WSR 00-04-080

PERMANENT RULES

DEPARTMENT OF

SOCIAL AND HEALTH SERVICES
(Medical Assistance Administration)

[ Filed February 1, 2000, 2:13 p.m. ]

Date of Adoption: February 1, 2000.

Purpose: To clarify changes made by the Economic Services Administration/Medical Assistance Administration 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.

Citation of Existing Rules Affected by this Order: Repealing WAC 388-538-001, 388-538-090, and 388-538-150; and amending WAC 388-538-050, 388-538-060, 388-538-070, 388-538-080, 388-538-095, 388-538-100, 388-538-110, 388-538-120, 388-538-130, and 388-538-140.

Statutory Authority for Adoption: RCW 74.08.090, 74.09.510 and [74.09.]522.

Other Authority: 1115 Federal Waiver, 42 U.S.C. 1396 (a), (e), (p), 42 U.S.C. 1396r-6(b), 42 U.S.C. 1396u-2.

Adopted under notice filed as WSR 99-20-109 on October 6, 1999.

Changes Other than Editing from Proposed to Adopted Version:
CHANGED FROM: TO: REASON:
388-538-050 Definitions
"'Client' means an individual eligible for any medical program who is not enrolled with a managed care plan or PCCM provider. In..." "'Client' means an individual eligible for any medical program who is not enrolled with a managed care plan or primary care case manager (PCCM). In..." Spelled out the abbreviation PCCM for clarity.
New Added: "'Emergency medical condition" means a condition meeting the conditions in 42 USC 1396u-2 (b)(2)(C). This definition as specifically applied to managed care differs slightly from the MAA definition in WAC 388-500-0005 Definitions - general. Added per stakeholder request.
New Added: "'Emergency services' means services as defined in 42 USC 1396u-2 (b)(2)(B). This definition applies specifically to managed care, which may differ from common usage. Added per stakeholder request.
"'End enrollment' means an enrollee is currently enrolled in HO..." "'End enrollment' means an enrollee is currently enrolled in Healthy Options (HO)..." Spelled out "healthy options" as this is the first time it is used in the text.
"Health care service" or "service" means a service provided for... "'Health care service' or 'service' means a service or item provided..." Added "item" for clarity and per stakeholder request.
"'Healthy options program' or 'HO program' means medical assistance administration's managed care..." "'Healthy option program' or 'HO program' means MAA's managed care..." Replaced "medical assistance administration's" with MAA since MAA spelled out earlier.
"'Managed care' means a comprehensive system of medical and health care delivery..." "'Managed care' means a pre-paid comprehensive system of medical and health care delivery..." Added "pre-paid" for clarity and per stakeholder request.
"'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."

"'Timely' in relation to the

provision of services, means an

enrollee has the right to receive

medically necessary health care

without unreasonable delay."

Added "without unreasonable

delay" and deleted "according

to timeline standards in the

healthy options contract" per

stakeholder request.

388-538-060(2)
"American Indian/Alaskan Native" "American Indian/Alaska Native" Per stakeholder request to use

correct designation.

388-538-060 (4)(d)(iii)
"...The notice includes...and the date by which the client must respond." "...The notice includes...and the date by which the client must respond in order to change plan assignment." Added "in order to change plan assignment" per stakeholder request.
388-538-065(1)
"Certain children and pregnant women who are enrolled in the BHP.... MAA determines Medicaid eligibility for BHP enrollee children and pregnant women." "Certain children and pregnant women enrolled through BHP.... MAA determines Medicaid eligibility for children and pregnant women who enroll through BHP." Deleted "who are," "in the," and

"BHP enrollee" and added "through" & "who enroll through BHP" per stakeholder request.

388-538-065(2)
"...also apply to Medicaid eligible BHP enrollees, except as..." except as..." "...also apply to Medicaid eligible clients enrolled through BHP, Changed "BHP enrollees" to "clients enrolled through BHP" per stakeholder request.
388-538-065 (2)(a)
"...the state agency that administers the BHP;" "...the state agency that administers BHP;" Deleted "the" per stakeholder request.
388-538-065 (2)(b)
"American Indian/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. "American Indian/Native Alaska (AI/AN) clients cannot choose fee-for-service or PCCM under BHP as described under WAC 388-538-060(2). They must enroll plan." in a BHP health care plan." Changed "Alaskan" to "Alaska" per stakeholder request. Deleted "under BHP" for clarification.
388-538-065 (2)(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)." "If a Medicaid eligible client applying for BHP does not choose a plan within ninety days, the client is transferred from BHP to HO and is assigned as described in WAC 388-538-060(4)." Changed wording per stakeholder request.
388-538-070(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 or 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." "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 or 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." Deleted last sentence per division director request.
388-538-080(1)
"'Exemption' means the client is excused from mandatory enrollment when the client has not yet chosen or been assigned to a plan or PCCM provider." Deleted definition of "exemption." Deleted definition since the word is defined in the definitions section of this chapter, per stakeholder request.
388-538-080 (2)(a)(i)
"...severe medical diagnosis;" "...severe medical diagnoses;" Changed word from singular to plural to reflect correct policy.
388-538-080 (2)(a)(ii)
"The client's established provider is not with any available managed care plan;" "The client's established provider is not available through any managed care plan;" Deleted "with any" and added "through any" per stakeholder request.
388-538-080(3)
"...If the request is approved for a limited time, the client is notified of the time limitation and the process for renewing the exemption." "...If the request is approved for a limited time, the client is notified in writing or by telephone of the time limitation, the process for renewing their exemption, and their fair hearing rights." Added "in writing or by telephone" & "fair hearing rights" and deleted "and" per stakeholder request.
388-538-095 (1)(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." "A client is entitled to timely access to medically necessary services as defined in WAC 388-500-0005." Added "timely access" per stakeholder request. Deleted the definition of "medically necessary" and remainder of sentence per stakeholder request.
388-538-095 (1)(b)
"In addition, plans may cover services not required under the HO contract." "In addition, plans may, at their discretion, cover services not required under the HO contract." Added "at their discretion" per stakeholder request.
388-538-095 (3)(a)
"...to deliver the scope of services contracted with the plan." "...to deliver the scope of services contracted with the plan, in a timely fashion, according to the requirements of the HO contract." Added the "in a timely fashion" phrase per stakeholder request.
388-538-095 (4)(b)(ii)
"All nonemergency services received from nonparticipating providers ..." "All nonemergency services covered under the HO contract and received from nonparticipating providers..." Added "covered under the HO contract and" per stakeholder request.
388-538-095(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 provider may bill an enrollee for noncovered services as described in subsection (4) of this section if the enrollee and provider sign an agreement. The provider must give the original agreement to the enrollee and file a copy in the enrollee's record." Changed language to clarify information about the form and what needs to be on it. Moved information about limited English proficient clients to end of section in (b).
388-538-095 (5)(a)
"The written consent form must be approved by MAA and include all of the following:" "The agreement must state all of the following:" Changed language to clarify the agreement is not a standard MAA consent form.
388-538-095 (5)(a)(i)
"A description of the specific service the enrollee is agreeing to pay for;" "The specific service to be provided;" Eliminated first phrase to fit with introductory phrase in (5)(a) and reworded to reduce unnecessary verbiage.
388-538-095 (5)(a)(ii)
"A statement that the service is not covered by MAA or the plan;" "That the service is not covered by either MAA or the plan;" Eliminated first phrase to fit with introductory phrase in (5)(a) and added "either" per stakeholder request.
388-538-095 (5)(a)(iii)(B)
"The service is covered only when a participating provider provides it." "The service is covered only when provided by a participating provider." Changed language to eliminate awkward wording.
388-538-095 (5)(a)(iv)
"A statement that the enrollee

chooses to receive the service;"

"The enrollee chooses to receive

and pay for the service;"

Eliminated first phrase to fit with

introductory phrase in (5)(a).

Added "and pay for" to eliminate

following sentence.

388-538-095 (5)(a)(v)
"A statement that the enrollee agrees to pay for the service; and" Deleted Added to sentence above.
388-538-095 (5)(a)(vi)

"A statement explaining why the enrollee is choosing to pay for the service, such as:"

388-538-095 (5)(a)(v)

"Why the enrollee is choosing to pay for the service, such as:"

Renumbered per deletion above. Eliminated first phrase to fit with introductory phrase in (5)(a).
388-538-095 (5)(a)(vi)(B)
"...rather than wait to receive services in a participating..." "...rather than wait to receive services at no cost in a participating..." Added "at no cost" to clarify what the enrollee is forfeiting by agreeing to pay for services.
388-538-095 (5)(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." "For limited English proficient enrollees, the agreement must be translated or interpreted into the enrollee's primary language to be valid and enforceable." Inserted new (5)(b) and renumbered and reworded old (5)(b) as (5)(c) (below).

388-538-095 (5)(c)
New "The agreement is void and Unenforceable, and the enrollee is under no obligation to pay the provider if the service is covered by MAA or the plan as described in subsection (1) of this section, even if the provider is not paid for the covered service ..." Renumbered old (5)(b) as new (5)(c); changed "written consent" to "agreement" and "has not been" to "is not" for clarity.
388-538-100(1)
"A managed care enrollee may obtain emergency services, as defined in 42 USC 1396u-2(b), for emergency medical conditions, as defined in 42 USC 1396u-2(c) in any hospital emergency department." "A managed care enrollee may obtain emergency services for emergency medical conditions in any hospital emergency department." Deleted references to federal regulations since these terms are now defined in Definitions per stakeholder request.
388-538-100(3)
"An enrollee who requests emergency services is entitled to receive and exam to determine if the enrollee has an emergency medical condition." "Emergency medical services for nonemergency medical conditions must be authorized by the plan for plan enrollees." Inserted new (3) and renumbered (3) as new (4) per stakeholder request.
388-538-100(4)
New "An enrollee who requests emergency services is entitled to an exam to determine if the enrollee has an emergency medical condition." Renumbered old (3) as new (4) per stakeholder request to insert new (3).
388-538-110(1)
"A managed care enrollee has the right to voice a complaint or appeal a plan, PCP or provider decision." "A managed care enrollee has the right to voice a complaint or submit an appeal of a plan, PCP or provider decision, action, or inaction. An enrollee may do this through the plan's complaint and appeal process, and through the department's fair hearing process. Added language to clarify the enrollee's rights per stakeholder request.
388-538-110(6)
"An enrollee who appeals a plan, PCP, or provider decision is entitled to all of the following:" "When an enrollee is not satisfied with how the plan resolves a complaint, or if the plan does not resolve a complaint in a timely fashion, the enrollee may submit an appeal to the plan. An enrollee may also appeal a plan, PCP, or provider decision or reconsideration of any action or inaction. An enrollee who..." Added introductory sentences to clarify enrollees' rights.
388-538-110(7)
"The plan's medical director or designee reviews all appeals and requests for fair hearings when the issues involve medical necessity." "An enrollee may file a fair hearing request without also filing an appeal with the plan or exhausting the plan's appeal process." Inserted new section (7) and renumbered and reworded old section (7) as new section (8) to clarify policy.
388-538-110(8)
New "The plan's medical director or designee reviews all fair hearings requests and any related appeals when the issues involve medical necessity." Renumbered old section (7) as new section (8) and reworded per stakeholder request.
388-538-120(1)
"A managed care plan enrollee has the right to a timely referral for a second opinion when:" "A managed care plan enrollee has the right to a timely referral for a second opinion upon request when:" Added "upon request" per stakeholder request.
388-538-120(2)
"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." "A managed care plan enrollee has the right to a second opinion from a primary or specialty care physician who is participating with the plan." Changed "in" to "with" & deleted "existing" and "network" per stakeholder request.
388-538-130 (2)(j)
"...but is willing to enroll in the established provider's plan." "...but is willing to enroll in the established provider's plan for the next enrollment month." Added "for the next enrollment month" for clarity.
388-538-130 (2)(j)(iii)
"If the request to end enrollment is approved, it may be effective back to the beginning of the current month." "If the request to end enrollment is approved, it may be effective back to the beginning of the month of request." Deleted "current" and added "of request" to clarify the time involved.
388-538-130(3)
"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."

"If the request to end enrollment

is approved for a limited time, the

client is notified in writing or by

telephone of the process for

renewing the disenrollment, and

their fair hearing rights."

Added "in writing or by tele-

phone" & "fair hearing rights" and deleted "and" per stakeholder request. Changed "exemption" to "disenrollment" to use the correct term.

388-538-130(7)
"...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 date that enrollment will end." "...If MAA approves the plan's request to remove the enrollee, MAA sends a notice at least ten days in advance of the effective date that enrollment will end. The notice includes the reason for MAA's approval to end enrollment and information about the client's fair hearing rights." Reworded for clarity regarding the notice.

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 2, Amended 10, Repealed 3.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 2, Amended 10, Repealed 3.

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 2, Amended 10, Repealed 3. Effective Date of Rule: Thirty-one days after filing.

February 1, 2000

Marie Myerchin-Redifer, Manager

Rules and Policies Assistance Unit

Reviser'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 00-05 issue of the Register.

Washington State Code Reviser's Office