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

     Purpose: The department is amending this rule to update and clarify existing sections, clarify/add criteria regarding the department's patient review and coordination (PRC) program; add language regarding the monthly capitated premiums the department pays to managed care organizations (MCOs); remove language regarding information on the original agreement when the provider may bill the client for noncovered services; add language regarding MCO coverage of emergency services; and add language to clarify the department pays MCOs a delivery case rate separate from the capitation payment when an enrollee delivers a child(ren) and the MCO pays for any part of labor and delivery.

     Citation of Existing Rules Affected by this Order: Amending WAC 388-538-050, 388-538-060, 388-538-061, 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.

     Statutory Authority for Adoption: RCW 74.08.090 and 74.09.522.

      Adopted under notice filed as WSR 08-09-029 on April 8, 2008.

     Changes Other than Editing from Proposed to Adopted Version: Current language in subsection (8) deleted: The department helps facilitate the choice of a PCP by providing information regarding available providers in the MCOs in the client's service area. Subsection (8) was replaced as follows: (8) The department: (a) Helps facilitate the choice of a PCP by providing information regarding available providers contracted with the MCOs in the client's service area; and (b) Upon request, will assist clients in identifying an MCO with which their provider participates.

     A final cost-benefit analysis is available by contacting Michael Paulson, P.O. Box 45530, Olympia, WA 98504-5530, phone (360) 725-1641, fax (360) 753-7315, e-mail paulsmj@dshs.wa.gov.

     Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 14, Repealed 0.

     Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0;      Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 14, Repealed 0.

     Date Adopted: July 18, 2008.

Blake D. Chard

for Robin Arnold-Williams

Secretary

     "Action" means one or more of the following:

     (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 a managed care organization (MCO) to act within the time frames provided in 42 C.F.R. 438.408(b).

     "Ancillary health services"(( -- )) means healthcare services ((ordered by a provider, including but not limited to, laboratory services, radiology services, and physical therapy)) that are auxiliary, accessory, or secondary to a primary healthcare service.

     "Appeal"(( -- )) means a request by an enrollee or provider with written permission of an enrollee for reconsideration of an action.

     "Assign" or "assignment"(( -- )) means the department selects an MCO or primary care case management (PCCM) provider to serve a client who has not selected an MCO or PCCM provider.

     "Auto enrollment"(( -- ))((When)) means the department has automatically ((enrolls)) enrolled a client into an MCO in ((his or her)) the client's area of residence.

     "Basic health" or "BH"(( -- ))((The health care)) means the healthcare program authorized by chapter 70.47 RCW and administered by the health care authority (HCA).

     "Basic health plus" -- Refer to WAC 388-538-065.

     "Children with special ((health care)) healthcare needs"((--)) means children ((under)) younger than age nineteen ((years of age)) who are identified by the department as having special ((health care)) healthcare needs. This includes:

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

     (2) Children eligible for Supplemental Security Income under Title ((16)) XVI of the Social Security Act (SSA); and

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

     "Client"(( -- )) means, for the purposes of this chapter, an individual eligible for any medical assistance program, including managed care programs, but who is not enrolled with an MCO or PCCM provider. In this chapter, "client" refers to a person before he or she is enrolled in managed care, while "enrollee" refers to an individual eligible for any medical assistance program who is enrolled in managed care.

     "Department"(( -- )) means the department of social and health services (DSHS).

     "Disenrollment" See "end enrollment."

     "Emergency medical condition"(( -- )) means a condition meeting the definition in 42 C.F.R. 438.114(a).

     "Emergency services"(( -- )) means services defined in 42 C.F.R. 438.114(a).

     "End enrollment"(( -- )) means ending the enrollment of an enrollee ((is currently enrolled in managed care, either with an MCO or with a PCCM provider, and his or her enrollment is discontinued and he or she returns 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 assistance program ((who is)) enrolled in managed care ((through)) with an MCO or PCCM provider that has a contract with the state.

     "Enrollee's representative"(( -- )) means an individual with a legal right or written authorization from the enrollee to act on behalf of the enrollee in making decisions.

     "Enrollees with special health care needs"(( -- ))((Persons)) means enrollees having chronic and disabling conditions((, including persons with special health care needs that meet all of the following)) and the 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 psychological, 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 department approval of a client's preenrollment request to remain in the fee-for-service delivery system for one of the reasons outlined in WAC 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 department's hearing process.

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

     "Healthy Options program" or "HO program"(( -- )) means the department's prepaid managed care health program for Medicaid-eligible clients and clients enrolled in the state children's health insurance program (SCHIP).

     "Managed care"(( -- )) means a comprehensive ((health care)) healthcare delivery system that includes preventive, primary, specialty, and ancillary services. These services are provided through either an MCO or PCCM provider.

     "Managed care contract"(( -- )) means the agreement between the department and an MCO to provide prepaid contracted services to enrollees.

     "Managed care organization" or "MCO"(( -- )) means an organization having a certificate of authority or certificate of registration from the office of insurance commissioner that contracts with the department under a comprehensive risk contract to provide prepaid ((health care)) healthcare services to eligible clients under the department's managed care programs.

     "Mandatory enrollment"(( -- )) means the department's requirement that a client enroll in managed care.

     "Mandatory service area"(( -- )) means a service area in which eligible clients are required to enroll in an MCO.

     (("Medicare/Medicaid integration program" or "MMIP" -- The department's prepaid managed care program that integrates medical and long-term care services for clients who are sixty-five years of age or older and eligible for Medicare only or eligible for Medicare and Medicaid. Clients eligible for Medicaid only are not eligible for this program.))

     "Nonparticipating provider"(( -- )) means a healthcare provider that does not have a written agreement with an MCO but that provides MCO-contracted ((health care)) healthcare services to managed care enrollees with the MCO's authorization.

     "Participating provider"(( -- )) means a healthcare provider with a written agreement with an MCO to provide ((health care)) healthcare services to the MCO's managed care enrollees. A participating provider must look solely to the MCO for payment for such services.

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

     "Primary care provider" or "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" or "PA"(( -- )) means a process by which enrollees or providers must request and receive department approval for services provided through the department's fee-for-service system, 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"(( -- )) means in relation to the provision of services, ((means)) an enrollee has the right to receive medically necessary ((health care)) healthcare as expeditiously as the enrollee's health condition requires. In relation to authorization of services and grievances and appeals, "timely" means according to the department's managed care program contracts and the time frames stated in this chapter.

     "Washington Medicaid integration partnership" or "WMIP"((--)) means the managed care program that is designed to integrate medical, mental health, chemical dependency treatment, and long-term care services into a single coordinated health plan for eligible aged, blind, or disabled clients.

[Statutory Authority: RCW 74.08.090 and 74.09.522. 06-03-081, § 388-538-050, filed 1/12/06, effective 2/12/06. Statutory Authority: RCW 74.08.090, 74.09.522, 2003 E1 c 25 § 201(4), 2004 c 276 § 201(4), 42 USC 1396N (section 1915 (b) and (c) of the Social Security Act of 1924). 05-01-066, § 388-538-050, filed 12/8/04, effective 1/8/05. Statutory Authority: RCW 74.08.090, 74.09.522. 03-18-109, § 388-538-050, filed 9/2/03, effective 10/3/03. 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 assistance programs for which enrollment is mandatory;

     (b) Resides in an area where enrollment is mandatory; and

     (c) Is not exempt from managed care enrollment or the department has not ended the client's managed care enrollment, consistent with WAC 388-538-130, and any related hearing has been held and decided.

     (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) The department's fee-for-service system.

     (3) ((A client may)) To enroll with an MCO or PCCM provider ((by calling the department's toll-free enrollment line or by sending a completed enrollment form to the department's unit responsible for managed care enrollment as listed on the department's enrollment form.)), a client may:

     (a) ((A client must enroll with an MCO or PCCM provider available in the area where the client lives.)) Call the department's toll-free enrollment line at 800-562-3022;

     (b) ((All family members must either enroll with the same MCO or enroll with PCCM providers.)) Mail a postage-paid completed managed care enrollment form (healthy options sign-up form, DSHS 13-664) to the department's unit responsible for managed care enrollment; or

     (c) ((Enrollees may request an MCO or PCCM provider change at any time)) Fax the managed care enrollment form (healthy options sign-up form, DSHS 13-664) to the department at 360-725-2144.

     (4) A client must enroll with an MCO provider available in the area where the client resides.

     (5) All family members of an enrollee placed in the patient review and coordination (PRC) program under WAC 388-501-0135 must enroll with the same MCO but may enroll in a different MCO than the family member placed in the PRC program.

     (((d))) (6) When a client requests enrollment with an MCO or PCCM provider, the department enrolls a client effective the earliest possible date given the requirements of the department's enrollment system. The department does not enroll clients retrospectively.

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

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

     (b) If the client does not have a family member or family members enrolled with an MCO that is currently under contract with the department, and the client was previously enrolled with the MCO or PCCM provider, and the department can identify the previous enrollment, the client is reenrolled 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 care provider (PCP), the department attempts to contact the client to complete the required choice. If the department is not able to contact the client in a timely manner, the department 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, the department 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 tribal PCCM provider and the client meets the criteria of subsection (2) of this section, the department 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, the department assigns the client to an MCO as described in (d) of this subsection;

     (iv) Not available through any MCO or as a PCCM provider, the department 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)((,)) or (b)((, or (c))) of this subsection, the department assigns the client as follows:

     (i) If an AI/AN client does not choose an MCO or PCCM provider, the department assigns the client to a tribal PCCM provider if that client ((lives)) resides 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 the department'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 provider, the department assigns the client to an MCO available in the area where the client ((lives)) resides. The MCO is responsible for primary care provider (PCP) choice and assignment.

     (iii) For clients who are new recipients ((to medical assistance)) or who have had a break in eligibility of greater than two months, the department sends a written notice to each household of one or more clients who are assigned to an MCO or PCCM provider. The assigned client has ten calendar days to contact the department to change the MCO or PCCM provider assignment before enrollment is effective. 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 the assignment, and the toll-free telephone number of either:

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

     (B) The department (for enrollees assigned to a PCCM provider).

     (iv) If the client has a break in eligibility of less than two months, the client will be automatically reenrolled with his or her previous MCO or PCCM provider and no notice will be sent.

     (((5))) (8) The department:

     (a) Helps facilitate the choice of a PCP by providing information regarding available providers contracted with the MCOs in the client's service area; and

     (b) Upon request, will assist clients in identifying an MCO with which their provider participates.

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

     (a) An MCO enrollee((s)) may choose:

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

     (ii) A different PCP((s)) or clinic((s)) participating with the enrollee's MCO for different family members.

     (b) The MCO assigns a PCP or clinic that meets the access standards set forth in the relevant managed care contract if the enrollee does not choose a PCP or clinic((;)).

     (c) An MCO enrollee((s)) may change PCPs or clinics in an MCO for any reason, 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,)) An MCO enrollee((s)) may file a grievance with the MCO ((and may change plans)) if the MCO does not approve an enrollee's request to change PCPs or clinics.

     (e) MCO enrollees required to participate in the department's PRC program may be limited in their right to change PCPs (see WAC 388-501-0135).

[Statutory Authority: RCW 74.08.090 and 74.09.522. 06-03-081, § 388-538-060, filed 1/12/06, effective 2/12/06. Statutory Authority: RCW 74.08.090, 74.09.522, 2003 E1 c 25 § 201(4), 2004 c 276 § 201(4), 42 USC 1396N (section 1915 (b) and (c) of the Social Security Act of 1924). 05-01-066, § 388-538-060, filed 12/8/04, effective 1/8/05. Statutory Authority: RCW 74.08.090, 74.09.522. 03-18-109, § 388-538-060, filed 9/2/03, effective 10/3/03. 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.]

     (2) Unless otherwise stated in this section, all of the provisions of chapter 388-538 WAC apply to clients enrolled in WMIP ((and MMIP)).

     (3) The following sections of chapter 388-538 WAC do not apply to WMIP enrollees ((or MMIP enrollees)):

     (a) WAC 388-538-060. However, WAC ((388-538-060(5))) 388-538-060(9), describing enrollees' ability to choose their PCP, does apply to WMIP enrollees ((and MMIP enrollees));

     (b) WAC 388-538-063;

     (c) WAC 388-538-065;

     (d) WAC 388-538-068; and

     (e) WAC 388-538-130. However, WAC 388-538-130 (3) and (4), describing the process used when the department receives a request from an MCO to remove an enrollee from enrollment in managed care, do apply to WMIP enrollees ((and MMIP enrollees)). Also, WAC 388-538-130(9), describing the MCO's ability to refer enrollees to the department's "Patient Review and ((Restriction)) Coordination" program, does apply to WMIP enrollees ((and MMIP enrollees)).

     (4) The process for enrollment of WMIP ((and MMIP)) clients is as follows:

     (a) Enrollment in WMIP ((and MMIP)) is voluntary, subject to program limitations in ((subsection)) (b) and (((c))) (d) of this subsection.

     (b) For WMIP, the department automatically enrolls clients, with the exception of American Indian/Alaska natives and clients eligible for both Medicare and Medicaid, when they:

     (i) Are aged, blind, or disabled;

     (ii) Are twenty-one years of age or older; and

     (iii) Receive categorically needy medical assistance.

     (c) ((For MMIP, clients may enroll when they:

     (i) Are sixty-five years of age or older; and

     (ii) Receive Medicare and/or Medicaid.

     (d))) American Indian/Alaska native (AI/AN) clients and clients who are eligible for both Medicare and Medicaid who meet the eligibility criteria in (b) ((or (c))) of this subsection may voluntarily enroll or end enrollment in WMIP ((or MMIP)) at any time.

     (((e))) (d) The department will not enroll a client in WMIP ((or MMIP)), or will end an enrollee's enrollment in WMIP ((or MMIP)) when the client has, or becomes eligible for, CHAMPUS/TRICARE or any other third-party ((health care)) healthcare coverage that would:

     (i) Require the department to either exempt the client from enrollment in managed care; or

     (ii) End the enrollee's enrollment in managed care.

     (((f))) (e) A client or enrollee in WMIP ((or MMIP)), or the client's or enrollee's representative, may end enrollment from the MCO at any time without cause. The client may then reenroll at any time with the MCO. The department ends enrollment for clients prospectively to the first day of the month following the request to end enrollment, except as provided in ((subsection (g))) (f) of this subsection.

     (((g) Clients)) (f) A client or enrollee may request that the department retroactively end enrollment from WMIP ((and MMIP)). On a case-by-case basis, the department may retroactively end enrollment from WMIP ((and MMIP)) when, in the department's judgment:

     (i) The client or enrollee has a documented and verifiable medical condition; and

     (ii) Enrollment in managed care could cause an interruption of on-going treatment that could jeopardize the client's or enrollee's life or health or ability to attain, maintain, or regain maximum function.

     (5) In addition to the scope of medical care services described in WAC 388-538-095, WMIP ((and MMIP are designed to include the following services:

     (a) For WMIP enrollees - )) includes mental health, chemical dependency treatment, and long-term care services((; and

     (b) For MMIP enrollees - long-term care services)).

     (6) The department sends each client written information about covered services when the client is eligible to enroll in WMIP ((or MMIP)), and any time there is a change in covered services. In addition, the department requires MCOs to provide new enrollees with written information about covered services. This notice informs the client about the right to end enrollment and how to do so.

[Statutory Authority: RCW 74.08.090 and 74.09.522. 06-03-081, § 388-538-061, filed 1/12/06, effective 2/12/06. Statutory Authority: RCW 74.08.090, 74.09.522, 2003 E1 c 25 § 201(4), 2004 c 276 § 201(4), 42 USC 1396N (section 1915 (b) and (c) of the Social Security Act of 1924). 05-01-066, § 388-538-061, filed 12/8/04, effective 1/8/05.]

     (a) Have a certificate of registration from the office of the insurance commissioner (OIC) that allows the MCO to provide the healthcare services ((in subsection (1) of this section));

     (b) Accept the terms and conditions of the department's managed care contract;

     (c) Be able to meet the network and quality standards established by the department; and

     (d) Accept the prepaid rates published by the department.

     (2) The department reserves the right not to contract with any otherwise qualified MCO.

[Statutory Authority: RCW 74.08.090 and 74.09.522. 06-03-081, § 388-538-067, filed 1/12/06, effective 2/12/06. Statutory Authority: RCW 74.08.090, 74.09.522, 2003 E1 c 25 § 201(4), 2004 c 276 § 201(4), 42 USC 1396N (section 1915 (b) and (c) of the Social Security Act of 1924). 05-01-066, § 388-538-067, filed 12/8/04, effective 1/8/05. Statutory Authority: RCW 74.08.090, 74.09.522. 03-18-112, § 388-538-067, filed 9/2/03, effective 10/3/03. Statutory Authority: RCW 74.09.080, RCW 74.08.510, [74.08.]522, 74.09.450, 1115 Waiver, 42 U.S.C. 1396. 02-01-075, § 388-538-067, filed 12/14/01, effective 1/14/02.]

     (1) Have a core provider agreement with the department;

     (2) Be a recognized urban Indian health center or tribal clinic;

     (3) Accept the terms and conditions of the department's PCCM contract;

     (4) Be able to meet the quality standards established by the department; and

     (5) Accept PCCM rates published by the department.

[Statutory Authority: RCW 74.08.090 and 74.09.522. 06-03-081, § 388-538-068, filed 1/12/06, effective 2/12/06. 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, § 388-538-068, filed 12/14/01, effective 1/14/02.]

     (a) Have been ((determined using generally accepted actuarial methods)) developed in accordance with generally accepted actuarial principles and practices;

     (b) Are appropriate for the populations to be covered and the services to be furnished under the MCO contract;

     (c) Have been certified by actuaries who meet the qualification standards established by the American Academy of Actuaries and follow the practice standards established by the Actuarial Standards Board;

     (d) Are based on historical analysis of financial cost and/or rate information; and

     (((c))) (e) Are paid based on legislative allocations.

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

     (3) The department does not pay providers under the fee-for-service system for ((services)) a service that ((are)) is the MCO's responsibility, 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)) healthcare services.

     (4) The department pays an enhancement rate to federally qualified ((health care)) healthcare centers (FQHC) and rural health clinics (RHC) for each client enrolled with MCOs through the FQHC or RHC. The enhancement rate from the department is in addition to the negotiated payments FQHCs and RHCs receive from the MCOs for services provided to MCO enrollees.

     (5) The department pays MCOs a delivery case rate, separate from the capitation payment, when an enrollee delivers a child(ren) and the MCO pays for any part of labor and delivery.

[Statutory Authority: RCW 74.08.090 and 74.09.522. 06-03-081, § 388-538-070, filed 1/12/06, effective 2/12/06. Statutory Authority: RCW 74.08.090, 74.09.522, 2003 E1 c 25 § 201(4), 2004 c 276 § 201(4), 42 USC 1396N (section 1915 (b) and (c) of the Social Security Act of 1924). 05-01-066, § 388-538-070, filed 12/8/04, effective 1/8/05. Statutory Authority: RCW 74.08.090, 74.09.522. 03-18-109, § 388-538-070, filed 9/2/03, effective 10/3/03. 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 ˝/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 MCO contract for MCO enrollees. MCOs may, at their discretion, cover additional services not required under the MCO contract. However, the department may not require the MCO to cover any additional services outside the scope of services negotiated in the MCO's contract with the department.

     (c) The department covers medically necessary services described in WAC 388-501-0060 and 388-501-0065 that are excluded from coverage in the MCO contract.

     (d) The department covers services through the fee-for-service system 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 the department 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. The department informs an enrollee((s)) about the enrollee's program coverage, limitations to covered services, and how to obtain covered services.

     (e) MCO enrollees may obtain ((certain)) specific services described in the managed care contract from either an MCO provider or from a ((department-enrolled)) provider with a ((current core provider)) separate agreement with the department without needing to obtain a referral from the PCP or MCO. These services ((are described in the managed care contract, and)) are communicated to enrollees by the department and MCOs as described in (f) of this subsection.

     (f) The department 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 the department, and which services are covered by MCOs. In addition, the department requires MCOs to provide new enrollees with written information about covered services.

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

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

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

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

     (d) An enrollee may request a hearing for review of PCCM provider or the department 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 the department.

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

     (a) The department 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) The department 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 MCO contract;

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

     (e) The department requires the MCO to coordinate benefits with other insurers in a manner that does not reduce benefits to the enrollee or result in costs to the enrollee;

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

     (g) For enrollees temporarily outside their MCO((s)) services area, the MCO is required to cover enrollees for up to ninety days for emergency care and medically necessary covered benefits that cannot wait until the enrollees return to their MCO services area.

     (4) Unless the MCO chooses to cover these services, or an appeal, independent review, or a hearing decision reverses an MCO or department 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 MCO 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 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 the department or the MCO;

     (iii) An explanation of why the service is not covered by the MCO or the department, 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 enrollees with limited English proficiency, 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 the department 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 74.04.050, 74.08.090, 74.09.530, and 74.09.700. 06-24-036, § 388-538-095, filed 11/30/06, effective 1/1/07. Statutory Authority: RCW 74.08.090 and 74.09.522. 06-03-081, § 388-538-095, filed 1/12/06, effective 2/12/06. Statutory Authority: RCW 74.08.090, 74.09.522, 2003 E1 c 25 § 201(4), 2004 c 276 § 201(4), 42 USC 1396N (section 1915 (b) and (c) of the Social Security Act of 1924). 05-01-066, § 388-538-095, filed 12/8/04, effective 1/8/05. Statutory Authority: RCW 74.08.090, 74.09.522. 03-18-109, § 388-538-095, filed 9/2/03, effective 10/3/03. 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.]

     Reviser's note: RCW 34.05.395 requires the use of underlining and deletion marks to indicate amendments to existing rules. The rule published above varies from its predecessor in certain respects not indicated by the use of these markings.
AMENDATORY SECTION(Amending WSR 06-03-081, filed 1/12/06, effective 2/12/06)

WAC 388-538-100   Managed care emergency services.   (1) A managed care enrollee may obtain emergency services, for emergency medical conditions from any qualified Medicaid provider. ("Emergency services" and "emergency medical condition" are ((as)) defined in ((this chapter)) WAC 388-538-050.)

     (a) The managed care organization (MCO) covers emergency services for MCO enrollees.

     (b) The department covers emergency services for primary care case management (PCCM) enrollees.

     (2) Emergency services for emergency medical conditions do not require prior authorization by the MCO, primary care provider (PCP), PCCM provider, or the department.

     (3) MCOs must cover all emergency services provided to an enrollee by a provider who is qualified to furnish Medicaid services, without regard to whether the provider is a participating or nonparticipating provider.

     (4) An enrollee who requests emergency services is entitled to receive an exam to determine if the enrollee has an emergency medical condition. What constitutes an emergency medical condition may not be limited on the basis of diagnosis or symptoms.

     (5) The MCO must cover emergency services provided to an enrollee when:

     (a) The enrollee had an emergency medical condition, including cases in which the absence of immediate medical attention would not have had the outcomes specified in the definition of an emergency medical condition; and

     (b) The plan provider or other MCO representative instructs the enrollee to seek emergency services.

     (6) In any disagreement between a hospital and the MCO about whether the enrollee is stable enough for discharge or transfer, or whether the medical benefits of an unstabilized transfer outweigh the risks, the judgment of the attending physician(s) actually caring for the enrollee at the treating facility prevails.

     (7) Under 42 C.F.R. 438.114, the enrollee's MCO must cover and pay for:

     (a) Emergency services provided to enrollees by an emergency room provider, hospital or fiscal agent outside the managed care system; and

     (b) Any screening and treatment the enrollee requires subsequent to the provision of the emergency services.

[Statutory Authority: RCW 74.08.090 and 74.09.522. 06-03-081, § 388-538-100, filed 1/12/06, effective 2/12/06; 03-18-110, § 388-538-100, filed 9/2/03, effective 10/3/03. 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, § 388-538-100, 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, § 388-538-100, 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), § 388-538-100, 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.]

     (2) An MCO enrollee may voice a grievance or appeal an action by an MCO to the MCO either orally or in writing.

     (3) MCOs must maintain records of grievances and appeals and must review the information as part of the MCO's quality strategy.

     (4) MCOs must provide information describing the MCO's grievance system to all providers and subcontractors.

     (5) Each MCO must have a grievance system in place for enrollees. The system must comply with the requirements of this section and the regulations of the state office of the insurance commissioner (OIC). If a conflict exists between the requirements of this chapter and OIC regulations, the requirements of this chapter take precedence. The MCO grievance system must include all of the following:

     (a) A grievance process for complaints about any matter other than an action, as defined in WAC 388-538-050. See subsection (6) of this section for this process;

     (b) An appeal process for an action, as defined in WAC 388-538-050. See subsection (7) of this section for the standard appeal process and subsection (8) of this section for the expedited appeal process;

     (c) Access to the department's hearing process for actions as defined in WAC 388-538-050. The department's hearing process described in chapter 388-02 WAC applies to this chapter. Where conflicts exist, the requirements in this chapter take precedence. See WAC 388-538-112 for the department's hearing process for MCO enrollees;

     (d) Access to an independent review (IR) as described in RCW 48.43.535, for actions as defined in WAC 388-538-050 (see WAC 388-538-112 for additional information about the IR); and

     (e) Access to the board of appeals (BOA) for actions as defined in WAC 388-538-050 (also see chapter 388-02 WAC and WAC 388-538-112).

     (6) The MCO grievance process:

     (a) Only an enrollee may file a grievance with an MCO; a provider may not file a grievance on behalf of an enrollee.

     (b) To ensure the rights of MCO enrollees are protected, each MCO's grievance process must be approved by the department.

     (c) MCOs must inform enrollees in writing within fifteen days of enrollment about enrollees' rights and how to use the MCO's grievance process, including how to use the department's hearing process. The MCOs must have department approval for all written information the MCO sends to enrollees.

     (d) The MCO must give enrollees any assistance necessary in taking procedural steps for grievances (e.g., interpreter services and toll-free numbers).

     (e) The MCO must acknowledge receipt of each grievance either orally or in writing, and each appeal in writing, within five working days.

     (f) The MCO must ensure that the individuals who make decisions on grievances are individuals who:

     (i) Were not involved in any previous level of review or decision making; and

     (ii) If deciding any of the following, are ((health care)) healthcare professionals who have appropriate clinical expertise in treating the enrollee's condition or disease:

     (A) A grievance regarding denial of an expedited resolution of an appeal; or

     (B) A grievance involving clinical issues.

     (g) The MCO must complete the disposition of a grievance and notice to the affected parties within ninety days of receiving the grievance.

     (7) The MCO appeal process:

     (a) An MCO enrollee, or the enrollee's representative with the enrollee's written consent, may appeal an MCO action.

     (b) To ensure the rights of MCO enrollees are protected, each MCO's appeal process must be approved by the department.

     (c) MCOs must inform enrollees in writing within fifteen days of enrollment about enrollees' rights and how to use the MCO's appeal process and the department's hearing process. The MCOs must have department approval for all written information the MCO sends to enrollees.

     (d) For standard service authorization decisions, an enrollee must file an appeal, either orally or in writing, within ninety calendar days of the date on the MCO's notice of action. This also applies to an enrollee's request for an expedited appeal.

     (e) For appeals for termination, suspension, or reduction of previously authorized services, if the enrollee is requesting continuation of services, the enrollee must file an appeal within ten calendar days of the date of the MCO mailing the notice of action. Otherwise, the time frames in subsection (7)(d) of this section apply.

     (f) The MCO's notice of action must:

     (i) Be in writing;

     (ii) Be in the enrollee's primary language and be easily understood as required in 42 C.F.R. 438.10 (c) and (d);

     (iii) Explain the action the MCO or its contractor has taken or intends to take;

     (iv) Explain the reasons for the action;

     (v) Explain the enrollee's or the enrollee's representative's right to file an MCO appeal;

     (vi) Explain the procedures for exercising the enrollee's rights;

     (vii) Explain the circumstances under which expedited resolution is available and how to request it (also see subsection (8) of this section);

     (viii) Explain the enrollee's right to have benefits continue pending resolution of an appeal, how to request that benefits be continued, and the circumstances under which the enrollee may be required to pay the costs of these services (also see subsection (9) of this section); and

     (ix) Be mailed as expeditiously as the enrollee's health condition requires, and as follows:

     (A) For denial of payment, at the time of any action affecting the claim. This applies only when the client can be held liable for the costs associated with the action.

     (B) For standard service authorization decisions that deny or limit services, not to exceed fourteen calendar days following receipt of the request for service, with a possible extension of up to fourteen additional calendar days if the enrollee or provider requests extension. If the request for extension is granted, the MCO must:

     (I) Give the enrollee written notice of the reason for the decision for the extension and inform the enrollee of the right to file a grievance if the enrollee disagrees with that decision; and

     (II) Issue and carry out the determination as expeditiously as the enrollee's health condition requires and no later than the date the extension expires.

     (C) For termination, suspension, or reduction of previously authorized services, ten days prior to such termination, suspension, or reduction, except if the criteria stated in 42 C.F.R. 431.213 and 431.214 are met. The notice must be mailed by a method which certifies receipt and assures delivery within three calendar days.

     (D) For expedited authorization decisions, in cases where the provider indicates or the MCO determines that following the standard time frame could seriously jeopardize the enrollee's life or health or ability to attain, maintain, or regain maximum function, no later than three calendar days after receipt of the request for service.

     (g) The MCO must give enrollees any assistance necessary in taking procedural steps for an appeal (e.g., interpreter services and toll-free numbers).

     (h) The MCO must acknowledge receipt of each appeal.

     (i) The MCO must ensure that the individuals who make decisions on appeals are individuals who:

     (i) Were not involved in any previous level of review or decision making; and

     (ii) If deciding any of the following, are ((health care)) healthcare professionals who have appropriate clinical expertise in treating the enrollee's condition or disease:

     (A) An appeal of a denial that is based on lack of medical necessity; or

     (B) An appeal that involves clinical issues.

     (j) The process for appeals must:

     (i) Provide that oral inquiries seeking to appeal an action are treated as appeals (to establish the earliest possible filing date for the appeal), and must be confirmed in writing, unless the enrollee or provider requests an expedited resolution. Also see subsection (8) for information on expedited resolutions;

     (ii) Provide the enrollee a reasonable opportunity to present evidence, and allegations of fact or law, in person as well as in writing. The MCO must inform the enrollee of the limited time available for this in the case of expedited resolution;

     (iii) Provide the enrollee and the enrollee's representative opportunity, before and during the appeals process, to examine the enrollee's case file, including medical records, and any other documents and records considered during the appeal process; and

     (iv) Include as parties to the appeal, the enrollee and the enrollee's representative, or the legal representative of the deceased enrollee's estate.

     (k) MCOs must resolve each appeal and provide notice, as expeditiously as the enrollee's health condition requires, within the following time frames:

     (i) For standard resolution of appeals and notice to the affected parties, no longer than forty-five calendar days from the day the MCO receives the appeal. This time frame may not be extended.

     (ii) For expedited resolution of appeals, including notice to the affected parties, no longer than three calendar days after the MCO receives the appeal.

     (iii) For appeals for termination, suspension, or reduction of previously authorized services, no longer than forty-five calendar days from the day the MCO receives the appeal.

     (l) The notice of the resolution of the appeal must:

     (i) Be in writing. For notice of an expedited resolution, the MCO must also make reasonable efforts to provide oral notice (also see subsection (8) of this section).

     (ii) Include the results of the resolution process and the date it was completed.

     (iii) For appeals not resolved wholly in favor of the enrollee:

     (A) Include information on the enrollee's right to request a department hearing and how to do so (also see WAC 388-538-112);

     (B) Include information on the enrollee's right to receive services while the hearing is pending and how to make the request (also see subsection (9) of this section); and

     (C) Inform the enrollee that the enrollee may be held liable for the cost of services received while the hearing is pending, if the hearing decision upholds the MCO's action (also see subsection (10) of this section).

     (m) If an MCO enrollee does not agree with the MCO's resolution of the appeal, the enrollee may file a request for a department hearing within the following time frames (see WAC 388-538-112 for the department's hearing process for MCO enrollees):

     (i) For hearing requests regarding a standard service, within ninety days of the date of the MCO's notice of the resolution of the appeal.

     (ii) For hearing requests regarding termination, suspension, or reduction of a previously authorized service, within ten days of the date on the MCO's notice of the resolution of the appeal.

     (n) The MCO enrollee must exhaust all levels of resolution and appeal within the MCO's grievance system prior to requesting a hearing(())) with the department.

     (8) The MCO expedited appeal process:

     (a) Each MCO must establish and maintain an expedited appeal review process for appeals when the MCO determines (for a request from the enrollee) or the provider indicates (in making the request on the enrollee's behalf or supporting the enrollee's request), that taking the time for a standard resolution could seriously jeopardize the enrollee's life or health or ability to attain, maintain, or regain maximum function.

     (b) When approving an expedited appeal, the MCO will issue a decision as expeditiously as the enrollee's health condition requires, but not later than three business days after receiving the appeal.

     (c) The MCO must ensure that punitive action is not taken against a provider who requests an expedited resolution or supports an enrollee's appeal.

     (d) If the MCO denies a request for expedited resolution of an appeal, it must:

     (i) Transfer the appeal to the time frame for standard resolution; and

     (ii) Make reasonable efforts to give the enrollee prompt oral notice of the denial, and follow up within two calendar days with a written notice.

     (9) Continuation of previously authorized services:

     (a) The MCO must continue the enrollee's services if all of the following apply:

     (i) The enrollee or the provider files the appeal on or before the later of the following:

     (A) Unless the criteria in 42 C.F.R. 431.213 and 431.214 are met, within ten calendar days of the MCO mailing the notice of action, which for actions involving services previously authorized, must be delivered by a method which certifies receipt and assures delivery within three calendar days; or

     (B) The intended effective date of the MCO's proposed action.

     (ii) The appeal involves the termination, suspension, or reduction of a previously authorized course of treatment;

     (iii) The services were ordered by an authorized provider;

     (iv) The original period covered by the original authorization has not expired; and

     (v) The enrollee requests an extension of services.

     (b) If, at the enrollee's request, the MCO continues or reinstates the enrollee's services while the appeal is pending, the services must be continued until one of the following occurs:

     (i) The enrollee withdraws the appeal;

     (ii) Ten calendar days pass after the MCO mails the notice of the resolution of the appeal and the enrollee has not requested a department hearing (with continuation of services until the department hearing decision is reached) within the ten days;

     (iii) Ten calendar days pass after the state office of administrative hearings (OAH) issues a hearing decision adverse to the enrollee and the enrollee has not requested an independent review (IR) within the ten days (see WAC 388-538-112);

     (iv) Ten calendar days pass after the IR mails a decision adverse to the enrollee and the enrollee has not requested a review with the board of appeals within the ten days (see WAC 388-538-112);

     (v) The board of appeals issues a decision adverse to the enrollee (see WAC 388-538-112); or

     (vi) The time period or service limits of a previously authorized service has been met.

     (c) If the final resolution of the appeal upholds the MCO's action, the MCO may recover the amount paid for the services provided to the enrollee while the appeal was pending, to the extent that they were provided solely because of the requirement for continuation of services.

     (10) Effect of reversed resolutions of appeals:

     (a) If the MCO or OAH reverses a decision to deny, limit, or delay services that were not provided while the appeal was pending, the MCO must authorize or provide the disputed services promptly, and as expeditiously as the enrollee's health condition requires.

     (b) If the MCO or OAH reverses a decision to deny authorization of services, and the enrollee received the disputed services while the appeal was pending, the MCO must pay for those services.

[Statutory Authority: RCW 74.08.090 and 74.09.522. 06-03-081, § 388-538-110, filed 1/12/06, effective 2/12/06; 03-18-110, § 388-538-110, filed 9/2/03, effective 10/3/03. 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, § 388-538-110, 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, § 388-538-110, filed 2/1/00, effective 3/3/00. 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.]

     (2) A PCCM enrollee may voice a grievance or file an appeal, either orally or in writing. PCCM enrollees use the department's grievance and appeal processes.

     (3) The grievance process for PCCM enrollees;

     (a) A PCCM enrollee may file a grievance with the department. A provider may not file a grievance on behalf of a PCCM enrollee.

     (b) The department provides PCCM enrollees with information equivalent to that described in WAC 388-538-110 (7)(c).

     (c) When a PCCM enrollee files a grievance with the department, the enrollee is entitled to:

     (i) Any reasonable assistance in taking procedural steps for grievances (e.g., interpreter services and toll-free numbers);

     (ii) Acknowledgment of the department's receipt of the grievance;

     (iii) A review of the grievance. The review must be conducted by a department representative who was not involved in the grievance issue; and

     (iv) Disposition of a grievance and notice to the affected parties within ninety days of the department receiving the grievance.

     (4) The appeal process for PCCM enrollees:

     (a) A PCCM enrollee may file an appeal of a department action with the department. A provider may not file an appeal on behalf of a PCCM enrollee.

     (b) The department provides PCCM enrollees with information equivalent to that described in WAC 388-538-110 (8)(c).

     (c) The appeal process for PCCM enrollees follows that described in chapter 388-02 WAC. Where a conflict exists, the requirements in this chapter take precedence.

[Statutory Authority: RCW 74.08.090 and 74.09.522. 06-03-081, § 388-538-111, filed 1/12/06, effective 2/12/06; 03-18-110, § 388-538-111, filed 9/2/03, effective 10/3/03.]

     (2) ((An)) A managed care organization (MCO) enrollee must exhaust all levels of resolution and appeal within the MCO's grievance system prior to requesting a hearing with the department. See WAC 388-538-110 for the MCO grievance system.

     (3) If an MCO enrollee does not agree with the MCO's resolution of the enrollee's appeal, the enrollee may file a request for a department hearing within the following time frames:

     (a) For hearing requests regarding a standard service, within ninety calendar days of the date of the MCO's notice of the resolution of the appeal.

     (b) For hearing requests regarding termination, suspension, or reduction of a previously authorized service, and the enrollee is requesting continuation of services, within ten calendar days of the date on the MCO's notice of the resolution of the appeal.

     (4) The entire appeal and hearing process, including the MCO appeal process, must be completed within ninety calendar days of the date the MCO enrollee filed the appeal with the MCO, not including the number of days the enrollee took to subsequently file for a department hearing.

     (5) Expedited hearing process:

     (a) The office of administrative hearings (OAH) must establish and maintain an expedited hearing process when the enrollee or the enrollee's representative requests an expedited hearing and OAH indicates that the time taken for a standard resolution of the claim could seriously jeopardize the enrollee's life or health and ability to attain, maintain, or regain maximum function.

     (b) When approving an expedited hearing, OAH must issue a hearing decision as expeditiously as the enrollee's health condition requires, but not later than three business days after receiving the case file and information from the MCO regarding the action and MCO appeal.

     (c) When denying an expedited hearing, OAH gives prompt oral notice to the enrollee followed by written notice within two calendar days of request and transfer the hearing to the time frame for a standard service.

     (6) Parties to the hearing include the department, the MCO, the enrollee, and the enrollee's representative or the representative of a deceased enrollee's estate.

     (7) If an enrollee disagrees with the hearing decision, then the enrollee may request an independent review (IR) in accordance with RCW 48.43.535.

     (8) If there is disagreement with the IR decision, any party may request a review by the department's board of appeals (BOA) within twenty-one days of the IR decision. The department's BOA issues the final administrative decision.

[Statutory Authority: RCW 74.08.090 and 74.09.522. 06-03-081, § 388-538-112, filed 1/12/06, effective 2/12/06. Statutory Authority: RCW 74.08.090, 74.09.522, 2003 E1 c 25 § 201(4), 2004 c 276 § 201(4), 42 USC 1396N (section 1915 (b) and (c) of the Social Security Act of 1924). 05-01-066, § 388-538-112, filed 12/8/04, effective 1/8/05. Statutory Authority: RCW 74.08.090, 74.09.522, and 74.09.450. 04-13-002, § 388-538-112, filed 6/2/04, effective 7/3/04. Statutory Authority: RCW 74.08.090, 74.09.522. 03-18-110, § 388-538-112, filed 9/2/03, effective 10/3/03.]

     (a) The enrollee needs more information about treatment recommended by the provider or managed care organization (MCO); or

     (b) The enrollee believes the MCO is not authorizing medically necessary care.

     (2) A managed care enrollee has a right to a second opinion from a participating provider. At the MCO's discretion, a clinically appropriate nonparticipating provider who is agreed upon by the MCO and the enrollee may provide the second opinion.

     (3) Primary care case management (PCCM) enrollees have a right to a timely referral for a second opinion by another provider who has a core provider agreement with the department.

[Statutory Authority: RCW 74.08.090 and 74.09.522. 06-03-081, § 388-538-120, filed 1/12/06, effective 2/12/06. Statutory Authority: RCW 74.08.090, 74.09.522, 2003 E1 c 25 § 201(4), 2004 c 276 § 201(4), 42 USC 1396N (section 1915 (b) and (c) of the Social Security Act of 1924). 05-01-066, § 388-538-120, filed 12/8/04, effective 1/8/05. 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, § 388-538-120, 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, § 388-538-120, 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), § 388-538-120, 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.]

     (2) A client or enrollee, or the client's or enrollee's representative as defined in RCW 7.70.065, may request the department to exempt or end enrollment in managed care as described in this section.

     (a) If a client requests exemption prior to the enrollment effective date, the client is not enrolled until the department approves or denies the request.

     (b) If an enrollee requests to end enrollment, the enrollee remains enrolled pending the department's final decision, unless staying in managed care would adversely affect the enrollee's health status.

     (c) The client or enrollee receives timely notice by telephone or in writing when the department approves or denies the client's or enrollee's request. The department follows a telephone denial by written notification. The written notice contains all of the following:

     (i) The action the department intends to take;

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

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

     (iv) The client's or enrollee's right to request a hearing; and

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

     (3) A managed care organization (MCO) or primary care case management (PCCM) provider may request the department to end enrollment. The request must be in writing and be sufficient to satisfy the department that the enrollee's behavior is inconsistent with the MCO's or PCCM provider's rules and regulations (e.g., intentional misconduct). The department does not approve a request to remove an enrollee from managed care when the request is solely due to an adverse change in the enrollee's health or the cost of meeting the enrollee's ((health care)) healthcare needs. The MCO or PCCM provider's request must include documentation that:

     (a) The provider furnished clinically appropriate evaluation(s) to determine whether there is a treatable problem contributing to the enrollee's behavior;

     (b) Such evaluation either finds no treatable condition to be contributing, or after evaluation and treatment, 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 of the provider's intent to request the enrollee's removal, unless the department has waived the requirement for provider notice because the enrollee's conduct presents the threat of imminent harm to others. The provider's notice must include:

     (i) The enrollee's right to use the provider's grievance system as described in WAC 388-538-110 and 388-538-111; and

     (ii) The enrollee's right to use the department's hearing process, after the enrollee has exhausted all grievance and appeals available through the provider's grievance system (see WAC 388-538-110 and 388-538-111 for provider grievance systems, and WAC 388-538-112 for the hearing process for enrollees).

     (4) When the department receives a request from an MCO or PCCM provider to remove an enrollee from enrollment in managed care, the department attempts to contact the enrollee for the enrollee's perspective. If the department approves the request, the department sends a notice at least ten days in advance of the effective date that enrollment will end. The notice includes:

     (a) The reason the department approved ending enrollment; and

     (b) Information about the enrollee's hearing rights.

     (5) The department will exempt a client from mandatory enrollment or end an enrollee's enrollment in managed care when any of the following apply:

     (a) The client or enrollee is receiving foster care placement services from the division of children and family services (DCFS);

     (b) The client has or the enrollee becomes eligible for Medicare, basic health (BH), CHAMPUS/TRICARE, or any other third-party ((health care)) healthcare coverage comparable to the department's managed care coverage that would require exemption or involuntarily ending enrollment from:

     (i) An MCO, in accordance with the department's managed care contract; or

     (ii) A primary care case management (PCCM) provider, according to the department's PCCM contract.

     (c) The enrollee is no longer eligible for managed care.

     (6) The department will grant a client's request for exemption or an enrollee's request to end enrollment when:

     (a) The client or enrollee is American Indian/Alaska native (AI/AN) as specified in WAC 388-538-060(2);

     (b) The client or enrollee has been identified by the department as a child who meets the definition of "children with special ((health care)) healthcare needs";

     (c) The client or enrollee is homeless or is expected to live in temporary housing for less than one hundred twenty days from the date of the request; or

     (d) The client or enrollee speaks limited English or is hearing impaired and the client or enrollee can communicate with a provider who communicates in the client's or enrollee's language or in American sign language and is not available through the MCO and the MCO does not have a provider available who can communicate in the client's language and an interpreter is not available.

     (7) On a case-by-case basis, the department may grant a client's request for exemption or an enrollee's request to end enrollment when, in the department's judgment, the client or enrollee has a documented and verifiable medical condition, and enrollment in managed care could cause an interruption of treatment that could jeopardize the client's or enrollee's life or health or ability to attain, maintain, or regain maximum function.

     (8) Upon request, the department may exempt the client or end enrollment for the period of time the circumstances or conditions that lead to exemption or ending enrollment are expected to exist. The department may periodically review those circumstances or conditions to determine if they continue to exist. If the department approves the request for a limited time, the client or enrollee is notified in writing or by telephone of the time limitation, the process for renewing the exemption or the ending of enrollment.

     (((9) An MCO may refer enrollees to the department's patients requiring regulation (PRR) program according to WAC 388-501-0135.))

[Statutory Authority: RCW 74.08.090 and 74.09.522. 06-03-081, § 388-538-130, filed 1/12/06, effective 2/12/06; 03-18-111, § 388-538-130, filed 9/2/03, effective 10/3/03. 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, § 388-538-130, 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, § 388-538-130, 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, § 388-538-130, 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.]

     (a) Have a clearly defined quality organizational structure and operation, including a fully operational quality assessment, measurement, and improvement program;

     (b) Have effective means to detect over and under utilization of services;

     (c) Maintain a system for provider and practitioner credentialing and recredentialing;

     (d) Ensure that MCO subcontracts and the delegation of MCO responsibilities are in accordance with the department standards and regulations;

     (e) Ensure MCO oversight of delegated entities responsible for any delegated activity to include:

     (i) A delegation agreement with each entity describing the responsibilities of the MCO and the entity;

     (ii) Evaluation of the entity prior to delegation;

     (iii) An annual evaluation of the entity; and

     (iv) Evaluation or regular reports and follow-up on issues out of compliance with the delegation agreement or the department's managed care contract specifications.

     (f) Cooperate with a department-contracted, qualified independent external review organization (EQRO) conducting review activities as described in 42 C.F.R. 438.358;

     (g) Have an effective mechanism to assess the quality and appropriateness of care furnished to enrollees with special ((health care)) healthcare needs;

     (h) Assess and develop individualized treatment plans for enrollees with special ((health care)) healthcare needs which ensure integration of clinical and nonclinical disciplines and services in the overall plan of care;

     (i) Submit annual reports to the department on performance measures as specified by the department;

     (j) Maintain a health information system that:

     (i) Collects, analyzes, integrates, and reports data as requested by the department;

     (ii) Provides information on utilization, grievances and appeals, enrollees ending enrollment for reasons other than the loss of Medicaid eligibility, and other areas as defined by the department;

     (iii) Collects data on enrollees, providers, and services provided to enrollees through an encounter data system, in a standardized format as specified by the department; and

     (iv) Ensures data received from providers is adequate and complete by verifying the accuracy and timeliness of reported data and screening the data for completeness, logic, and consistency.

     (k) Conduct performance improvement projects designed to achieve significant improvement, sustained over time, in clinical care outcomes and services, and that involve the following:

     (i) Measuring performance using objective quality indicators;

     (ii) Implementing system changes to achieve improvement in service quality;

     (iii) Evaluating the effectiveness of system changes;

     (iv) Planning and initiating activities for increasing or sustaining performance improvement;

     (v) Reporting each project status and the results as requested by the department; and

     (vi) Completing each performance improvement project timely so as to generally allow aggregate information to produce new quality of care information every year.

     (l) Ensure enrollee access to ((health care)) healthcare services;

     (m) Ensure continuity and coordination of enrollee care; and

     (n) Maintain and monitor availability of ((health care)) healthcare services for enrollees.

     (2) The department may:

     (i) Impose intermediate sanctions in accordance with 42 C.F.R. 438.700 and corrective action for substandard rates of clinical performance measures and for deficiencies found in audits and on-site visits;

     (ii) Require corrective action for findings for noncompliance with any contractual state or federal requirements; and

     (iii) Impose sanctions for noncompliance with any contractual, state, or federal requirements not corrected.

[Statutory Authority: RCW 74.08.090 and 74.09.522. 06-03-081, § 388-538-140, filed 1/12/06, effective 2/12/06; 03-18-111, § 388-538-140, filed 9/2/03, effective 10/3/03. 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, § 388-538-140, 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, § 388-538-140, 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), § 388-538-140, 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.]

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