WSR 17-04-054
(Washington Apple Health)
[Filed January 27, 2017, 9:43 a.m.]
Original Notice.
Preproposal statement of inquiry was filed as WSR 16-22-059.
Title of Rule and Other Identifying Information: WAC 182-538A-130 Exemptions and ending enrollment in fully integrated managed care (FIMC) and 182-538A-190 Behavioral health services only (BHSO).
Hearing Location(s): Health Care Authority (HCA), Cherry Street Plaza Building, Pear Conference Room 107, 626 8th Avenue, Olympia, WA 98504 (metered public parking is available street side around building. A map is available at or directions can be obtained by calling (360) 725-1000), on March 7, 2017, at 10:00 a.m.
Date of Intended Adoption: Not sooner than March 8, 2017.
Submit Written Comments to: HCA Rules Coordinator, P.O. Box 45504, Olympia, WA 98504-5504, delivery 626 8th Avenue, Olympia, WA 98504, email, fax (360) 586-9727, by 5:00 p.m. on March 7, 2017.
Assistance for Persons with Disabilities: Contact Amber Lougheed by March 3, 2017, email, (360) 725-1349, or TTY (800) 848-5429 or 711.
Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: Changes to these rules are necessary because the agency is delegating third-party activities to managed care organizations.
Reasons Supporting Proposal: See Purpose above.
Statutory Authority for Adoption: RCW 41.05.021, 41.05.160.
Statute Being Implemented: RCW 41.05.021, 41.05.160.
Rule is not necessitated by federal law, federal or state court decision.
Name of Proponent: HCA, governmental.
Name of Agency Personnel Responsible for Drafting: Melinda Froud, P.O. Box 42716, Olympia, WA 98504-2716, (360) 725-1408; Implementation and Enforcement: Becky McAninch-Dake, P.O. Box 45530, Olympia, WA 98504-5530, (360) 725-1642.
No small business economic impact statement has been prepared under chapter 19.85 RCW. The agency has determined that the proposed filing does not impose a disproportionate cost impact on small businesses or nonprofits.
A cost-benefit analysis is not required under RCW 34.05.328. RCW 34.05.328 does not apply to HCA rules unless requested by the joint administrative rules review committee or applied voluntarily.
January 27, 2017
Wendy Barcus
Rules Coordinator
AMENDATORY SECTION (Amending WSR 16-05-051, filed 2/11/16, effective 4/1/16)
WAC 182-538A-130 Exemptions and ending enrollment in fully integrated managed care (FIMC).
(1) Fully integrated managed care (FIMC) and behavioral health services only (BHSO) are mandatory for individuals residing in FIMC regional service areas.
(2) The medicaid agency enrolls a client ((into)) residing in an FIMC regional service area in either FIMC or BHSO, depending on the client's eligibility, in accordance with WAC 182-538A-060.
(((2) WAC 182-538A-060 applies to disenrollment and choice.
(3) A client may end enrollment in FIMC if:
(a) The client has comparable coverage; or
(b) The client's request to end enrollment is approved by the agency under one of the following circumstances:
(i) The enrollee moves out of the FIMC regional service area;
(ii) Medically necessary care is unavailable from the MCO including, but not limited to, when:
(A) The MCO does not, because of moral or religious objections, deliver the service the enrollee seeks; or
(B) The enrollee needs related services performed at the same time and not all related services are available within the network and the enrollee's primary care provider or another provider determines receiving the services separately would subject the enrollee to unnecessary risk.)) (3) The agency ends an enrollee's enrollment in FIMC according to the rules in WAC 182-538-130.
(4) If ((an enrollee)) the agency ends enrollment ((in)) for an FIMC enrollee based on WAC 182-538-130, the ((agency enrolls the)) enrollee ((in BHSO if the enrollee)) is required to enroll in BHSO if eligible.
AMENDATORY SECTION (Amending WSR 16-05-051, filed 2/11/16, effective 4/1/16)
WAC 182-538A-190 Behavioral health services only (BHSO).
This section applies to enrollees receiving behavioral health services only (BHSO) under the fully integrated managed care (FIMC) medicaid contract.
(1) The medicaid agency requires eligible clients in FIMC regional service areas to enroll in the BHSO program.
(2) A BHSO enrollee in an FIMC regional service area may change managed care organizations (MCOs) but may not disenroll from the BHSO program.
(3) For BHSO enrollees, the MCO covers the behavioral health benefit included in the FIMC medicaid contract.
(4) WAC 182-538-110 applies to BHSO enrollees in FIMC regional service areas.
(5) The agency assigns the BHSO enrollee to an MCO available in the area where the client resides.
(6) A BHSO enrollee may change MCOs for any reason with the change becoming effective according to the agency's managed care policy.
(((7) The agency ends enrollment in BHSO managed care when the enrollee becomes eligible for any third-party health care coverage comparable to BHSO.))