Current through Register Vol. 24-18, September 15, 2024
(1) The medicaid agency requires a client to
enroll in integrated managed care (IMC) when that client:
(a) Is eligible for one of the Washington
apple health programs for which enrollment is mandatory;
(b) Resides in an area where enrollment is
mandatory; and
(c) Is not exempt
from IMC enrollment and the agency has not ended the client's managed care
enrollment, consistent with WAC
182-538-130.
(2) American Indian and Alaska
native (AI/AN) clients and their descendants may choose one of the following:
(a) Enrollment with a managed care
organization (MCO) available in their regional service area;
(b) Enrollment with a PCCM provider through a
tribal clinic or urban Indian center available in their area; or
(c) The agency's fee-for-service system for
physical health or behavioral health or both.
(3) To enroll with an MCO or PCCM provider, a
client may:
(a) Enroll online via the
Washington Healthplanfinder at
https://www.wahealthplanfinder.org;
(b) Call the agency's toll-free enrollment
line at 800-562-3022; or
(c) Go to
the Provider One client portal at
https://www.waproviderone.org/client
and follow the instructions.
(4) An enrollee in IMC must enroll with an
MCO available in the regional service area where the enrollee
resides.
(5) All family members
will be enrolled with the same MCO, except family members of an enrollee placed
in the patient review and coordination (PRC) program under WAC
182-501-0135
need not enroll in the same MCO as the family member placed in the PRC program.
(6) An enrollee may be placed into
the PRC program by the MCO or the agency. An enrollee placed in the PRC program
must follow the enrollment requirements of the program as stated in WAC
182-501-0135.
(7) When a client requests enrollment with an
MCO or PCCM provider, the agency enrolls a client effective the earliest
possible date given the requirements of the agency's enrollment
system.
(8) The agency assigns a
client who does not choose an MCO or PCCM provider as follows:
(a) If the client was enrolled with an MCO or
PCCM provider within the previous six months, the client is reenrolled with the
same MCO or PCCM provider;
(b) If
(a) of this subsection does not apply and the client has a family member
enrolled with an MCO, the client is enrolled with that MCO;
(c) The client is reenrolled within the
previous six months with their prior MCO plan if:
(i) The agency identifies the prior MCO and
the program is available; and
(ii)
The client does not have a family member enrolled with an agency-contracted MCO
or PCCM provider.
(d) 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; or
(e) If
the client cannot be assigned according to (a), (b), (c), or (d) of this
subsection, the agency :
(i) Assigns the
client according to agency policy, or this rule, or both;
(ii) Does not assign clients to any MCO that
has a total statewide market share of forty percent or more of clients who are
enrolled in apple health IMC. On a quarterly basis, the agency reviews
enrollment data to determine each MCO's statewide market share in apple health
IMC;
(iii) Applies performance
measures associated with increasing or reducing assignment consistent with this
rule and agency policy or its contracts with MCOs.
(f) If the client cannot be assigned
according to (a) or (b) of this subsection, the agency assigns the client as
follows:
(i) If a client who is not AI/AN
does not choose an MCO, the agency assigns the client to an MCO available in
the area where the client resides. The MCO is responsible for primary care
provider (PCP) choice and assignment.
(ii) For clients who are newly eligible or
who have had a break in eligibility of more than six months, the agency sends a
written notice to each household of one or more clients who are assigned to an
MCO. The assigned client has ten calendar days to contact the agency to change
the MCO assignment before enrollment is effective. The notice includes:
(A) The agency's toll-free number;
(B) The toll-free number and name of the MCO
to which each client has been assigned;
(C) The effective date of enrollment;
and
(D) The date by which the
client must respond in order to change the assignment.
(9) An MCO enrollee's
selection of a PCP or assignment to a PCP occurs as follows:
(a) An MCO enrollee may choose:
(i) A PCP or clinic that is in the enrollee's
MCO and accepting new enrollees; or
(ii) A different PCP or clinic 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 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.
(d) An MCO enrollee may file a grievance with
the MCO if the MCO does not approve an enrollee's request to change PCPs or
clinics.
(e) MCO enrollees required
to participate in the agency's PRC program may be limited in their right to
change PCPs (see WAC
182-501-0135
).
Statutory Authority:
RCW
41.05.021, 42 C.F.R. 438. 13-02-010,
§182-538-060, filed 12/19/12, effective 2/1/13. 11-14-075, recodified as
§182-538-060, filed 6/30/11, effective 7/1/11. Statutory Authority:
RCW
74.08.090 and
74.09.522. 08-15-110, §
388-538-060, filed 7/18/08, effective 8/18/08; 06-03-081, § 388-538-060,
filed 1/12/06, effective 2/12/06. Statutory Authority:
RCW
74.08.090,
74.09.522, 2003 E 1 c 25§
201(4), 2004 c 276 § 201(4),
42 U.S.C.
1396 N (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.
