Current through Register Vol. 24-18, September 15, 2024
(1)
Involuntary disenrollment for
health and safety concerns. If a qualified health home or care
coordinator believes there are unresolved health or safety concerns with a
health home client, the medicaid agency reviews the health home's written
request for involuntary disenrollment of the client from the health home
program.
(a) Concerns about health and safety
include, but are not limited to:
(i)
Inappropriate or threatening behavior, such as inappropriate sexual or physical
behavior;
(ii) Illegal or criminal
activity;
(iii) Harassment;
or
(iv) Environmental hazards, such
as methamphetamine laboratories, dangerous animals, poor sanitation, or an
unsafe home structure.
(b) The agency does not approve requests to
end enrollment that are solely due to uncooperative or disruptive behavior
resulting from a client's special needs, disability, or behavioral health
condition, except when continued enrollment in the health home seriously
impairs the health home's ability to furnish services to the client or other
clients.
(c) Health homes
requesting disenrollment must provide a client's assessment with any reasonable
modifications attempted or made of policies, practices, procedures, or the
provision of auxiliary aids or services, based on available evidence, in light
of a client's special needs, disability, or behavioral health
condition.
(d) A client's
involuntary disenrollment is for one year, beginning on the first day of the
month following the date on the notice of involuntary disenrollment.
(2)
Disenrollment
request. The agency grants a request from a qualified health home to
involuntarily disenroll a client when the request is submitted to the agency in
writing and includes documentation for the agency to determine that the
criteria under subsection (1) of this section is met.
(3)
Client notification and appeal
rights. The agency notifies the qualified health home of the agency's
decision within ten business days. If the request is approved, the agency sends
a written notice of involuntary disenrollment to the client. The notice
includes:
(a) The client's administrative
hearing rights as described in chapter 182-526 WAC;
(b) The specific factual basis for
disenrolling the client;
(c) The
applicable provision under subsection (1) of this section, and any other
applicable rule on which the disenrollment is based; and
(d) Any other information required by WAC
182-5180005.
(4)
Reenrollment. The agency may reenroll a client with a qualified
health home within one year if:
(a) All of the
concerns that led to the involuntary disenrollment are resolved; and
(b) The client continues to meet the health
home eligibility criteria in this chapter.
