Current through Register Vol. 24-18, September 15, 2024
(1) To provide
physical or behavioral health services under the apple health IMC contract, a
managed care organization (MCO) must:
(a)
Contract with the agency; and
(b)
Contract with an agency-contracted behavioral health administrative service
organization (BH-ASO) that maintains an adequate provider network to deliver
services to clients in IMC regional service areas.
(2) An MCO must meet the following
qualifications to be eligible to contract with the agency:
(a) Have a certificate of registration from
the Washington state office of the insurance commissioner (OIC) that allows the
MCO to provide health care services under a risk-based contract;
(b) Accept the terms and conditions of the
agency's managed care contract;
(c)
Meet the network and quality standards established by the agency; and
(d) Pass a readiness review, including an
on-site visit conducted by the agency.
(3)
(a) The
agency may from time to time conduct a procurement for new apple health MCOs or
to reduce or expand the use of existing apple health MCOs.
(b) The agency may conduct a procurement when
the agency determines in its sole discretion there is a need to:
(i) Expand or reduce current MCO
contracts;
(ii) Enhance current MCO
provider networks; or
(iii)
Establish new contracts for integrated managed care in one or more regional
services areas; or
(iv) Adjust the
program to ensure adherence to state and federal law.
(c) In accordance with
RCW
74.09.522 and
74.09.871,
the agency will give significant weight to the following factors in any
procurement process:
(i) Demonstrated
commitment to, and experience in, serving low-income populations;
(ii) Demonstrated commitment to, and
experience in, serving persons who have mental illness, substance use
disorders, or co-occurring disorders;
(iii) Demonstrated commitment to, and
experience with, partnerships with county and municipal criminal justice
systems, housing services, and other critical support services necessary to
achieve the outcomes established in
RCW
70.320.020,
71.24.435,
and
71.36.025;
(iv) Recognition that meeting enrollees'
physical and behavioral health care needs is a shared responsibility of
contracted behavioral health administrative services organizations, MCOs,
service providers, the state, and communities;
(v) Consideration of past and current
performance and participation in other state or federal behavioral health
programs as a contractor;
(vi)
Quality of services provided to enrollees under previous contracts with the
state of Washington or other states;
(vii) Accessibility, including appropriate
utilization, of services offered to enrollees;
(viii) Demonstrated capability to perform
contracted services, including the ability to supply an adequate provider
network; and
(ix) The ability to
meet any other requirements established by the agency.
(d) The agency may define and consider
additional factors as part of any procurement including, but not limited to:
(i) Timely processing of, and payments to,
providers in the MCO networks, including reconciliation of outstanding
payments; and
(ii) The optimal
number of MCOs per regional services area, based on population and in the
manner that the agency determines most beneficial for the program, clients, and
providers.
(4) The agency reserves the right not to
contract with any otherwise qualified MCO.
Statutory Authority:
RCW
41.05.021, 42 C.F.R. 438. 13-02-010,
§182-538-067, filed 12/19/12, effective 2/1/13. 11-14-075, recodified as
§182-538-067, filed 6/30/11, effective 7/1/11. Statutory Authority:
RCW
74.08.090 and
74.09.522. 08-15-110, §
388-538-067, filed 7/18/08, effective 8/18/08; 06-03-081, § 388-538-067,
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, § 388-538-067, filed 12/8/04, effective
1/8/05. 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.
