clinic" to the primary care case management (PCCM) provider requirements;

Х Add "delivery case rate payment" under the managed care payment section;

Х Clarify that the department covers medically necessary categorically needy services that are excluded from coverage in the managed care organization's (MCO) contract;

Х Clarify ninety-day coverage policy for enrollees outside their service area for emergency care and for medically necessary covered benefits that cannot wait;

Х Clarify that the MCO must acknowledge receipt of grievances either orally or in writing within five working days and each appeal in writing within five working days;

Х Remove the incorrect reference to "provider" under WAC 388-538-110 (7)(f)(v) and replace it with enrollee's representative;

Х Remove the word "appeal" and replace it with "hearing requests" under WAC 388-538-110 (7)(m) and (n);

Х Remove the word "appeal" and replace it with "hearing requests" under WAC 388-538-112 [(3)](a) and (b);

Х Add contract language on MCO oversight of delegated entities responsible for any delegated activity under quality of care;

Х Add language on individualized treatment plans for enrollees with special health care needs which ensure integration of clinical and nonclinical disciplines and services in the overall plan of care; and

Х Add contract language on noncompliance with any contractual, state, or federal requirements.

аааааCitation of Existing Rules Affected by this Order: Amending WAC 388-538-050, 388-538-060, 388-538-061, 388-538-063, 388-538-065, 388-538-067, 388-538-068, 388-538-070, 388-538-095, 388-538-100, 388-538-110, 388-538-111, 388-538-112, 388-538-120, 388-538-130, and 388-538-140.

аааааStatutory Authority for Adoption: RCW 74.08.090 and 74.09.522.

ааааа Adopted under notice filed as WSR 05-23-027 on November 8, 2005.

аааааA final cost-benefit analysis is available by contacting Penny Dow/Michael Paulson, Division of Program Support, P.O. Box 45530, Olympia, WA 98504-5530, phone (360) 725-1636 or (360) 725-1641, fax (360) 753-7315, e-mail dowpl@dshs.wa.gov or paulsmj@dshs.wa.gov. The preliminary cost-benefit analysis is unchanged and will be final.

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

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

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

аааааNumber of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 16, Repealed 0.

аааааNumber of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; аааааPilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 16, Repealed 0.

аааааDate Adopted: January 9, 2006.

Andy Fernando, Manager

Rules and Policies Assistance Unit

аааааReviser's note: The material contained in this filing exceeded the page-count limitations of WAC 1-21-040 for appearance in this issue of the Register. It will appear in the 06-04 issue of the Register.

Х	Change all references of "Medical Assistance Administration (MAA)" to "the department";
Х	Add a definition for "enrollees representative";
Х	Clarify where in the department to send a completed enrollment form;
Х	Add the requirement of being a "recognized urban Indian Health Center or tribal clinic" to the primary care case management (PCCM) provider requirements;
Х	Add "delivery case rate payment" under the managed care payment section;
Х	Clarify that the department covers medically necessary categorically needy services that are excluded from coverage in the managed care organization's (MCO) contract;
Х	Clarify ninety-day coverage policy for enrollees outside their service area for emergency care and for medically necessary covered benefits that cannot wait;
Х	Clarify that the MCO must acknowledge receipt of grievances either orally or in writing within five working days and each appeal in writing within five working days;
Х	Remove the incorrect reference to "provider" under WAC 388-538-110 (7)(f)(v) and replace it with enrollee's representative;
Х	Remove the word "appeal" and replace it with "hearing requests" under WAC 388-538-110 (7)(m) and (n);
Х	Remove the word "appeal" and replace it with "hearing requests" under WAC 388-538-112 [(3)](a) and (b);
Х	Add contract language on MCO oversight of delegated entities responsible for any delegated activity under quality of care;
Х	Add language on individualized treatment plans for enrollees with special health care needs which ensure integration of clinical and nonclinical disciplines and services in the overall plan of care; and
Х	Add contract language on noncompliance with any contractual, state, or federal requirements.