WSR 18-04-088
[Filed February 5, 2018, 3:40 p.m.]
Original Notice.
Preproposal statement of inquiry was filed as WSR 17-23-073.
Title of Rule and Other Identifying Information: WAC 182-538-070 Payments to managed care organizations (MCOs).
Hearing Location(s): On March 13, 2018, at 10:00 a.m., at the Health Care Authority (HCA), Cherry Street Plaza, Sue Crystal Conference Room 106A, 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.
Date of Intended Adoption: Not sooner than March 14, 2018.
Submit Written Comments to: HCA Rules Coordinator, P.O. Box 42716, Olympia, WA 98504-2716, email, fax 360-586-9727, by March 13, 2018.
Assistance for Persons with Disabilities: Contact Amber Lougheed, phone 360-725-1349, fax 360-586-9727, TTY 800-848-5429 or 711, email, by March 9, 2018.
Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: The agency is amending WAC 182-538-070 Payments to managed care organizations (MCOs), to align language regarding enhancement payments for MCO enrollees assigned to federally qualified health centers and rural health clinics with the agency's rules found in chapters 182-548 and 182-549 WAC.
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: Katie Pounds, P.O. Box 42716, Olympia, WA 98504-2716, 360-725-1346; Implementation and Enforcement: Alison Robbins, P.O. Box 45530, Olympia, WA 98504-5530, 360-725-1634.
A school district fiscal impact statement is not required under RCW 28A.305.135.
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.
The proposed rule does not impose more-than-minor costs on businesses. Following is a summary of the agency's analysis showing how costs were calculated. The proposed rule does not impose any costs or new requirements on businesses.
February 5, 2018
Wendy Barcus
Rules Coordinator
AMENDATORY SECTION (Amending WSR 15-24-098, filed 12/1/15, effective 1/1/16)
WAC 182-538-070 Payments to managed care organizations (MCOs).
(1) The medicaid agency pays apple health managed care organizations (MCOs) monthly capitated premiums that:
(a) Have been developed using 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 analysis of historical cost, rate information, or both; and
(e) Are paid based on legislative allocations.
(2) The MCO is solely responsible for payment of MCO-contracted health care services. The agency will not pay for a service that is the MCO's responsibility, even if the MCO has not paid the provider for the service.
(3) The agency pays an enhancement rate ((to federally qualified health care centers (FQHC) and rural health clinics (RHC))) for each MCO enrollee assigned to ((the FQHC or RHC. The enhancement rate from the agency is in addition to the negotiated payments FQHCs and RHCs receive from the MCOs for services provided to MCO enrollees. To ensure that the appropriate amounts are paid to each FQHC or RHC, the agency performs an annual reconciliation of the enhancement payments with the FQHC or RHC)) a federally qualified health center (FQHC) or rural health clinic (RHC) according to chapters 182-548 and 182-549 WAC.
(4) The agency 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.