Current through Register Vol. 24-18, September 15, 2024
The medicaid agency enrolls clients into integrated managed
care (IMC) based on the rules in WAC
182-538-060.
IMC is mandatory in all regional service areas.
(1)
Authority to request. The
following people may request that the agency approve an exemption or end
enrollment in managed care:
(a) A client or
enrollee;
(b) A client or
enrollee's authorized representative under WAC
182-503-0130;
or
(c) A client or enrollee's
representative as defined in
RCW
7.70.065.
(2)
Standards to exempt or end
enrollment.
(a) The agency exempts or
ends enrollment from mandatory managed care when any of the following apply:
(i) The client or enrollee is eligible for
medicare;
(ii) The client or
enrollee is not eligible for managed care enrollment, for Washington apple
health programs, or both.
(b) The agency grants a request to exempt or
to end enrollment in managed care, with the change effective the earliest
possible date given the requirements of the agency's enrollment system, when
the client or enrollee:
(i) Is American Indian
or Alaska native or is a descendant of an AI/AN client and requests not to be
in managed care;
(ii) Lives in an
area or is enrolled in a Washington apple health program in which participation
in managed care is voluntary;
(iii)
Requires care that meets the criteria in subsection (3) of this section for
case-by-case clinical exemptions or to end enrollment; or
(iv) Is a child or youth with special health
care needs as defined in WAC
182-538-050.
(3)
Case-by-case clinical
criteria. Clinical criteria for an enrollee or client to be exempted or
end enrollment in IMC.
(a) The agency may
approve a request for exemption or to end enrollment when the following
criteria are met:
(i) The care must be
medically necessary;
(ii) The
medically necessary care at issue is covered under the agency's managed care
contracts and is not a benefit under the behavioral health services only (BHSO)
program;
(iii) The client is
receiving the medically necessary care at issue from an established provider or
providers who are not available through any contracted MCO; and
(iv) It is medically necessary to continue
that care from the established provider or providers.
(b) If a client requests exemption prior to
enrollment, the client is not enrolled until the agency approves or denies the
request.
(c) If an enrollee request
to end enrollment is received after the enrollment effective date, the enrollee
remains enrolled pending the agency's decision.
(4)
Approved request.
(a) When the agency approves a request for
exemption or to end enrollment, the agency will notify the client or enrollee
of its decision by telephone or in writing.
(b) For clients who are not AI/AN, the
following rules apply:
(i) If the agency
approves the request for a limited time, the client or enrollee is notified of
the time limitation and the process for renewing the exemption.
(ii) The agency limits the period of time
based on the circumstances or how long the conditions described are expected to
exist.
(iii) The agency may
periodically review those circumstances or conditions to determine if they
continue to exist.
(iv) Any
authorized exemption will continue only until the client can be enrolled in
managed care.
(5)
BHSO.
(a) When a client is exempt from mandatory
IMC or their enrollment in the mandatory IMC program ends, the exemption is for
the physical health benefit only. The client remains enrolled in behavioral
health services only (BHSO) for the behavioral health benefit.
(b) AI/AN clients are an exception in that
they can choose to receive their behavioral health benefit on a fee-for-service
basis.
(6)
Denied
request. When the agency denies a request for exemption or to end
enrollment:
(a) The agency will notify the
client or enrollee of its decision by telephone or in writing and confirms a
telephone notification in writing.
(b) When a client or enrollee is
limited-English proficient, the written notice must be available in the
client's or enrollee's primary language under
42 C.F.R.
438.10.
(c) The written notice must contain all the
following information:
(i) The agency's
decision;
(ii) The reason for the
decision;
(iii) The specific rule
or regulation supporting the decision; and
(iv) The right to request an agency
administrative hearing.
(7)
Administrative hearing
request. If a client or enrollee does not agree with the agency's
decision regarding a request for exemption or to end enrollment, the client or
enrollee may file a request for an agency administrative hearing based on
RCW
74.09.741, the rules in this chapter, and the
agency hearing rules in chapter 182-526 WAC.
(8)
MCO request. The agency will
grant a request from an MCO to end enrollment of an enrollee when the request
is submitted to the agency in writing and includes sufficient documentation for
the agency to determine that the criteria to end enrollment in this subsection
is met.
(a) All of the following criteria
must be met to end enrollment:
(i) The
enrollee puts the safety or property of the contractor or the contractor's
staff, providers, patients, or visitors at risk and the enrollee's conduct
presents the threat of imminent harm to others, except for enrollees described
in (c) of this subsection;
(ii) A
clinically appropriate evaluation was conducted to determine whether there was
a treatable problem contributing to the enrollee's behavior and there was not a
treatable problem or the enrollee refused to participate;
(iii) The enrollee's health care needs have
been coordinated as contractually required and the safety concerns cannot be
addressed; and
(iv) The enrollee
has received written notice from the MCO of its intent to request to end
enrollment of the enrollee, unless the requirement for notification has been
waived by the agency because the enrollee's conduct presents the threat of
imminent harm to others. The MCO's notice to the enrollee includes the
enrollee's right to use the MCO's grievance process to review the request to
end enrollment.
(b) The
agency will not approve a request to end enrollment when the request is solely
due to any of the following:
(i) An adverse
change in the enrollee's health status;
(ii) The cost of meeting the enrollee's
health care needs or because of the enrollee's utilization of
services;
(iii) The enrollee's
diminished mental capacity; or
(iv)
Uncooperative or disruptive behavior resulting from the enrollee's special
needs or behavioral health condition, except when continued enrollment in the
MCO or PCCM seriously impairs the entity's ability to furnish services to
either this particular enrollee or other enrollees.
(c) The agency will not approve a request to
end enrollment of an enrollee's behavioral health services. The agency may
determine to transition the enrollee to behavioral health services only
(BHSO).
(d) When the agency
receives a request from an MCO to end enrollment of an enrollee, the agency
reviews each request on a case-by-case basis. The agency will respond to the
MCO in writing with the decision. If the agency grants the request to end
enrollment:
(i) The MCO will notify the
enrollee in writing of the decision. The notice must include:
(A) The enrollee's right to use the MCO's
grievance system as described in WAC
182-538-110;
and
(B) The enrollee's right to use
the agency's hearing process (see WAC
182-526-0200
for the hearing process for enrollees).
(ii) The agency will send a written notice to
the enrollee at least 10 calendar days in advance of the effective date that
enrollment will end. The notice to the enrollee includes the information in
subsection (3)(c) of this section.
(e) The MCO will continue to provide services
to the enrollee until the date the person is no longer enrolled.
(f) The agency may exempt the client for the
period of time the circumstances are expected to exist. The agency may
periodically review those circumstances to determine if they continue to exist.
Any authorized exemption will continue only until the client can be enrolled in
IMC.
Statutory Authority:
RCW
41.05.021, 42 C.F.R. 438. 13-02-010,
§182-538-130, filed 12/19/12, effective 2/1/13. 11-14-075, recodified as
§182-538-130, filed 6/30/11, effective 7/1/11. Statutory Authority:
RCW
74.08.090 and
74.09.522. 08-15-110, §
388-538-130, filed 7/18/08, effective 8/18/08; 06-03-081, § 388-538-130,
filed 1/12/06, effective 2/12/06; 03-18-111, § 388-538-130, 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, § 388-538-130, 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, § 388-538-130, 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, §
388-538-130, 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), § 388-538-130, filed 8/29/95, effective 9/1/95. Statutory
Authority:
RCW
74.08.090. 93-17-039 (Order 3621), §
388-538-130, filed 8/11/93, effective
9/11/93.
