WSR 05-01-066

PERMANENT RULES

DEPARTMENT OF

SOCIAL AND HEALTH SERVICES
(Medical Assistance Administration)

[ Filed December 8, 2004, 4:23 p.m. , effective January 8, 2005 ]


Purpose: The rules clarify existing managed care rules; revise WAC 388-538-060 to remove language regarding contract access standards; to simplify enrollment process; and adopt rules for the Washington Medicaid integration partnership (WMIP) and the Medicare/Medicaid integration program (MMIP).

Citation of Existing Rules Affected by this Order: Amending WAC 388-538-050, 388-538-060, 388-538-065, 388-538-067, 388-538-070, 388-538-095, 388-538-112, and 388-538-120.

Statutory Authority for Adoption: RCW 74.08.090.

Other Authority: RCW 74.09.522, ESSB 5404, section 201(4), chapter 25, Laws of 2003, section 201(4), chapter 276, Laws of 2004, 42 USC 1396N (section 1915 (b) and (c) of the Social Security Act of 1924).

Adopted under notice filed as WSR 04-21-057 and 04-21-058 on October 18, 2004.

Changes Other than Editing from Proposed to Adopted Version: The following changes, other than editing, were made to the rule as a result of comments of received:


AMENDED SECTION:


WAC 388-538-050 Definitions, new language added at the adopted rule is double underlined.

The word "contracts" was added to the definition below and the "s" was removed from the word program.

"Timely" - in relation to the provision of services, means an enrollee has the right to receive medically necessary health care as expeditiously as the enrollee's health condition requires. In relation to authorization of services and grievances and appeals, means in accordance with the ((healthy options (HO)/state childrens health insurance program (SCHIP) contract)) department's managed care program contracts and the time frames stated in this chapter.


Added the words "is designed to integrate" instead of "integrates."

"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.


NEW SECTION: Added language at adoption is double underlined, deleted language is lined through.


WAC 388-538-061 Managed care provided through the Washington Medicaid Integration Partnership (WMIP) or Medicare/Medicaid Integration Program (MMIP)

(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) of this section.

(ab) For WMIP, MAA 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.

(bc) For MMIP, clients are eligible to voluntarily may enroll when they:

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

(ii) Receive Medicare and/or Medicaid.

(cd) American Indian/Alaska Native (AI/AN) clients and clients who are eligible for 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.

(de) MAA 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 accessible third-party health care coverage that would require exemption or involuntary disenrollment from managed care.

(ef) A clients or enrolleed 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 re-enroll at any time with the MCO. MAA ends enrollment for clients prospectively to the first of the month following request to end enrollment, except as provided in subsection (g) of this section.

(fg) Clients may request that MAA retroactively end enrollment from WMIP and MMIP. On a case-by-case basis, MAA may retroactively end enrollment from WMIP and MMIP when, in MAA'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 described in WAC 388-538-095, the following services are also included in the MCO contract for WMIP and MMIP enrollees WMIP and MMIP are designed to include the following services:

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

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

(6) MAA 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, MAA requires MCOs to provide new enrollees with written information about covered services. This notice informs the client about the right to disenroll and how to do so.

A final cost-benefit analysis is available by contacting Alison Robbins, MAA Care Coordinator, Medical Assistance Administration, P.O. Box 45530, Olympia, WA 98504-5530, phone (360) 725-1634, fax (360) 753-7315, e-mail robbiaa@dshs.wa.gov. No changes were made. The preliminary cost-benefit analysis will be final.

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 1, 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 6, 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 1, Amended 6, Repealed 0.

Date Adopted: December 3, 2004.

Brian H. Lindgren, Manager

Rules and Policies Assistance Unit

3479.3
AMENDATORY SECTION(Amending WSR 03-18-109, filed 9/2/03, effective 10/3/03)

WAC 388-538-050   Definitions.   The following definitions and abbreviations and those found in WAC 388-500-0005, Medical definitions, apply to this chapter.

"Action" means:

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

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

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

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

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

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

"Appeal" means a request by a provider or covered enrollee for reconsideration of an action.

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

"Auto enrollment" means that MAA automatically enrolls a client into an MCO in his or her area, rather than waiting for the client to enroll with an MCO.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

"Exemption" means a client, not currently enrolled in managed care, makes a pre-enrollment 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 state fair hearing process.

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

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

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

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

"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 of social and health services ())DSHS(())) under a comprehensive risk contract to provide prepaid health care services to eligible ((medical assistance administration ())MAA(())) clients under ((MAA's)) the department's managed care programs.

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

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

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

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

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

"Timely" - in relation to the provision of services, means an enrollee has the right to receive medically necessary health care as expeditiously as the enrollee's health condition requires. In relation to authorization of services and grievances and appeals, means in accordance with the ((healthy options (HO)/state childrens health insurance program (SCHIP) contract)) 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, 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.]


AMENDATORY SECTION(Amending WSR 03-18-109, filed 9/2/03, effective 10/3/03)

WAC 388-538-060   Managed care and choice.   (1) MAA requires a client to enroll in managed care when that client meets all of the following conditions:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

(b) If the client does not have family members enrolled with an MCO that is currently under contract with DSHS, and the client was previously enrolled ((in the last six months with an)) with the MCO or PCCM provider, and DSHS 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 ((case)) care provider (PCP), MAA attempts to contact the client to complete the required choice. If MAA is not able to contact the client in a timely manner, MAA documents the attempted contacts and, using the best information available, assigns the client as follows. If the client's preferred PCP is:

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

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

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

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

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

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

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

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

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

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

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

(iii) For clients who are new to medical assistance or who have had a break in eligibility of greater than two months, MAA 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 MAA 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 MAA's assignment, and ((either)) the toll-free telephone number of either:

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

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

(iv) ((An assigned client has at least thirty calendar days to contact MAA to change the MCO or PCCM provider assignment before enrollment is effective)) If the client has a break in eligibility of less than two months, the client will be automatically re-enrolled with his or her previous MCO or PCCM provider and no notice will be sent.

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

(a) MCO enrollees may choose:

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

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

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

(c) MCO enrollees 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, MCO enrollees may file a grievance with the MCO and may change plans if the MCO denies an enrollee's request to change PCPs or clinics.

[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.]


NEW SECTION
WAC 388-538-061   Managed care provided through the Washington Medicaid Integration Partnership (WMIP) or Medicare/Medicaid Integration Program (MMIP).   (1) The purpose of this section is to describe the managed care requirements for clients eligible for either the Washington Medicaid Integration Partnership (WMIP) or the Medicare/Medicaid Integration Program (MMIP).

(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), 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 WAC 388-538-130(4), describing the process used when MAA 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 MAA's "Patient Review and Restriction" 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) of this section.

(b) For WMIP, MAA 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 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) MAA 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 coverage that would require exemption or involuntary disenrollment from managed care.

(f) 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 re-enroll at any time with the MCO. MAA ends enrollment for clients prospectively to the first of the month following request to end enrollment, except as provided in subsection (g) of this section.

(g) Clients may request that MAA retroactively end enrollment from WMIP and MMIP. On a case-by-case basis, MAA may retroactively end enrollment from WMIP and MMIP when, in MAA'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 described in WAC 388-538-095, WMIP and MMIP are designed to include the following services:

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

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

(6) MAA 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, MAA requires MCOs to provide new enrollees with written information about covered services. This notice informs the client about the right to disenroll and how to do so.

[]

3480.1
AMENDATORY SECTION(Amending WSR 02-01-075, filed 12/14/01, effective 1/14/02)

WAC 388-538-065   Medicaid-eligible basic health (BH) enrollees.   (1) Certain children and pregnant women who have applied for, or are enrolled in, managed care through basic health (BH) (chapter 70.47 RCW) are eligible for Medicaid under pediatric and maternity expansion provisions of the Social Security Act. The medical assistance administration (MAA) determines Medicaid eligibility for children and pregnant women who enroll through BH.

(2) The administrative rules and regulations that apply to managed care enrollees also apply to Medicaid-eligible clients enrolled through BH, except as follows:

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

(b) American Indian/Alaska Native (AI/AN) clients cannot choose fee-for-service or PCCM as described in WAC 388-538-060(2). They must enroll in a BH-contracted MCO.

(c) If a Medicaid eligible client applying for BH does not choose an MCO ((within ninety days)), the client is transferred from BH to the department of social and health services (DSHS) for assignment to managed care.

[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, 388-538-065, 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, 388-538-065, filed 2/1/00, effective 3/3/00.]


AMENDATORY SECTION(Amending WSR 03-18-112, filed 9/2/03, effective 10/3/03)

WAC 388-538-067   Managed care provided through managed care organizations (MCOs).   (1) Managed care organizations (MCOs) may contract with the department of social and health services (DSHS) to provide prepaid health care services to eligible ((medical assistance administration (MAA))) clients. The MCOs must meet the qualifications in this section to be eligible to contract with DSHS. The MCO must:

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

(b) Accept the terms and conditions of DSHS' HO contract;

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

(d) Accept the prepaid rates published by DSHS.

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

[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.]


AMENDATORY SECTION(Amending WSR 03-18-109, filed 9/2/03, effective 10/3/03)

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

(a) Have been determined using generally accepted actuarial methods;

(b) Are based on ((analyses of)) historical ((healthy options (HO) contractual rates and MCO experience in providing health care for the populations eligible for HO)) analysis of financial cost and/or rate information; and

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

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

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

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

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

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

[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 1/2/97. Statutory Authority: RCW 74.08.090 and 1995 2nd sp.s. c 18. 95-18-046 (Order 3886), 388-538-070, filed 8/29/95 effective 9/1/95. Statutory Authority: RCW 74.08.090. 93-17-039 (Order 3621), 388-538-070, filed 8/11/93, effective 9/11/93.]


AMENDATORY SECTION(Amending WSR 03-18-109, filed 9/2/03, effective 10/3/03)

WAC 388-538-095   Scope of care for managed care enrollees.   (1) Managed care enrollees are eligible for the scope of medical care as described in WAC 388-529-0100 for categorically needy clients.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

(e) An enrollee may appeal an MCO action using the MCO's appeal process, as described in WAC 388-538-110. After exhausting the MCO's appeal process, an enrollee may also request a department fair hearing for review of an MCO action as described in WAC 388-538-112;

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

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

(a) For all managed care enrollees:

(i) Services that are not medically necessary;

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

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

(b) For MCO enrollees:

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

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

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

(A) The service is not medically necessary; or

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

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

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

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

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

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

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

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

[Statutory Authority: RCW 74.08.090, 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.]


AMENDATORY SECTION(Amending WSR 04-13-002, filed 6/2/04, effective 7/3/04)

WAC 388-538-112   The ((medical assistance administration's (MAA's))) department of social and health services' (DSHS) fair hearing process for enrollee appeals of managed care organization (MCO) actions.   (1) The fair hearing process described in chapter 388-02 WAC applies to the fair hearing process described in this chapter. Where a conflict exists, the requirements in this chapter take precedence.

(2) An MCO enrollee must exhaust all levels of resolution and appeal within the MCO's grievance system prior to filing an appeal (a request for a department fair hearing) with MAA. 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 fair hearing within the following time frames:

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

(b) For appeals regarding termination, suspension, or reduction of a previously authorized service, or 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 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 fair hearing.

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

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

(7) If there is disagreement with the IR decision, the department of social and health services (DSHS) board of appeals (BOA) issues the final administrative decision.

[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.]


AMENDATORY SECTION(Amending WSR 02-01-075, filed 12/14/01, effective 1/14/02)

WAC 388-538-120   Enrollee request for a second medical opinion.   (1) A managed care enrollee has the right to a timely referral for a second opinion upon request when:

(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 ((primary or specialty care physician who is participating with the MCO)) 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) provider enrollees have a right to a timely referral for a second opinion by another provider who has a core provider agreement with medical assistance administration (MAA).

[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.]

Washington State Code Reviser's Office