exv10w2



 




Exhibit
10.2



DEPARTMENT OF SOCIAL AND HEALTH SERVICES




2008 — 2009 CONTRACT




FOR




HEALTHY OPTIONS




AND




STATE CHILDREN’S HEALTH

INSURANCE PLAN




APPROVED AS TO FORM BY THE ATTORNEY GENERAL’S OFFICE





 









 








TABLE OF CONTENTS




	 	 	 	 	 	 	 
	 	 	 	 	 	 	Page
	1. GENERAL TERMS AND CONDITIONS	 	1
	 
	 	1.1	 	Central Contract Services	 	1
	 
	 	1.2	 	Confidential Information	 	1
	 
	 	1.3	 	Contract	 	1
	 
	 	1.4	 	Contracts Administrator	 	1
	 
	 	1.5	 	Contractor	 	1
	 
	 	1.6	 	Debarment	 	1
	 
	 	1.7	 	DSHS or the Department	 	1
	 
	 	1.8	 	Encrypt	 	1
	 
	 	1.9	 	Hardened Password	 	1
	 
	 	1.10	 	Personal Information	 	1
	 
	 	1.11	 	Physically Secure	 	2
	 
	 	1.12	 	RCW	 	2
	 
	 	1.13	 	Regulation	 	2
	 
	 	1.14	 	Secured Area	 	2
	 
	 	1.15	 	Subcontract	 	2
	 
	 	1.16	 	Subrecipient	 	2
	 
	 	1.17	 	Tracking	 	2
	 
	 	1.18	 	Transport	 	2
	 
	 	1.19	 	Trusted Systems	 	2
	 
	 	1.20	 	Unique User ID	 	3
	 
	 	1.21	 	WAC	 	3
	 
	 	1.22	 	Amendment	 	3
	 
	 	1.23	 	Assignment	 	3
	 
	 	1.24	 	WAC	 	3
	 
	 	1.25	 	Compliance with Applicable Law	 	3
	 
	 	1.26	 	Confidentiality	 	5
	 
	 	1.27	 	Debarment Certification	 	6
	 
	 	1.28	 	Disputes	 	7
	 
	 	1.29	 	Force Majeure	 	7
	 
	 	1.30	 	Governing Law and Venue	 	8
	 
	 	1.31	 	Independent Contractor	 	8
	 
	 	1.32	 	Insolvency	 	8
	 
	 	1.33	 	Inspection	 	8
	 
	 	1.34	 	Insurance	 	9
	 
	 	1.35	 	Maintenance of Records	 	10
	 
	 	1.36	 	Order of Precedence	 	11
	 
	 	1.37	 	Severability	 	11
	 
	 	1.38	 	Survivability	 	11
	 
	 	1.39	 	Waiver	 	12
	2. ADDITIONAL GENERAL TERMS & CONDITIONS–CLIENT SERVICE CONTRACTS	 	12
	 
	 	2.1	 	Contractor Certification Regarding Ethics	 	12
	 
	 	2.2	 	Health and Safety	 	12






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	 	2.3	 	Indemnification and Hold Harmless	 	12
	 
	 	2.4	 	Industrial Insurance Coverage	 	12
	 
	 	2.5	 	No Federal or State Endorsement	 	12
	 
	 	2.6	 	Notices	 	13
	 
	 	2.7	 	Notification of Organizational Changes	 	13
	 
	 	2.8	 	Notice of Overpayment	 	13
	 
	 	2.9	 	Ownership of Material	 	14
	 
	 	2.10	 	Solvency	 	14
	 
	 	2.11	 	State Conflict of Interest Safeguards	 	15
	 
	 	2.12	 	Subrecipients	 	15
	 
	 	2.13	 	Termination for Convenience	 	16
	 
	 	2.14	 	Termination by the Contractor for Default	 	18
	 
	 	2.15	 	Termination by DSHS for Default	 	18
	 
	 	2.16	 	Termination - Information on Outstanding Claims	 	18
	 
	 	2.17	 	Terminations - Pre-termination Processes	 	18
	 
	 	2.18	 	Treatment of Client Property	 	19
	 
	 	2.19	 	Treatment of Property	 	19
	3. DEFINITIONS	 	19
	 
	 	3.1	 	Action	 	19
	 
	 	3.2	 	Actuarially Sound Capitation Rates	 	19
	 
	 	3.3	 	Advance Directive	 	20
	 
	 	3.4	 	Ancillary Services	 	20
	 
	 	3.5	 	Appeal	 	20
	 
	 	3.6	 	Appeal Process	 	20
	 
	 	3.7	 	Children With Special Health Care Needs	 	20
	 
	 	3.8	 	Cold Call Marketing	 	20
	 
	 	3.9	 	Comparable Coverage	 	20
	 
	 	3.10	 	Consumer Assessment of Health Plans Survey (CAHPS®)	 	20
	 
	 	3.11	 	Continuity of Care	 	20
	 
	 	3.12	 	Coordination of Care	 	20
	 
	 	3.13	 	Covered Services	 	21
	 
	 	3.14	 	Duplicate Coverage	 	21
	 
	 	3.15	 	EPSDT	 	21
	 
	 	3.16	 	Eligible Clients	 	21
	 
	 	3.17	 	Emergency Medical Condition	 	21
	 
	 	3.18	 	Emergency Services	 	21
	 
	 	3.19	 	Enrollee	 	21
	 
	 	3.20	 	Enrollee with Special Health Care Needs	 	21
	 
	 	3.21	 	External Quality Review (EQR)	 	21
	 
	 	3.22	 	External Quality Review Organization (EQRO)	 	22
	 
	 	3.23	 	External Quality Review Protocols	 	22
	 
	 	3.24	 	External Quality Review Report - (EQRR)	 	22
	 
	 	3.25	 	Grievance	 	22
	 
	 	3.26	 	Grievance Process	 	22
	 
	 	3.27	 	Grievance System	 	22
	 
	 	3.28	 	Health Care Professional	 	22






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	 	3.29	 	Health Employer Data and Information Set - (HEDIS®)	 	22
	 
	 	3.30	 	Health Employer Data and Information Set (HEDIS®) Compliance Audit Program	 	23
	 
	 	3.31	 	Managed Care	 	23
	 
	 	3.32	 	Managed Care Organization (MCO)	 	23
	 
	 	3.33	 	Marketing	 	23
	 
	 	3.34	 	Marketing Materials	 	23
	 
	 	3.35	 	Medically Necessary Services	 	23
	 
	 	3.36	 	National CAHPS® Benchmarking Database - (NCBD)	 	23
	 
	 	3.37	 	National Committee for Quality Assurance - (NCQA)	 	23
	 
	 	3.38	 	Participating Provider	 	24
	 
	 	3.39	 	Peer-Reviewed Medical Literature	 	24
	 
	 	3.40	 	Physician Group	 	24
	 
	 	3.41	 	Physician Incentive Plan	 	24
	 
	 	3.42	 	Post-stabilization Services	 	24
	 
	 	3.43	 	Potential Enrollee	 	24
	 
	 	3.44	 	Primary Care Provider (PCP)	 	24
	 
	 	3.45	 	Quality	 	24
	 
	 	3.46	 	Risk	 	25
	 
	 	3.47	 	Service Areas	 	25
	 
	 	3.48	 	State Children’s Health Insurance Program (SCHIP)	 	25
	 
	 	3.49	 	Substantial Financial Risk	 	25
	 
	 	3.50	 	Validation	 	25
	4. ENROLLMENT	 	25
	 
	 	4.1	 	Service Areas	 	26
	 
	 	4.2	 	Eligible Client Groups	 	27
	 
	 	4.3	 	Client Notification	 	27
	 
	 	4.4	 	Exemption from Enrollment	 	27
	 
	 	4.5	 	Enrollment Period	 	27
	 
	 	4.6	 	Enrollment Process	 	27
	 
	 	4.7	 	Effective Date of Enrollment	 	28
	 
	 	4.8	 	Enrollment Listing and
Requirements for Contractor’s Response	 	29
	 
	 	4.9	 	Termination of Enrollment	 	30
	 
	 	4.10	 	Enrollment Not Discriminatory	 	33
	5. MARKETING AND INFORMATION REQUIREMENTS	 	34
	 
	 	5.1	 	Marketing	 	34
	 
	 	5.2	 	Information Requirements for Enrollees and Potential Enrollees	 	35
	 
	 	5.3	 	Equal Access for Enrollees & Potential Enrollees with Communication Barriers	 	38
	6. PAYMENT AND SANCTIONS	 	41
	 
	 	6.1	 	Rates/Premiums	 	41
	 
	 	6.2	 	Delivery Case Rate Payment	 	43
	 
	 	6.3	 	Renegotiation of Rates	 	43
	 
	 	6.4	 	Reinsurance/Risk Protection	 	43
	 
	 	6.5	 	Recoupments	 	43
	 
	 	6.6	 	Information for Rate Setting	 	44
	 
	 	6.7	 	Payments to Critical Access Hospitals (CAH)	 	44
	 
	 	6.8	 	Stop Loss for Hemophiliac Drugs	 	44






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	 	6.9	 	Encounter Data	 	44
	 
	 	6.10	 	Emergency Services by Non-Contracted Providers	 	45
	 
	 	6.11	 	Data Certification Requirements	 	45
	 
	 	6.12	 	Sanctions	 	45
	7. ACCESS AND CAPACITY	 	48
	 
	 	7.1	 	Access and Capacity Policy and Procedure Requirements	 	48
	 
	 	7.2	 	Network Capacity	 	48
	 
	 	7.3	 	Service Delivery Network	 	48
	 
	 	7.4	 	Timely Access to Care	 	49
	 
	 	7.5	 	Hours of Operation for Network Providers	 	49
	 
	 	7.6	 	24/7 Availability	 	49
	 
	 	7.7	 	Appointment Standards	 	50
	 
	 	7.8	 	Integrated Provider Network Database (IPND)	 	50
	 
	 	7.9	 	Provider Network-Distance Standards	 	50
	 
	 	7.10	 	Distance Standards for High Volume Specialty Care Providers	 	52
	 
	 	7.11	 	Standards for Specialty and Primary Care Providers	 	52
	 
	 	7.12	 	Access to Specialty Care	 	52
	 
	 	7.13	 	Capacity Limits and Order of Acceptance	 	52
	 
	 	7.14	 	Assignment of Enrollees	 	53
	 
	 	7.15	 	Provider Network Changes	 	54
	8. QUALITY OF CARE	 	54
	 
	 	8.1	 	Quality Assessment and Performance Improvement (QAPI) Program	 	54
	 
	 	8.2	 	Performance Improvement Projects	 	56
	 
	 	8.3	 	Performance Measures using Health Employer Data & Information Set (HEDIS®)	 	58
	 
	 	8.4	 	Consumer Assessment of Health Plans Survey (CAHPS®)	 	60
	 
	 	8.5	 	External Quality Review	 	62
	 
	 	8.6	 	Enrollee Mortality	 	64
	 
	 	8.7	 	Practice Guidelines	 	64
	 
	 	8.8	 	Drug Formulary Review and Approval	 	65
	 
	 	8.9	 	Health Information Systems	 	65
	 
	 	8.10	 	Technical Assistance	 	65
	9. POLICIES AND PROCEDURES	 	66
	10. SUBCONTRACTS	 	68
	 
	 	10.1	 	Subcontracts Policy and Procedure Requirements	 	68
	 
	 	10.2	 	Contractor Remains Legally Responsible	 	68
	 
	 	10.3	 	Solvency Requirements for Subcontractors	 	68
	 
	 	10.4	 	Provider Nondiscrimination	 	69
	 
	 	10.5	 	Required Provisions	 	69
	 
	 	10.6	 	Health Care Provider Subcontracts	 	70
	 
	 	10.7	 	Health Care Provider Subcontracts Delegating Administrative Functions	 	72
	 
	 	10.8	 	Excluded Providers	 	73
	 
	 	10.9	 	Home Health Providers	 	73
	 
	 	10.10	 	Physician Incentive Plans	 	74
	 
	 	10.11	 	Payment to FQHCs/RHCs	 	76
	 
	 	10.12	 	Provider Education	 	76
	 
	 	10.13	 	Claims Payment Standards	 	76






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	 	10.14	 	FQHC/RHC Report	 	77
	 
	 	10.15	 	Provider Credentialing	 	77
	11. ENROLLEE RIGHTS AND PROTECTIONS	 	79
	 
	 	11.1	 	General Requirements	 	79
	 
	 	11.2	 	Cultural Considerations	 	80
	 
	 	11.3	 	Advance Directives	 	80
	 
	 	11.4	 	Enrollee Choice of PCP	 	81
	 
	 	11.5	 	Direct Access for Enrollees with Special Health Care Needs	 	82
	 
	 	11.6	 	Prohibition on Enrollee Charges for Covered Services	 	82
	 
	 	11.7	 	Provider/Enrollee Communication	 	82
	 
	 	11.8	 	Enrollee Self-Determination	 	83
	12. UTILIZATION MANAGEMENT PROGRAM AND AUTHORIZATION OF SERVICES	 	83
	 
	 	12.1	 	Utilization Management Program	 	83
	 
	 	12.2	 	Authorization of Services	 	85
	 
	 	12.3	 	Fraud and Abuse Requirements–Policies and Procedures	 	88
	13. GRIEVANCE SYSTEM	 	89
	 
	 	13.1	 	General Requirements	 	89
	 
	 	13.2	 	Grievance Process	 	90
	 
	 	13.3	 	Appeal Process	 	91
	 
	 	13.4	 	Expedited Appeal Process	 	93
	 
	 	13.5	 	Hearings	 	93
	 
	 	13.6	 	Independent Review	 	94
	 
	 	13.7	 	Board of Appeals	 	94
	 
	 	13.8	 	Continuation of Services	 	94
	 
	 	13.9	 	Effect of Reversed Resolutions of Appeals and Fair Hearings	 	96
	 
	 	13.10	 	Actions, Grievances, Appeals and Independent Reviews	 	96
	14. BENEFITS	 	97
	 
	 	14.1	 	Scope of Services	 	97
	 
	 	14.2	 	Medical Necessity Determination	 	99
	 
	 	14.3	 	Enrollee Self-Referral	 	99
	 
	 	14.4	 	Women's Health Care Services	 	100
	 
	 	14.5	 	Maternity Newborn Length of Stay	 	100
	 
	 	14.6	 	Continuity of Care	 	100
	 
	 	14.7	 	Coordination of Care	 	101
	 
	 	14.8	 	Second Opinions	 	102
	 
	 	14.9	 	Sterilizations and Hysterectomies	 	103
	 
	 	14.10	 	Experimental and Investigational Services	 	103
	 
	 	14.11	 	Enrollee Hospitalized at Enrollment	 	104
	 
	 	14.12	 	Enrollee Hospitalized at Disenrollment	 	105
	 
	 	14.13	 	General Description of Covered Services	 	105
	 
	 	14.14	 	Exclusions	 	113
	 
	 	14.15	 	Coordination of Benefits and Subrogation of Rights of Third Party Liability	 	116
	 
	 	14.16	 	Patient Review and Restriction (PRR)	 	117
	Attachment A	 	Schedule of Events and Website References	 	 
	Exhibit A	 	Premiums, Service Areas and Capacity	 	 











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2008
—  2009 HO & SCHIP Contract 



	1.	 	GENERAL TERMS AND CONDITIONS
	 
	 	 	The words and phrases listed below, as used in this Contract, shall each have the following
definitions:






	 	1.1	 	Central Contract Servicesmeans the DSHS central headquarters contracting
office, or successor section or office.
	 
	 	1.2	 	Confidential Information means information that is exempt from disclosure to
the public or other unauthorized persons under Chapter 42.56 RCW or other federal or
state law. Confidential Information includes, but is not limited to, Personal
Information.
	 
	 	1.3	 	Contract means the entire written agreement between DSHS and the Contractor,
including any Exhibits, documents, and materials incorporated by reference.
	 
	 	1.4	 	Contracts Administrator means the manager, or successor, of Central Contract
Services or successor section or office.
	 
	 	1.5	 	Contractor means the individual or entity performing services pursuant to this
Contract and includes the Contractor’s owners, members, officers, directors, partners,
employees, and/or agents, unless otherwise stated in this Contract. For purposes of
any permitted Subcontract, “Contractor” includes any Subcontractor and its owners,
members, officers, directors, partners, employees, and/or agents.
	 
	 	1.6	 	Debarment means an action taken by a Federal official to exclude a person or
business entity from participating in transactions involving certain federal funds.
	 
	 	1.7	 	DSHS or the Department means the state of Washington Department of Social and
Health Services and its employees and authorized agents.
	 
	 	1.8	 	Encrypt means to encipher or encode electronic data using software that
generates a minimum key length of 128 bits.
	 
	 	1.9	 	Hardened Password means a string of at least eight characters containing at
least one alphabetic character, at least one number and at least one special character
such as an asterisk, ampersand or exclamation point.
	 
	 	1.10	 	Personal Information means information identifiable to any person, including,
but not limited to, information that relates to a person’s name, health, finances,
education, business, use or receipt of governmental services or other activities,
addresses, telephone numbers, Social Security Numbers, driver license numbers, other
identifying numbers, and any financial identifiers.




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	 	1.11	 	Physically Secure means that access is restricted through physical means to
authorized individuals only.
	 
	 	1.12	 	RCW means the Revised Code of Washington. All references in this Contract to
RCW chapters or sections shall include any successor, amended, or replacement statute.
Pertinent RCW chapters can be accessed at http://slc.leg.wa.gov/.
	 
	 	1.13	 	Regulation means any federal, state, or local regulation, rule, or ordinance.
	 
	 	1.14	 	Secured Area means an area to which only authorized representatives of the
entity possessing the Confidential Information have access. Secured Areas may include
buildings, rooms or locked storage containers (such as a filing cabinet) within a room,
as long as access to the Confidential Information is not available to unauthorized
personnel.
	 
	 	1.15	 	Subcontract means any separate agreement or contract between the Contractor and
an individual or entity (“Subcontractor”) to perform all or a portion of the duties and
obligations that the Contractor is obligated to perform pursuant to this Contract.
	 
	 	1.16	 	Subrecipient means a non-federal entity that expends federal awards received
from a pass-through entity to carry out a federal program, but does not include an
individual that is a beneficiary of such a program. A subrecipient may also be a
recipient of other federal awards directly from a federal awarding agency.
	 
	 	1.17	 	Tracking means a record keeping system that identifies when the sender begins
delivery of Confidential Information to the authorized and intended recipient, and when
the sender receives confirmation of delivery from the authorized and intended recipient
of Confidential Information.
	 
	 	1.18	 	Transport means the movement of Confidential Information from one entity to
another, or within an entity, that:






	 	1.18.1	 	Places the Confidential Information outside of a Secured Area or system (such as a
local area network), and
	 
	 	1.18.2	 	Is accomplished other than via a Trusted System.






	 	1.19	 	Trusted Systems include only the following methods of physical delivery:






	 	1.19.1	 	Hand-delivery by a person authorized to have access to the Confidential
Information with written acknowledgement of receipt, and
	 
	 	1.19.2	 	United States Postal Service (“USPS”) delivery services that include Tracking,
such as Certified Mail, Express Mail or Registered Mail.




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	 	1.19.3	 	Any other method of physical delivery will not be deemed a Trusted System.






	 	1.20	 	Unique User ID means a string of characters that identifies a specific user and
which, in conjunction with a password, passphrase or other mechanism, authenticates a
user to an information system.
	 
	 	1.21	 	WAC means the Washington Administrative Code. All references in this Contract
to WAC chapters or sections shall include any successor, amended, or replacement
regulation. Pertinent WAC chapters or sections can be accessed at
http://slc.leg.wa.gov/.
	 
	 	1.22	 	Amendment: This Agreement may only be modified by a written amendment signed by
both parties. Only personnel authorized to bind each of the parties may sign an
amendment.
	 
	 	1.23	 	Assignment: The Contractor shall not assign this Agreement or Program Agreement
to a third party without the prior written consent of DSHS.
	 
	 	1.24	 	Billing Limitations:






	 	1.24.1	 	DSHS shall pay the Contractor only for services provided in accordance with this
Contract.
	 
	 	1.24.2	 	DSHS shall not pay any claims for payment for services submitted more than twelve
(12) months after the calendar month in which the services were performed.
	 
	 	1.24.3	 	The Contractor shall not bill and DSHS shall not pay for services performed under
this Contract, if the Contractor has charged or will charge another agency of the
state of Washington or any other party for the same services.






	 	1.25	 	Compliance with Applicable Law: In the provision of services under this
Contract, the Contractor and its subcontractors shall comply with all applicable federal, state
and local laws and regulations, and all amendments thereto, that are in effect when
the Contract is signed or that come into effect during the term of this Contract
(42 CFR 438.6(f)(1) and 438.100(d)). This includes, but is not limited to:






	 	1.25.1	 	Title XIX and Title XXI of the Social Security Act;
	 
	 	1.25.2	 	Title VI of the Civil Rights Act of 1964;
	 
	 	1.25.3	 	Title IX of the Education Amendments of 1972, regarding any education programs and
activities;
	 
	 	1.25.4	 	The Age Discrimination Act of 1975;




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	 	1.25.5	 	The Rehabilitation Act of 1973;
	 
	 	1.25.6	 	The Budget Deficit Reduction Act of 2005
	 
	 	1.25.7	 	The False Claim Act
	 
	 	1.25.8	 	All federal and state professional and facility licensing and accreditation
requirements/standards that apply to services performed under the terms of this
Contract, including but not limited to:






	 	1.25.8.1	 	All applicable standards, orders, or requirements issued under Section 306
of the Clean Water Act (33 US 1368), Executive Order 11738, and Environmental
Protection Agency (EPA) regulations (40 CFR Part 15), which prohibit the use of
facilities included on the EPA List of Violating Facilities. Any violations
shall be reported to DSHS, DHHS, and the EPA.
	 
	 	1.25.8.2	 	Any applicable mandatory standards and policies relating to energy
efficiency that are contained in the State Energy Conservation Plan, issued in
compliance with the Federal Energy Policy and Conservation Act.
	 
	 	1.25.8.3	 	Those specified for laboratory services in the Clinical Laboratory
Improvement Amendments (CLIA).
	 
	 	1.25.8.4	 	Those specified in Title 18 RCW for professional licensing.
	 
	 	1.25.8.5	 	Industrial Insurance — Title 51 RCW.
	 
	 	1.25.8.6	 	Reporting of abuse as required by RCW 26.44.030.
	 
	 	1.25.8.7	 	Federal Drug and Alcohol Confidentiality Laws in 42 CFR Part 2.
	 
	 	1.25.8.8	 	EEO Provisions.
	 
	 	1.25.8.9	 	Copeland Anti-Kickback Act.
	 
	 	1.25.8.10	 	Davis-Bacon Act.
	 
	 	1.25.8.11	 	Byrd Anti-Lobbying Amendment.
	 
	 	1.25.8.12	 	All federal and state nondiscrimination laws and regulations.
	 
	 	1.25.8.13	 	Americans with Disabilities Act: The Contractor shall make reasonable
accommodation for enrollees with disabilities, in accord with the Americans with
Disabilities Act, for all covered services and shall assure physical and
communication barriers




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	 	 	 	shall not inhibit enrollees with disabilities from obtaining covered services.
	 
	 	1.25.8.14	 	Any other requirements associated with the receipt of federal funds.






	 	1.26	 	Confidentiality: The Contractor shall not use, publish, transfer, sell or
otherwise disclose any, including but not limited to medical records, Confidential
Information gained by reason of this Contract for any purpose that is not directly
connected with Contractor’s performance of the services contemplated hereunder, except:
	 
	 	 	 	As provided by law; or In the case of Personal Information, with the prior written
consent of the person to whom the Personal Information pertains or their legal
guardian.






	 	1.26.1	 	The Contractor and DSHS agree to share Personal Information regarding enrollees in
a manner that complies with applicable state and federal law protecting
confidentiality of such information (including but not limited to the Health
Insurance Portability and Accountability Act (HIPAA) of 1996, codified at 42 USC
1320(d) et.seq. and 45 CFR parts 160, 162, and 164., the HIPAA regulations, 42 CFR
431 Subpart F, 42 CFR 438.224, RCW 5.60.060(4), and RCW 70.02). The Contractor and
the Contractor’s subcontractors shall fully cooperate with DSHS efforts to implement
HIPAA requirements.
	 
	 	1.26.2	 	The Contractor shall protect and maintain all Confidential Information gained by
reason of this Contract against unauthorized use, access, disclosure, modification
or loss. This duty requires that Contractor to employ reasonable security measures,
which include restricting access to the Confidential Information by:
	 
	 	1.26.3	 	Encrypting electronic Confidential Information during Transport;
	 
	 	1.26.4	 	Physically Securing and Tracking media containing Confidential Information during
Transport;
	 
	 	1.26.5	 	Limiting access to staff that have an authorized business requirement to view the
Confidential Information;
	 
	 	1.26.6	 	Using access lists, Unique User ID and Hardened Password authentication to protect
Confidential Information;
	 
	 	1.26.7	 	Physically Securing any computers, documents or other media containing the
Confidential Information; and
	 
	 	1.26.8	 	Encrypting all Confidential Information that is stored on portable devices
including but not limited to laptop computers and flash memory devices;




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	 	1.26.9	 	Upon request by DSHS the Contractor shall return the Confidential Information or
certify in writing that the Contractor employed a DSHS approved method to destroy
the information. Contractor may obtain information regarding approved destruction
methods from the DSHS contact identified on page one of this Contract.
	 
	 	1.26.10	 	In the event of a theft, loss, unauthorized disclosure, or other potential or
known compromise of Confidential Information, the Contractor shall notify DSHS in
writing, as described in accord with the Notices section of the General Terms and
Conditions, within one (1) business day of the discovery of the event. Contractor
must also take actions to mitigate the risk of loss and comply with any notification
or other requirement imposed by law.






	 	1.27	 	Debarment Certification: The Contractor, by signature to this contract,
certifies that the Contractor is not presently debarred, suspended, proposed for
debarment, declared ineligible, or voluntarily excluded by any Federal department or
agency from participating in transactions. The Contractor also agrees to include the
above requirement in any and all subcontracts into which it enters.
	 
	 	 	 	The Contractor certifies that it does not knowingly have a director, officer,
partner, or anyone with a beneficial ownership of more than five percent (5%) of
the Contractor’s equity, or have an employee, consultant or subcontractor who is
significant or material to the provision of services under this Contract, who has
been, or is affiliated with someone who has been debarred, suspended, or otherwise
excluded by any federal agency (SSA 1932(d)(1)). A list of debarred, suspended or
otherwise excluded parties is available on the following Internet website:
www.arnet.gov/epls.






	 	1.27.1	 	The Contractor is not required to consult the excluded parties list, but may
instead rely on certification from directors, officers, partners, employees,
contractors, or persons with beneficial ownership of more than five percent (5%) of the Contractor’s equity, that they are not debarred
or excluded from a federal program.
	 
	 	1.27.2	 	The Contractor is required to notify DSHS in writing, as described in the Notices
section of the General Terms and Conditions, , when circumstances change that affect
such certifications referenced in this Section.
	 
	 	1.27.3	 	The Contractor shall provide to DSHS in writing, as described in the Notices
section of the General Terms and Conditions, a list of persons with a beneficial
ownership of more than five percent (5%) of the Contractor’s equity no later than
February 28 of each year of this Contract. If no person has a beneficial ownership
of more than five percent (5%) of the Contractor’s equity, the Contractor shall so
notify DSHS.




6









 







	 	 	 	
DSHS.







	 	1.28	 	Disputes: When a dispute arises over an issue that pertains in any way to this
Contract, the parties agree to the following process to address the dispute:






	 	1.28.1	 	The Contractor and DSHS shall attempt to resolve the dispute through informal
means between the Contractor and the Office Chief of the DSHS, Division of
Healthcare Services, Office of Quality and Care Management.
	 
	 	1.28.2	 	If the Contractor or DSHS is not satisfied with the outcome of the resolution with
the Office Chief, the Contractor may submit the disputed issue in writing, for
review, within ten (10) working days of the outcome to:




Director

Department of Social and Health Services

Division of Healthcare Services

P.O. Box 45502

Olympia, WA 98504-5502





	 	 	 	The Director may request additional information from the Office Chief and/or
the Contractor. The Director shall issue a written review decision to the
Contractor within thirty (30) calendar days of receipt of all information
relevant to the issue. The review decision will be provided to the Contractor
as described in the Notices section of the General Terms and Conditions.






	 	1.28.3	 	When the Contractor disagrees with the review decision of the Director, the
Contractor may request independent mediation of the dispute. DSHS shall be bound by
the decision of the Director if the Contractor is satisfied with the decision. The
request for mediation must be submitted to the Director, in writing, within ten (10)
working days of the contractor’s receipt of the Director’s review decision. The Contractor and DSHS shall
mutually agree on the selection of the independent mediator and shall bear all
costs associated with mediation equally. The results of mediation shall not
be binding on either party.
	 
	 	1.28.4	 	Both parties agree to make their best efforts to resolve disputes arising from
this Contract and agree that the dispute resolution process described herein shall
precede any court action. This dispute resolution process is the sole
administrative remedy available under this Contract.






	 	1.29	 	Force Majeure: If the Contractor is prevented from performing any of its
obligations hereunder in whole or in part as a result of a major epidemic, act of God,
war, civil disturbance, court order or any other cause beyond its control, such
nonperformance shall not be a ground for termination for




7









 






	 	 	 	default. Immediately upon the occurrence of any such event, the Contractor shall commence to use its best efforts to
provide, directly or indirectly, alternative and, to the extent practicable, comparable
performance. Nothing in this Section shall be construed to prevent DSHS from
terminating this Contract for reasons other than for default during the period of
events set forth above, or for default, if such default occurred prior to such event.
	 
	 	1.30	 	Governing Law and Venue: This contract shall be construed and interpreted in
accordance with the laws of the state of Washington and the venue of any action brought
hereunder shall be in Superior Court for Thurston County. In the event that an action
is removed to U.S. District Court, venue shall be in the Western District of
Washington.
	 
	 	1.31	 	Independent Contractor: The parties intend that an independent contractor
relationship will be created by this contract. The Contractor and its employees or
agents performing under this contract are not employees or agents of the Department.
The Contractor, its employees, or agents performing under this contract will not hold
himself/herself out as, nor claim to be, an officer or employee of the Department by
reason hereof, nor will the Contractor, its employees, or agent make any claim of
right, privilege or benefit that would accrue to such employee. The Contractor
acknowledges and certifies that neither DSHS nor the State of Washington are guarantors
of any obligations or debts of the Contractor.
	 
	 	1.32	 	Insolvency:






	 	1.32.1	 	If the Contractor becomes insolvent during the term of this Contract:






	 	1.32.1.1	 	The State of Washington and enrollees shall not be in any manner liable for
the debts and obligations of the Contractor (42 CFR 438.106(a) and
438.116(a)(1));
	 
	 	1.32.1.2	 	In accord with the Prohibition on Enrollee Charges for Covered Services
provisions of the Enrollee Rights and Protections Section of this Contract,
under no circumstances shall the Contractor, or any providers used to deliver
services covered under the terms of this Contract, charge enrollees for covered
services (42 CFR 438.106(b)(1))).
	 
	 	1.32.1.3	 	The Contractor shall, in accord with RCW 48.44.055, or RCW 48.46.245,
provide for the continuity of care for enrollees.






	 	1.33	 	Inspection: The Contractor and its subcontractors shall cooperate with audits
performed by duly authorized representatives of the State of Washington, the federal
Department of Health and Human Services, auditors from the federal Government
Accountability Office, federal Office of the Inspector General and federal Office of
Management and Budget. With reasonable notice, generally thirty (30) calendar days,
the Contractor and its





8









 






	 	 	 	subcontractors shall provide access to its facilities and the
records pertinent to this Contract to monitor and evaluate performance under this
Contract, including, but not limited to, the quality, cost, use, health and safety and
timeliness of services, and assessment of the Contractor’s capacity to bear the
potential financial losses. The Contractor and its subcontractors shall provide immediate access to facilities and records pertinent to this Contract for Medicaid
fraud investigators (42 CFR 438.6(g)).
	 
	 	1.34	 	Insurance: The Contractor shall at all times comply with the following
insurance requirements:






	 	1.34.1	 	Commercial General Liability Insurance (CGL): The Contractor shall maintain CGL
insurance, including coverage for bodily injury, property damage, and contractual
liability, with the following minimum limits: Each Occurrence — $1,000,000; General
Aggregate — $2,000,000. The policy shall include liability arising out of premises,
operations, independent contractors, products-completed operations, personal injury,
advertising injury, and liability assumed under an insured contract. The State of
Washington, DSHS, its elected and appointed officials, agents, and employees shall
be named as additional insureds expressly for, and limited to, Contractor’s services
provided under this Contract.
	 
	 	1.34.2	 	Professional Liability Insurance (PL): The Contractor shall maintain Professional
Liability Insurance, including coverage for losses caused by errors and omissions,
with the following minimum limits: Each Occurrence — $1,000,000; General Aggregate
 — $2,000,000.
	 
	 	1.34.3	 	Worker’s Compensation: The Contractor shall comply with all applicable worker’s
compensation, occupational disease, and occupational health and safety laws and regulations. The State of Washington
and DSHS shall not be held responsible as an employer for claims filed by the
Contractor or its employees under such laws and regulations.
	 
	 	1.34.4	 	Employees and Volunteers: Insurance required of the Contractor under the Contract
shall include coverage for the acts and omissions of the Contractor’s employees and
volunteers.
	 
	 	1.34.5	 	Subcontractors: The Contractor shall ensure that all subcontractors have and
maintain insurance appropriate to the services to be performed. The Contractor shall
make available copies of Certificates of Insurance for subcontractors, to DSHS if
requested.
	 
	 	1.34.6	 	Separation of Insureds: All insurance Commercial General Liability policies shall
contain a “separation of insureds” provision.
	 
	 	1.34.7	 	Insurers: The Contractor shall obtain insurance from insurance




9









 






	 	 	 	companies authorized to do business within the State of Washington, with a “Best’s Reports’’
rating of A-, Class VII or better. Any exception must be approved by the DSHS.
Exceptions include placement with a “Surplus Lines” insurer or an insurer with a
rating lower than A-, Class VII.
	 
	 	1.34.8	 	Evidence of Coverage: The Contractor shall submit Certificates of Insurance in
accord with the Notices section of the General Terms and Conditions, for each
coverage required under this Contract upon execution of this Contract. Each
Certificate of Insurance shall be executed by a duly authorized representative of
each insurer.
	 
	 	1.34.9	 	Material Changes: The Contractor shall give DSHS, in accord with the Notices
section of the General Terms and Conditions, forty-five (45) calendar days advance
notice of cancellation or non-renewal of any insurance in the Certificate of
Coverage. If cancellation is due to non-payment of premium, the Contractor shall
give DSHS ten (10) calendar days advance notice of cancellation.
	 
	 	1.34.10	 	General: By requiring insurance, the State of Washington and DSHS do not
represent that the coverage and limits specified will be adequate to protect the
Contractor. Such coverage and limits shall not be construed to relieve the
Contractor from liability in excess of the required coverage and limits and shall
not limit the Contractor’s liability under the indemnities and reimbursements
granted to the State and DSHS in this Contract. All insurance provided in
compliance with this Contract shall be primary as to any other insurance or
self-insurance programs afforded to or maintained by the State.
	 
	 	 	 	The Contractor may waive the requirements as described in the
Commercial General Liability Insurance, Professional Liability Insurance,
Insurers and Evidence of Coverage provisions of this Section if self-insured.
In the event the Contractor is self insured, the Contractor must send to DSHS
by January 15th, of each Contract year, a signed written document, which
certifies that the contractor is self insured, carries coverage adequate to
meet the requirements of this Section, will treat DSHS as an additional
insured, expressly for, and limited to, the Contractor’s services provided
under this Contract, and provides a point of contact for DSHS.






	 	1.35	 	Maintenance of Records: The Contractor and its subcontractors shall maintain
financial, medical and other records pertinent to this Contract. All financial records
shall follow generally accepted accounting principles. Medical records and supporting
management systems shall include all pertinent information related to the medical
management of each enrollee. Other records shall be maintained as necessary to clearly
reflect all actions taken by the Contractor related to this Contract.




10









 






	 	 	 	All records and reports relating to this Contract shall be retained by the
Contractor and its subcontractors for a minimum of six (6) years after final
payment is made under this Contract. However, when an audit, litigation, or other
action involving records is initiated prior to the end of said period, records
shall be maintained for a minimum of six (6) years following resolution of such
action.
	 
	 	1.36	 	Order of Precedence: In the interpretation of this Contract and incorporated
documents, the various terms and conditions shall be construed as much as possible to
be complementary. In the event that such interpretation is not possible the following
order of precedence shall apply:







	 	1.36.1	 	Title XIX of the federal Social Security Act of 1935, as amended, and its
implementing regulations, as well as federal statutes and regulations concerning the
operation of Managed Care Organizations.
	 
	 	1.36.2	 	State of Washington statues and regulations concerning the operation of the DSHS
programs participating in this Contract, including but not limited to RCW 74.09.522
and chapters 388-538 (Managed Care), 388-865 (Mental Health) and 388-805 (DASA) WAC.
	 
	 	1.36.3	 	State of Washington statutes and regulations concerning the operation of Health
Maintenance Organizations, Health Care Service Contractors, and Life and Disability
Insurance Carriers.
	 
	 	1.36.4	 	General Terms and Conditions of this Contract.
	 
	 	1.36.5	 	Any other term and condition of this Contract and exhibits if any, as indicated on page one of this Contract.
	 
	 	1.36.6	 	Any other material incorporated herein by reference.








	 	1.37	 	Severability: If any term or condition of this Contract is held invalid by any
court, such invalidity shall not affect the validity of the other terms or conditions
of this Contract.
	 
	 	1.38	 	Survivability: The terms and conditions contained in this Contract that shall
survive the expiration or termination of this Contract include but are not limited to:
Confidentiality, Indemnification and Hold Harmless, Inspection and Maintenance of
Records.






	 	1.38.1	 	After termination of this Contract, the Contractor remains obligated to:






	 	1.38.1.1	 	Cover hospitalized enrollees until discharge consistent with the Enrollee
Hospitalized at Termination of Enrollment provisions of the Benefits Section of
this Contract.
	 
	 	1.38.1.2	 	Submit reports required in this Contract.




11









 






	 	1.38.1.3	 	Provide access to records required in accord with the Inspection provisions
of this Section.
	 
	 	1.38.1.4	 	Provide the administrative services associated with covered services (e.g.
claims processing, enrollee appeals) provided to enrollees prior to the
effective date of termination under the terms of this Contract.






	 	1.39	 	Waiver: Waiver of any breach or default on any occasion shall not be deemed to
be a waiver of any subsequent breach or default. Any waiver shall not be construed to
be a modification of the terms and conditions of this Contract. Only the DSHS Chief
Administrative Officer or designee has the authority to waive any term or condition of
this Contract on behalf of DSHS.






	2.	 	ADDITIONAL GENERAL TERMS AND CONDITIONS—CLIENT SERVICE CONTRACTS






	 	2.1.	 	Contractor Certification Regarding Ethics: The Contractor certifies that the
Contractor is now, and shall remain, in compliance with Chapter 42.52 RCW, Ethics in
Public Service, throughout the term of this Contract.
	 
	 	2.2.	 	Health and Safety: Contractor shall perform any and all of its obligations
under this Contract in a manner that does not compromise the health and safety of any DSHS client with whom the
Contractor has contact.
	 
	 	2.3.	 	Indemnification and Hold Harmless: Each party shall be responsible for, and
shall indemnify and hold the other party harmless from, all claims and/or damages to
persons and/or property resulting from its own negligent acts and omissions. The
Contractor shall indemnify and hold harmless DSHS from any claims by non-participating
providers related to the provision to enrollees of covered services under this
Contract. The Contractor waives its immunity under Title 51 RCW to the extent it is
required to indemnify, defend, and hold harmless the State and its agencies, officials,
agents, or employees.
	 
	 	2.4.	 	Industrial Insurance Coverage: The Contractor shall comply with the provisions
of Title 51 RCW, Industrial Insurance. If the Contractor fails to provide industrial
insurance coverage or fails to pay premiums or penalties on behalf of its employees, as
may be required by law, DSHS may collect from the Contractor the full amount payable to
the Industrial Insurance accident fund. DSHS may deduct the amount owed by the
Contractor to the accident fund from the amount payable to the Contractor by DSHS under
this contract, and transmit the deducted amount to the Department of Labor and
Industries, (L&I) Division of Insurance Services. This provision does not waive any of
L&I’s rights to collect from the Contractor.
	 
	 	2.5.	 	No Federal or State Endorsement: The award of this Contract does not indicate
an endorsement of the Contractor by the Centers of Medicare and






12










 








	 	 	 	Medicare and Medicaid Services (CMS), the federal government, or the State of Washington.
No federal funds have been used for lobbying purposes in connection with this Contract
or managed care program.






	 	2.6.	 	Notices: Whenever one party is required to give notice to the other under
this Contract, it shall be deemed given if mailed by United States Postal Services,
registered or certified mail, return receipt requested, postage prepaid and addressed
as follows:






	 	2.6.1.	 	In the case of notice to the Contractor, notice will be sent to the Contractor
Contact at the address for the Contractor on the first page of this Contract.
	 
	 	2.6.2.	 	In the case of notice to DSHS, send notice to:




Office Chief

Department of Social and Health Services

Division of Healthcare Services

Office of Quality and Care Management

P.O. Box 45530

Olympia, WA 98504-5530





	 	2.6.3.	 	Notices shall be effective on the date delivered as evidenced by the return
receipt or the date returned to the sender for non-delivery other than for
insufficient postage.
	 
	 	2.6.4.	 	Either party may at any time change its address for notification purposes by
mailing a notice in accord with this Section, stating the change and setting forth
the new address, which shall be effective on the tenth (10th) day
following the effective date of such notice unless a later date is specified.






	 	2.7.	 	Notification of Organizational Changes:






	 	2.7.1.	 	The Contractor shall provide DSHS with ninety (90) calendar days prior written
notice of any change in ownership or legal status.
	 
	 	2.7.2.	 	The Contractor shall provide DSHS written notice of any changes to key personnel
including, but not limited to, Chief Executive Officer, DSHS government relations
contact, and Medical Director as soon as reasonably possible.






	 	2.8.	 	Notice of Overpayment: If the Contractor receives a vendor overpayment
notice or a letter communicating the existence of an overpayment from DSHS, the
Contractor may protest the overpayment determination by requesting an adjudicative
proceeding. The Contractor’s request for an adjudicative proceeding must:






13












 






	 	2.8.1.	 	Be received by the Office of Financial Recovery (OFR) at Post Office Box 9501,
Olympia, Washington 98507-9501, within twenty-eight (28) calendar days of service of
the notice;
	 
	 	2.8.2.	 	Be sent by certified mail (return receipt) or other manner that proves OFR
received the request;
	 
	 	2.8.3.	 	Include a statement as to why the Contractor thinks the notice is incorrect; and
	 
	 	2.8.4.	 	Include a copy of the overpayment notice.






	 	2.8.4.1.	 	Timely and complete requests will be scheduled for a formal hearing by the
Office of Administrative Hearings. The Contractor may be offered a pre-hearing
or alternative dispute resolution conference in an attempt to resolve the
overpayment dispute prior to the hearing.
	 
	 	2.8.4.2.	 	Failure to provide OFR with a written request for a hearing within
twenty-eight (28) calendar days of service of a vendor overpayment notice or
other overpayment letter will result in an overpayment debt against the
Contractor. DSHS may charge the Contractor interest and any costs associated
with the collection of this overpayment. DSHS may collect an overpayment debt
through lien, foreclosure, seizure and sale of the Contractor’s real or personal
property; order to withhold and deliver; or any other collection action
available to DSHS to satisfy the overpayment debt.






	 	2.9.	 	Ownership of Material:DSHS recognizes that nothing in this Contract shall give
DSHS ownership rights to the systems developed or acquired by the Contractor during the
performance of this Contract. The Contractor recognizes that nothing in this Contract
shall give the Contractor ownership rights to the systems developed or acquired by DSHS
during the performance of this Contract.
	 
	 	2.10.	 	Solvency:






	 	2.10.1.	 	The Contractor shall have a Certificate of Registration as a Health Maintenance
Organization (HMO), Health Care Service Contractor (HCSC) or Life and Disability
Insurance Carrier, from the Washington State Office of the Insurance Commissioner
(OIC). The Contractor shall comply with the solvency provisions of chapters 48.21,
48.21a, 48.44 or 48.46 RCW, as amended.
	 
	 	2.10.2.	 	The Contractor agrees that DSHS may at any time access any information related to
the Contractor’s financial condition, or compliance




14









 






	 	 	 	with OIC requirements, from OIC and consult with OIC concerning such
information.






	 	2.11.	 	State Conflict of Interest Safeguards: The Contractor shall have conflict of
interest safeguards that, at a minimum, are equivalent to conflict of interest
safeguards imposed by federal law on parties involved in public contracting (41 USC
423).
	 
	 	2.12.	 	Subrecipients:






	 	2.12.1.	 	General. If the Contractor is a subrecipient of federal awards as defined by
Office of Management and Budget (OMB) Circular A-133 and this Agreement, the
Contractor shall:






	 	2.12.1.1.	 	Maintain records that identify, in its accounts, all federal awards
received and expended and the federal programs under which they were received,
by Catalog of Federal Domestic Assistance (CFDA) title and number, award number
and year, name of the federal agency, and name of the pass-through entity;
	 
	 	2.12.1.2.	 	Maintain internal controls that provide reasonable assurance that the
Contractor is managing federal awards in compliance with laws, regulations, and
provisions of contracts or grant agreements that could have a material effect on
each of its federal programs;
	 
	 	2.12.1.3.	 	Prepare appropriate financial statements, including a schedule of
expenditures of federal awards;
	 
	 	2.12.1.4.	 	Incorporate OMB Circular A-133 audit requirements into all agreements
between the Contractor and its Subcontractors who are subrecipients;
	 
	 	2.12.1.5.	 	Comply with any future amendments to OMB Circular A-133 and any successor
or replacement Circular or regulation;
	 
	 	2.12.1.6.	 	Comply with the applicable requirements of OMB Circular A-87 and any future
amendments to OMB Circular A-87, and any successor or replacement Circular or
regulation; and
	 
	 	2.12.1.7.	 	Comply with the Omnibus Crime Control and Safe streets Act of 1968, Title
VI of the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of
1973, Title II of the Americans with Disabilities Act of 1990, Title IX of the
Education Amendments of 1972, The Age Discrimination Act of 1975, and The
Department of Justice Non-Discrimination Regulations, 28 C.F.R. Part 42,
Subparts C.D.E. and G, and 28 C.F.R. Part 35 and 39. (Go to




15









 






	 	 	 	www.ojp.usdoj.gov/ocr/ for additional information and access to the
aforementioned Federal laws and regulations.)






	 	2.12.2.	 	Single Audit Act Compliance. If the Contractor is a subrecipient and expends
$500,000 or more in federal awards from any and/or all sources in any fiscal year,
the Contractor shall procure and pay for a single audit or a program-specific audit
for that fiscal year. Upon completion of each audit, the Contractor shall:






	 	2.12.2.1.	 	Submit to the DSHS contact person the data collection form and reporting
package specified in OMB Circular A-133, reports required by the
program-specific audit guide (if applicable), and a copy of any management
letters issued by the auditor;
	 
	 	2.12.2.2.	 	Follow-up and develop corrective action for all audit findings; in
accordance with OMB Circular A-133, prepare a “Summary Schedule of Prior Audit
Findings.”






	 	2.12.3.	 	Overpayments. If it is determined by DSHS, or during the course of a required
audit, that the Contractor has been paid unallowable costs under this or any Program
Agreement, DSHS may require the Contractor to reimburse DSHS in accordance with OMB
Circular A-87.






	 	2.13.	 	Termination for Convenience: Either party may terminate, upon one-hundred
twenty (120) calendar days advance written notice, performance of work under this
Contract in whole or in part, whenever, for any reason, either party determines that
such termination is in its best interest.






	 	2.13.1.	 	In the event that either party terminates the Contract for convenience the other
party may assert a claim for direct termini nation costs as follows:






	 	2.13.1.1.	 	In the event DSHS terminates this Contract for convenience, the Contractor
shall have the right to assert a claim for the Contractor’s direct termination
costs. Such claim must be:






	 	2.13.1.1.1.	 	Delivered to DSHS as provided in accord with the Notices section of
the General Terms and Conditions;
	 
	 	2.13.1.1.2.	 	Asserted within ninety (90) calendar days of termination for
convenience, or, in the event the termination was originally issued under
the provisions of the, Termination by DSHS for Default provision of this
Section, ninety (90) calendar days from the date the notice of termination
was deemed to have been issued under this Section. DSHS may extend said
ninety (90) calendar days if the Contractor makes a written
request to DSHS and DSHS deems the grounds for the request to be
reasonable.




16









 












	 	2.13.1.1.3.	 	DSHS will evaluate the claim for termination costs and either pay or
deny the claim. DSHS shall notify the Contractor of DSHS’ decision within
sixty (60) calendar days of receipt of the claim.






	 	2.13.1.2.	 	In the event the Contractor terminates this Contract for convenience, DSHS
shall have the right to assert a claim for DSHS’ direct termination costs. Such
claim must be:






	 	2.13.1.2.1.	 	Delivered to the Contractor as described in the Notices section of
the General Terms and Conditions.
	 
	 	2.13.1.2.2.	 	Asserted within ninety (90) calendar days of the date of termination
for convenience. The Contractor may extend said ninety (90) calendar days
if DSHS makes a written request to the Contractor and the Contractor deems
the grounds for the request to be reasonable.
	 
	 	2.13.1.2.3.	 	The Contractor shall evaluate the claim for termination costs and
either pay or deny the claim. The Contractor shall notify DSHS of the
Contractor’s decision within sixty (60) calendar days of receipt of the
claim.






	 	2.13.1.3.	 	In the event that either party disagrees with the other party’s decision to
pay or deny termination costs the disagreeing party shall have the right to a
dispute resolution as described in the Disputes section of the General Terms and
Conditions.
	 
	 	2.13.1.4.	 	In no event shall the claim from termination costs exceed the average
monthly amount paid to the Contractor for the twelve (12) months immediately
prior to termination.
	 
	 	2.13.1.5.	 	In addition to DSHS’ or Contractor’s direct termination costs, the
Contractor or DSHS shall be liable for administrative costs incurred by the
other party in procuring supplies or services similar to and/or replacing those
terminated.
	 
	 	2.13.1.6.	 	Neither the Contractor nor DSHS shall be liable for any termination costs
if it notifies the other party of its intent not to renew this Contract at least
one hundred twenty (120) calendar days prior to the renewal date.






	 	2.13.2.	 	In the event this Contract is terminated for the convenience of either party, the
effective date of termination shall be the last day of the month in which the one
hundred twenty (120) day notification period is
satisfied, or the last day of such later month as may be agreed upon by both
parties.




17









 












	 	2.14.	 	Termination by the Contractor for Default: The Contractor may terminate this
Contract whenever DSHS defaults in performance of the Contract and fails to cure the
default within a period of one hundred twenty (120) calendar days (or such longer
period as the Contractor may allow) after receipt from the Contractor of a written
notice, as described in the Notices section of the General Terms and Conditions,
specifying the default. For purposes of this Section, default means failure of DSHS to
meet one or more material obligations of this Contract. In the event it is determined
that DSHS was not in default, DSHS may claim damages for wrongful termination through
the dispute resolution provisions of this Contract or by a court of competent
jurisdiction. The procedure for determining damages shall be as described in the
Termination for Convenience section of the General Terms and Conditions.
	 
	 	2.15.	 	Termination by DSHS for Default: The Contract Administrator may terminate
this Contract whenever the Contractor defaults in performance of this Contract and
fails to cure the default within a period of one hundred twenty (120) calendar days (or
such longer period as DSHS may allow) after receipt from DSHS of a written notice, as
described in the Notices section of the General Terms and Conditions, specifying the
default. For purposes of this Section, default means failure of the Contractor to meet
one or more material obligations of this Contract. In the event it is determined that
the Contractor was not in default, the Contractor may claim damages for wrongful
termination through the dispute resolution provisions of this Contract or by a court of
competent jurisdiction. The procedure for determining damages shall be as stated in
accord with the Termination for Convenience Section of this Contract.
	 
	 	2.16.	 	Termination — Information on Outstanding Claims: In the event this Contract
is terminated, the Contractor shall provide DSHS, within three hundred and sixty-five
(365) calendar days, all available information reasonably necessary for the
reimbursement of any outstanding claims for services to enrollees (42 CFR 434.6(a)(6)).
Information and reimbursement of such claims is subject to the provisions of the
Payment and Sanctions Section of this Contract.
	 
	 	2.17.	 	Terminations — Pre-termination Processes: Either party to the Contract shall
give the other party to the Contract written notice, as described in the Notices
section of the General Terms and Conditions, of the intent to terminate this Contract
and the reason for termination.






	 	2.17.1.	 	If either party disagrees with the other party’s decision to terminate this
Contract, other than a termination for convenience, that party will have the right
to a dispute resolution as described in the Disputes section of the General Terms
and Conditions.




18









 












	 	2.17.2.	 	If the Contractor disagrees with a DSHS decision to terminate this Contract and
the dispute process is not successful, DSHS shall provide the Contractor a
pre-termination hearing prior to termination of the Contract under 42 CFR 438.708.
DSHS shall:






	 	2.17.2.1.	 	Give the Contractor written notice of the intent to terminate, the reason
for termination, and the time and place of the hearing;
	 
	 	2.17.2.2.	 	Give the Contractor (after the hearing) written notice of the decision
affirming or reversing the proposed termination of this Contract, and for an
affirming decision the effective date of termination; and
	 
	 	2.17.2.3.	 	For an affirming decision, give enrollees notice of the termination and
information consistent with 42 CFR 438.10 on their options for receiving
Medicaid services following the effective date of termination.






	 	2.18.	 	Treatment of Client Property: Unless otherwise provided, the Contractor shall
ensure that any adult client receiving services from the Contractor has unrestricted
access to the client’s personal property. The Contractor shall not interfere with any
adult client’s ownership, possession, or use of the client’s property. The Contractor
shall provide clients under age eighteen (18) with reasonable access to their personal
property that is appropriate to the client’s age, development, and needs. Upon
termination of the Contract, the Contractor shall immediately release to the client
and/or the client’s guardian or custodian all of the client’s personal property.
	 
	 	2.19.	 	Treatment of Property: All property purchased or furnished by DSHS for use by
the Contractor during this Contract term shall remain with DSHS. Title to all property
purchased or furnished by the Contractor for which the Contractor is entitled to
reimbursement by DSHS under this Contract shall pass to and vest in DSHS. The
Contractor shall protect, maintain, and insure all DSHS property in its possession
against loss or damage and shall return DSHS property to DSHS upon Contract termination
or expiration.






	3.	 	DEFINITIONS
	 
	 	 	The following definitions shall apply to this Contract:






	 	3.1.	 	Action means the denial or limited authorization of a requested service,
including the type or level of service; the reduction, suspension, or termination of a
previously authorized service; the denial, in whole or in part, of payment for a
service; or the failure to provide services or act in a timely manner as required
herein (42 CFR 438.400(b)).
	 
	 	3.2.	 	Actuarially Sound Capitation Rates means capitation rates that have been
developed in accordance with generally accepted actuarial principles and 




19









 






	 	 	 	practices; are
appropriate for the populations to be covered, and the services to be furnished under
the contract; and have been certified, as meeting the requirements of 42 CFR 438.6(c),
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 (42 CFR 438.6(c)).






	 	3.3.	 	Advance Directive means a written instruction, such as a living will or durable
power of attorney for health care, recognized under the laws of the State of
Washington, relating to the provision of health care when an individual is
incapacitated (WAC 388-501-0125, 42 CFR 438.6, 438.10, 422.128, and 489.100).
	 
	 	3.4.	 	Ancillary Services means health care services which are auxiliary, accessory,
or secondary to a primary health care service.
	 
	 	3.5.	 	Appeal means a request for review of an action (42 CFR 438.400(b)).
	 
	 	3.6.	 	Appeal Process means the Contractor’s procedures for reviewing an action.
	 
	 	3.7.	 	Children with Special Health Care Needs means children identified by DSHS to
the Contractor as children served under the provisions of Title V of the Social
Security Act.
	 
	 	3.8.	 	Cold Call Marketing means any unsolicited personal contact by the Contractor or
its designee, with a potential enrollee or an enrollee with another contracted managed
care organization for the purposes of marketing (42 CFR 438.104(a)).
	 
	 	3.9.	 	Comparable Coverage means an enrollee has other insurance that DSHS has
determined provides a full scope of health care benefits.
	 
	 	3.10.	 	Consumer Assessment of Healthcare Providers and Systems (CAHPS®) means a
family of standardized survey instruments, including a Medicaid survey used to measure
client experience of health care.
	 
	 	3.11.	 	Continuity of Care means the provision of continuous care for chronic or acute
medical conditions through enrollee transitions in providers or service areas, between
HO/SCHIP contractors and between Medicaid fee-for-service and HO/SCHIP in a manner that
does not interrupt medically necessary care or jeopardize the enrollee’s health.
	 
	 	3.12.	 	Coordination of Care means the Contractor’s mechanisms to assure that the
enrollee and providers have access to and take into consideration, all required
information on the enrollee’s conditions and treatments to ensure that the enrollee
receives appropriate health care services (42 CFR 438.208).




20









 












	 	3.13.	 	Covered Services means medically necessary services covered under the terms of
this Contract, as set forth in the Benefits Section of this Contract,.
	 
	 	3.14.	 	Duplicate Coverage means an enrollee is privately enrolled on any basis with
the Contractor and simultaneously enrolled with the Contractor under Healthy
Options/SCHIP.
	 
	 	3.15.	 	EPSDT (Early, Periodic Screening, Diagnosis and Treatment) means a package of
services in a preventive (well child) exam covered by Medicaid as defined in the Social
Security Act (SSA) Section 1905(r) and the DSHS EPSDT program policy and billing
instructions (see Attachment A for website link). Services covered by Medicaid include
a complete health history and developmental assessment, an unclothed physical exam,
immunizations, laboratory tests, health education and anticipatory guidance, and
screenings for: vision, dental, substance abuse, mental health and hearing, as well as
any medically necessary services found to be necessary during the EPSDT exam. EPSDT
services covered by the Contractor are described in the Benefits Section of this
Contract.
	 
	 	3.16.	 	Eligible Clients means Medicaid recipients certified eligible by DSHS, living
in the service area, and eligible to enroll for health care services under the terms of
this Contract, as described in the Enrollment Section of this Contract.
	 
	 	3.17.	 	Emergency Medical Condition means a medical condition manifesting itself by
acute symptoms of sufficient severity (including severe pain) such that a prudent
layperson, who possesses an average knowledge of health and medicine, could reasonably
expect the absence of immediate medical attention to result in: (a) placing the health
of the individual (or, with respect to a pregnant
woman, the health of the woman or her unborn child) in serious jeopardy; (b)
serious impairment to bodily functions; or (c) serious dysfunction of any bodily
organ or part (42 CFR 438.114(a)).
	 
	 	3.18.	 	Emergency Services means covered inpatient and outpatient services furnished
by a provider qualified to furnish the services needed to evaluate or stabilize an
emergency medical condition (42 CFR 438.114(a)).
	 
	 	3.19.	 	Enrollee means a Medicaid recipient who is enrolled in Healthy Options/SCHIP
managed care through a Managed Care Organization (MCO) having a Contract with DSHS (42
CFR 438.10(a)).
	 
	 	3.20.	 	Enrollee with Special Health Care Needs means an enrollee who has chronic and
disabling condition as defined in WAC 388-538-050.
	 
	 	3.21.	 	External Quality Review (EQR) means the analysis and evaluation by an EQRO of
aggregated information on quality, timeliness and access to the health care services
that the Contractor or its subcontractors furnish to Medicaid recipients (42 CFR
438.320).




21









 












	 	3.22.	 	External Quality Review Organization (EQRO) means an organization that meets
the competence and independence requirements set forth in 42 CFR 438.354, and performs
external quality review, other EQR-related activities as set forth in 42 CFR 438.358,
or both (42 CFR 438.320).
	 
	 	3.23.	 	External Quality Review Protocols means a series of nine (9) procedures or
guidelines for validating performance. Two of the nine protocols must be used by state
Medicaid agencies. These are: 1) Determining Contractor compliance with federal
Medicaid managed care regulations; and 2) Validation of performance improvement
projects undertaken by the Contractor. The current External Quality Review Protocols
can be found at the Centers for Medicare and Medicaid Services (CMS) website (see
Attachment A for website link).
	 
	 	3.24.	 	External Quality Review Report — (EQRR) means a technical report that
describes the manner in which the data from all EQR activities are aggregated and
analyzed, and conclusions drawn as to the quality, timeliness, and access to the care
furnished by the Contractor. DSHS will provide a copy of the EQRR to the Contractor,
through print or electronic media.
	 
	 	3.25.	 	Grievance means an expression of dissatisfaction about any matter other than
an action. Possible subjects for
grievances include, but are not limited to, the quality of care or services
provided, and aspects of interpersonal relationships such as rudeness of a provider
or employee, or failure to respect the enrollee’s rights (42 CFR 438.400(b)).
	 
	 	3.26.	 	Grievance Process means the procedure for addressing enrollees’ grievances (42
CFR 438.400(b)).
	 
	 	3.27.	 	Grievance System means the overall system that includes grievances and appeals
handled by the Contractor and access to the hearing system (42 CFR 438, Subpart F).
	 
	 	3.28.	 	Health Care Professional means a physician or any of the following acting
within their scope of practice; a podiatrist, optometrist, chiropractor, psychologist,
dentist, physician assistant, physical or occupational therapist, therapist assistant,
speech language pathologist, audiologist, registered or practical nurse (including
nurse practitioner, clinical nurse specialist, certified registered nurse anesthetist,
and certified nurse midwife), licensed certified social worker, registered respiratory
therapist, pharmacist and certified respiratory therapy technician (42 CFR 438.2).
	 
	 	3.29.	 	Health Employer Data and Information Set — (HEDISâ) means a set of
standardized performance measures designed to ensure that healthcare purchasers and
consumers have the information they need to reliably compare the performance of managed
health care plans. HEDISâ also includes a standardized survey of consumers’
experiences that evaluates plan




22









 






	 	 	 	performance in areas such as customer service, access
to care and claims processing. HEDISâ is sponsored, supported, and maintained by
National Committee for Quality Assurance (NCQA).






	 	3.30.	 	Health Employer Data and Information Set (HEDISâ) Compliance Audit
Program means a set of standards and audit methods used by an NCQA certified auditor to
evaluate information systems capabilities assessment (IS standards) and a Contractor’s
ability to comply with HEDISâ specifications (HD standards).
	 
	 	3.31.	 	Managed Care means a prepaid, comprehensive system of medical and health care
delivery, including preventive, primary, specialty and ancillary health services.
	 
	 	3.32.	 	Managed Care Organization (MCO) means an organization having a certificate of
authority or certificate of registration from the Office of Insurance Commissioner that
contracts with DSHS under a comprehensive risk contract
to provide prepaid health care services to eligible DSHS clients under the DSHS’
managed care programs (WAC 388-538-050).
	 
	 	3.33.	 	Marketing means any communication from the Contractor to a potential enrollee
or enrollee with another DSHS contracted MCO that can be reasonably interpreted as
intended to influence them to enroll with the Contractor or to either not enroll or end
enrollment with another DSHS contracted MCO (42 CFR 438.104(a)).
	 
	 	3.34.	 	Marketing Materials means materials that are produced in any medium, by or on
behalf of the Contractor that can be reasonably interpreted as intended as marketing
(42 CFR 438.104(a)).
	 
	 	3.35.	 	Medically Necessary Services means services that are “medically necessary” as
is defined in WAC 388-500-0005. In addition, medically necessary services shall
include services related to the enrollee’s ability to achieve age-appropriate growth
and development.
	 
	 	3.36.	 	National CAHPS® Benchmarking Database — (NCBD) means a national repository for
data from the Consumer Assessment of Healthcare Providers and Systems (CAHPS®). The
database facilitates comparisons of CAHPS® survey results by survey sponsors. Data is
compiled into a single national database, which enables NCBD participants to compare
their own results to relevant benchmarks (i.e., reference points such as national and
regional averages). The NCBD also offers an important source of primary data for
specialized research related to consumer assessments of quality as measured by CAHPS®.
	 
	 	3.37.	 	National Committee for Quality Assurance — (NCQA) means an organization
responsible for developing and managing health care measures




23









 






	 	 	 	that assess the quality of
care and services that commercial and Medicaid managed care clients receive.






	 	3.38.	 	Participating Provider means a person, health care provider, practitioner, or
entity, acting within their scope of practice, with a written agreement with the
Contractor to provide services to enrollees under the terms of this Contract.
	 
	 	3.39.	 	Peer-Reviewed Medical Literature means medical literature published in
professional journals that submit articles for review by experts who are not part of
the editorial staff. It does not include publications or supplements to publications
primarily intended as marketing material for pharmaceutical,
medical supplies, medical devices, health service providers, or insurance carriers.
	 
	 	3.40.	 	Physician Group means a partnership, association, corporation, individual
practice association, or other group that distributes income from the practice among
its members. An individual practice association is a physician group only if it is
composed of individual physicians and has no subcontracts with physician groups.
	 
	 	3.41.	 	Physician Incentive Plan means any compensation arrangement between the
Contractor and a physician or physician group that may directly or indirectly have the
effect of reducing or limiting services to enrollees under the terms of this Contract.
	 
	 	3.42.	 	Post-stabilization Services means covered services, related to an emergency
medical condition that are provided after an enrollee is stabilized in order to
maintain the stabilized condition or to improve or resolve the enrollee’s condition (42
CFR 438.114 and 422.113).
	 
	 	3.43.	 	Potential Enrollee means any Medicaid recipient eligible for enrollment in
Healthy Options/SCHIP who is not enrolled with a health care plan having a contract
with DSHS (42 CFR 438.10(a)).
	 
	 	3.44.	 	Primary Care Provider (PCP) means a participating provider who has the
responsibility for supervising, coordinating, and providing primary health care to
enrollees, initiating referrals for specialist care, and maintaining the continuity of
enrollee care. PCPs include, but are not limited to Pediatricians, Family
Practitioners, General Practitioners, Internists, Physician Assistants (under the
supervision of a physician), or Advanced Registered Nurse Practitioners (ARNP), as
designated by the Contractor. The definition of PCP is inclusive of primary care
physician as it is used in 42 CFR 438. All Federal requirements applicable to primary
care physicians will also be applicable to primary care providers as the term is used
in this Contract.
	 
	 	3.45.	 	Quality means the degree to which a Contractor increases the likelihood of
desired health outcomes of its enrollees through its structural and operational




24









 






	 	 	 	characteristics and through the provision of health services that are consistent with
current professional knowledge (42 CFR 438.320).






	 	3.46.	 	Risk means the possibility that a loss may be incurred because the cost of
providing services may exceed the payments made for services. When applied to
subcontractors, loss includes the loss of potential payments made as part of a
physician incentive plan, as defined herein.
	 
	 	3.47.	 	Service Areas means the geographic areas covered by this Contract as described
in the Enrollment Section of this Contract.
	 
	 	3.48.	 	State Children’s Health Insurance Program (SCHIP) means a program to provide
access to medical care for children whose family income exceeds the limit for Medicaid
eligibility, but is not greater than two hundred fifty percent (250%) of the federal
poverty level (FPL). SCHIP is authorized by Title XXI of the Social Security Act and
by RCW 74.09.450 (WAC 388-542).
	 
	 	3.49.	 	Substantial Financial Risk: A physician or physician group as defined in this
Section is at substantial financial risk when more than twenty-five percent (25%) of
the total maximum potential payments to the physician or physician group depend on the
use of referral services. When the panel size is fewer than 25,000 enrollees
arrangements that cause substantial financial risk include, but are not limited to, the
following:






	 	3.49.1.	 	Withholds greater than twenty-five percent (25%) of total potential payments.
	 
	 	3.49.2.	 	Withholds less than twenty-five percent (25%) of total potential payments but the
physician or physician group is potentially liable for more than twenty-five percent
(25%) of total potential payments.
	 
	 	3.49.3.	 	Bonuses greater than thirty-three percent (33%) of total potential payments, less
the bonus.
	 
	 	3.49.4.	 	Withholds plus bonuses if the withholds plus bonuses equal more than twenty-five
percent (25%) of total potential payments.
	 
	 	3.49.5.	 	Capitation arrangements if the difference between the minimum and maximum
possible payments is more than twenty-five percent (25%) of the maximum possible
payments, or the minimum and maximum possible payments are not clearly explained in
the Contract.






	 	3.50.	 	Validation means the review of information, data, and procedures to determine
the extent to which they are accurate, reliable, and free from bias and in accord with
standards for data collection and analysis (42 CFR 438.320).






	4.	 	ENROLLMENT




25









 












	 	4.1.	 	Service Areas:






	 	4.1.1.	 	The Contractor’s policies and procedures related to Enrollment shall ensure
compliance with the requirements described in this section.
	 
	 	4.1.2.	 	The Contractor’s service areas are described in Exhibit A, Premiums, Service
Areas, and Capacity. DSHS may modify Exhibit A, Premiums, Service Areas, and
Capacity for service area changes as described in this Section.
	 
	 	4.1.3.	 	Clients in the eligibility groups described in this Section are eligible to enroll
with the Contractor if they reside in the Contractor’s service areas.
	 
	 	4.1.4.	 	Service Area Changes:






	 	4.1.4.1.	 	With the written approval of DSHS, the Contractor may expand into additional
service areas at any time by giving written notice to DSHS, along with evidence,
as DSHS may require, demonstrating the Contractor’s ability to support the
expansion. DSHS may withhold approval of a requested expansion, if, in DSHS’
sole judgment, the requested expansion is not in the best interest of DSHS.
	 
	 	4.1.4.2.	 	The Contractor may decrease service areas by giving DSHS ninety (90)
calendar days’ written notice. The decrease shall not be effective until the
first day of the month that falls after the ninety (90) calendar days has
elapsed.
	 
	 	4.1.4.3.	 	The Contractor shall notify enrollees affected by any service area decrease
at least sixty (60) calendar days prior to the effective date. Notices shall be
approved in advance by DSHS. If the Contractor fails to notify affected
enrollees of a service area decrease sixty at least (60) calendar days prior to
the effective date, the decrease shall not be effective until the first day of
the month which falls sixty (60) calendar days from the date the Contractor
notifies enrollees.






	 	4.1.5.	 	If the U.S. Postal Service alters the zip code numbers or zip code boundaries
within the Contractor’s service areas, DSHS shall alter the service area zip code
numbers or the boundaries of the service areas with input from the affected
contractors.
	 
	 	4.1.6.	 	DSHS shall determine, in its sole judgment, which zip codes fall within each
service area. No zip code will be split between service areas.
	 
	 	4.1.7.	 	DSHS will determine whether an enrollee resides within a service area.




26









 












	 	4.2.	 	Eligible Client Groups: DSHS shall determine eligibility for enrollment under
this Contract. Clients in the following eligibility groups at the time of enrollment
are eligible for
enrollment under this Contract, and must enroll in Healthy Options/SCHIP unless the
enrollee has comparable coverage as defined herein, or is exempted pursuant to the
Exemption from Enrollment provisions of this Section.






	 	4.2.1.	 	Clients receiving Medicaid under Social Security Act (SSA) provisions for coverage
of families receiving Temporary Assistance for Needy Families and clients who are
not eligible for cash assistance who remain eligible for Medicaid.
	 
	 	4.2.2.	 	Children, from birth through eighteen (18) years of age, eligible for Medicaid
under expanded pediatric coverage provisions of the Social Security Act.
	 
	 	4.2.3.	 	Pregnant Women, eligible for Medicaid under expanded maternity coverage provisions
of the Social Security Act.
	 
	 	4.2.4.	 	Children eligible for SCHIP (see Attachment A for website link).






	 	4.3.	 	Client Notification: DSHS shall notify eligible clients of their rights and
responsibilities as Healthy Options/SCHIP enrollees at the time of initial eligibility
determination and at least annually. The Contractor shall provide enrollees with
additional information as described in this Contract (42 CFR 438.10).
	 
	 	4.4.	 	Exemption from Enrollment: A client may request exemption from enrollment.
Each request for exemption will be reviewed by DSHS pursuant to WAC 388-538 or WAC
388-542. When the client is already enrolled with the Contractor and wishes to be
exempted, the exemption request will be treated as a termination of enrollment request
consistent with the Termination of Enrollment provisions of this Section.
	 
	 	4.5.	 	Enrollment Period: Subject to the Effective Date of Enrollment provisions of
this Section, enrollment is continuously open. Enrollees shall have the right to
change enrollment prospectively, from one Healthy Options/SCHIP plan to another without
cause, each month except as described in the Patient Review and Restriction (PRR)
provisions of the Benefits Section of this Contract.
	 
	 	4.6.	 	Enrollment Process: To enroll with the Contractor, the client, the client’s
representative or responsible parent or guardian must complete and submit a DSHS
enrollment form to DSHS, or call the DSHS toll-free enrollment number.






	 	4.6.1.	 	If the client does not exercise their right to choose a Healthy Options/SCHIP
plan, DSHS will assign the client, and all eligible family




27









 






	 	 	 	members, to the same
Healthy Options/SCHIP plan in accord with the
Assignment of Enrollees provisions of the Access and Capacity Section of this
Contract.






	 	4.6.2.	 	DSHS will attempt to enroll all family members with the same Healthy Options/SCHIP
plan unless the following occurs:






	 	4.6.2.1.	 	A family member is covered by Basic Health, and the plan contracts with
DSHS, then DSHS will attempt to enroll the remainder of the family with the same
managed care plan. If the plan does not contract with DSHS, the remaining
family members will be enrolled with a single, but different Healthy
Options/SCHIP plan of the enrollee’s choice, or shall be assigned as described
above if no choice is made.
	 
	 	4.6.2.2.	 	A family member is placed into the Patient Review and Restriction (PRR)
program by the Contractor or DSHS. The PRR placed family member shall follow
the enrollment requirements described in the PRR provisions of the Benefits
Section of this Contract. The remaining family members shall be enrolled with a
single, Healthy Options/SCHIP plan of the choice, or shall be assigned as
described above if no choice is made.






	 	4.7.	 	Effective Date of Enrollment:






	 	4.7.1.	 	Except for a newborn whose mother is enrolled in a Healthy Options/SCHIP plan,
enrollment with the Contractor shall be effective on the later of the following
dates:






	 	4.7.1.1.	 	If the enrollment is processed on or before the DSHS cut-off date for
enrollment, enrollment shall be effective the first day of the month following
the month in which the enrollment is processed; or
	 
	 	4.7.1.2.	 	If the enrollment is processed after the DSHS cut-off date for enrollment,
enrollment shall be effective the first day of the second month following the
month in which the enrollment is processed.






	 	4.7.2.	 	Newborns whose mothers are enrollees shall be deemed enrollees and enrolled
beginning from the newborn’s date of birth or the mother’s date of enrollment,
whichever is later. If the mother’s enrollment is ended before the newborn receives
a separate client identifier from DSHS, the newborn’s enrollment shall end when the
mother’s enrollment ends, except as provided in the provisions of the Enrollee
Hospitalized at Termination of Enrollment of the Benefits Section of this Contract.
If the newborn does not receive a separate client identifier by the sixtieth (60th)
day of life, supplemental premiums and enrollment shall only be




28









 






	 	 	 	available through the end of the month in which the sixtieth (60th) day of
life falls in accord with Healthy Options Licensed Health Carrier Billing
Instructions, published by DSHS and incorporated by reference (see Attachment
A for website link).






	 	4.7.3.	 	Adopted children shall be covered consistent with the provisions of Title 48 RCW.
	 
	 	4.7.4.	 	No retroactive coverage is provided under this Contract, except as described in
this Section or by mutual agreement by both parties to this Contract.






	 	4.8.	 	Enrollment Data and Requirements for Contractor’s Response: DSHS will provide
the Contractor with data files with the information needed to perform the services
described in this Contract.






	 	4.8.1.	 	Data files will be sent to the Contractor at intervals specified within the DSHS
Companion Guides, published by DSHS and incorporated by reference (see Attachment A
for website link).
	 
	 	4.8.2.	 	The data file will be in the Health Insurance Portability and Accountability Act
(HIPAA) compliant 834, Benefit Enrollment and Maintenance format (45 CFR 162.1503).
	 
	 	4.8.3.	 	The data file will be transferred per specifications defined within DSHS Companion
Guides (see Attachment A for website link).
	 
	 	4.8.4.	 	Data is sent in two files. The “update” file, in the 834 benefit enrollment and
maintenance format, will list the enrollees whose enrollment is terminated by the
end of that month, and the enrollees for the following month with the Contractor.
The “audit” file will include all enrollees enrolled with the plan and for whom a
monthly premium will be paid for the following month.
	 
	 	4.8.5.	 	The data file will include but not be limited to the following enrollee personal
information: Name, address, SSN, age/sex, ethnicity, race and language markers.
	 
	 	4.8.6.	 	The Contractor shall have ten (10) calendar days from the receipt of the data
files to notify DSHS in writing of the refusal of an application for enrollment or
any discrepancy regarding DSHS’ proposed enrollment effective date. Written notice
shall include the reason for refusal and must be agreed to by DSHS. The effective
date of enrollment specified by DSHS shall be considered accepted by the Contractor
and shall be binding if the notice is not timely or DSHS does not agree with the
reasons stated in the notice. Subject to DSHS approval, the Contractor may refuse
to accept an enrollee for the following reasons:




29









 












	 	4.8.6.1.	 	DSHS has enrolled the enrollee with the Contractor in a service area the
Contractor is not contracted for.
	 
	 	4.8.6.2.	 	The enrollee is not eligible for enrollment under the terms of this
Contract.






	 	4.9.	 	Termination of Enrollment:






	 	4.9.1.	 	Voluntary Termination of Enrollment: Enrollees may request termination of
enrollment by submitting a written request to terminate enrollment to DSHS or by
calling the DSHS toll-free enrollment number (42 CFR 438.56(d)(1)(i)). Except as
provided in WAC 388-538 or WAC 388-542, the enrollment for enrollees whose
enrollment is terminated will be prospectively ended. The Contractor may not
request voluntary termination of enrollment on behalf of an enrollee.
	 
	 	4.9.2.	 	Involuntary Termination of Enrollment Initiated by DSHS for Ineligibility: The
enrollment of any enrollee under this Contract shall be terminated if the enrollee
becomes ineligible for enrollment due to a change in eligibility status.






	 	4.9.2.1.	 	When an enrollee’s enrollment is terminated for ineligibility, the
termination shall be effective:






	 	4.9.2.1.1.	 	The first day of the month following the month in which the enrollment
termination is processed by DSHS if it is processed on or before the DSHS
cut-off date for enrollment or the Contractor is informed by DSHS of the
enrollment termination prior to the first day of the month following the
month in which it is processed by DSHS.
	 
	 	4.9.2.1.2.	 	Effective the first day of the second month following the month in
which the enrollment termination is processed if it is processed after the
DSHS cut-off date for enrollment and the Contractor is not informed by DSHS
of the enrollment termination prior to the first day of the month following
the month in which it is processed by DSHS.






	 	4.9.2.2.	 	Enrollees Eligible for Supplemental Security Income (SSI):






	 	4.9.2.2.1.	 	Newborn enrollees who are determined by the Social Security
Administration (SSA) to have an SSI eligibility effective date within the
first sixty (60) days of life, not counting the birth date, shall be
ineligible for services under the terms of this Contract when DSHS receives
the SSI eligibility information from the SSA through the State Data
Exchange (SDX). Such newborn enrollees will have their
enrollment terminated retroactively effective the date of 




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	 	 	 	birth.
DSHS shall recoup premiums paid in accord with Recoupments
provisions of the Payment and Sanctions Section of this Contract.






	 	4.9.2.2.2.	 	Except as provided in this Section, enrollees determined by the SSA to
be eligible for SSI shall be ineligible for services under the terms of this
Contract when DSHS receives the SSI eligibility information from the SSA
through the electronic SDX. Such enrollees will have their enrollment
terminated prospectively. DSHS shall not recoup any premiums for enrollees
determined SSI eligible and the Contractor shall be responsible for
providing services under the terms of this Contract until the effective date
of the termination of enrollment.
	 
	 	4.9.2.2.3.	 	If the Contractor believes an enrollee has been determined by SSA to
be eligible for SSI, the Contractor shall present documentation of such
eligibility to DSHS, DSHS will attempt to verify the eligibility and, if the
enrollee is SSI eligible, DSHS will act upon SSI eligibility in accord with
this Section.






	 	4.9.3.	 	Newborns placed in foster care prior to discharge from their initial birth
hospitalization shall have their enrollment terminated effective their date of
birth.
	 
	 	4.9.4.	 	Involuntary Enrollment Termination Initiated by DSHS for Comparable Coverage or
Duplicate Coverage:






	 	4.9.4.1.	 	The Contractor shall notify DSHS, in accord with the Notices provision of
the General Terms and Conditions Section of this Contract, when an enrollee has
health care insurance coverage with the Contractor or any other carrier:






	 	4.9.4.1.1.	 	Within fifteen (15) working days when an enrollee is verified as
having duplicate coverage, as defined herein.
	 
	 	4.9.4.1.2.	 	Within forty-five (45) calendar days of the date when the Contractor
becomes aware that an enrollee has any health care insurance coverage with
any other insurance carrier. The Contractor is not responsible for the
determination of comparable coverage, as defined herein.






	 	4.9.4.2.	 	DSHS will involuntarily terminate the enrollment of any enrollee with
duplicate coverage or comparable coverage as follows:






	 	4.9.4.2.1.	 	When the enrollee has duplicate coverage that has been verified by
DSHS, DSHS shall terminate enrollment




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	 	 	 	retroactively to the beginning of the
month of duplicate coverage and recoup premiums as describe in the
Recoupments provisions of the Payment and Sanctions Section of this
Contract.






	 	4.9.4.2.2.	 	When the enrollee has comparable coverage which has been verified by
DSHS, DSHS shall terminate enrollment effective the first day of the second
month following the month in which the termination is processed if the
termination is processed on or before the DSHS cut-off date for enrollment
or, effective the first day of the third month following the month in which
the termination is processed if the termination is processed after the DSHS
cut-off date for enrollment.






	 	4.9.4.3.	 	When the enrollee is hospitalized outside the service area for more than
ninety (90) calendar days and the Contractor’s obligation to pay for services is
limited to ninety (90) calendar days under the Outside the Service Areas
provision of the Benefits Section of this Contract, DSHS shall terminate
enrollment effective the date that the Contractors obligation for payment ends.






	 	4.9.5.	 	Involuntary Termination Initiated by the Contractor: To request involuntary
termination of enrollment, the Contractor shall send written notice to DSHS as
described in Notices provision of the General Terms and Conditions Section of this
Contract.






	 	4.9.5.1.	 	DSHS shall review each involuntary termination request on a case-by-case
basis. The Contractor shall be notified in writing of an approval or
disapproval of the involuntary termination request within thirty (30) working
days of DSHS’ receipt of such notice and the documentation required to
substantiate the request. DSHS shall approve the request for involuntarily
termination of the enrollee when the Contractor has substantiated in writing all
of the following (42 CFR 438.56(b)(1)):






	 	4.9.5.1.1.	 	The enrollee’s behavior is inconsistent with the Contractor’s policies
and procedures addressing unacceptable enrollee behavior.
	 
	 	4.9.5.1.2.	 	The Contractor has provided a clinically appropriate evaluation to
determine whether there is a treatable condition contributing to the
enrollee’s behavior and such evaluation either finds no treatable condition
to be contributing, or, after evaluation and treatment, the
enrollee’s behavior continues to prevent the provider from safely
or prudently providing medical care to the enrollee.




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	 	4.9.5.1.3.	 	The enrollee received written notice from the Contractor of its intent
to request the enrollee’s termination of enrollment, unless the requirement
for notification has been waived by DSHS because the enrollee’s conduct
presents the threat of imminent harm to others. The Contractor’s notice to
the enrollee shall include the enrollee’s right to use the Contractor’s
grievance process to review the request to end the enrollee’s enrollment.






	 	4.9.5.2.	 	The Contractor shall continue to provide services to the enrollee until DSHS
has notified the Contractor in writing that enrollment is terminated.
	 
	 	4.9.5.3.	 	DSHS will not terminate enrollment of an enrollee solely due to a request
based on an adverse change in the enrollee’s health status, the cost of meeting
the enrollee’s health care needs, because of the enrollee’s utilization of
medical services, uncooperative or disruptive behavior resulting from their
special needs or treatable mental health condition (WAC 388-538-130 and 42 CFR
438.56(b)(2)).






	 	4.9.6.	 	An enrollee whose enrollment is terminated for any reason, other than
incarceration, at any time during the month is entitled to receive covered services,
at the Contractor’s expense, through the end of that month.
	 
	 	4.9.7.	 	In no event will an enrollee be entitled to receive services and benefits under
this Contract after the last day of the month in which their enrollment is
terminated, unless:






	 	4.9.7.1.	 	The enrollee is hospitalized at termination of enrollment and continued
payment is required in accord with the provisions of the Enrollee Hospitalized
at Enrollment and Enrollee Hospitalized at Termination of Enrollment in the
Benefits Section of this Contract.
	 
	 	4.9.7.2.	 	It is necessary to provide only coordination of care to transition the
enrollee’s care with another provider.
	 
	 	4.9.7.3.	 	It is necessary to satisfy the results of an appeal or hearing.






	 	4.10.	 	Enrollment Not Discriminatory:






	 	4.10.1.	 	The Contractor will not discriminate against enrollees or potential enrollees on
the basis of health status or need for health care services (42 CFR 438.6(d)(3)).
	 
	 	4.10.2.	 	The Contractor will not discriminate against enrollees or potential enrollees on
the basis of race, color, or national origin, and will not use 




33









 






	 	 	 	any policy or
practice that has the effect of discriminating on the basis of race, color, or
national origin (42 CFR 438.6(d)(4)).






	5.	 	MARKETING AND INFORMATION REQUIREMENTS






	 	5.1.	 	Marketing:






	 	5.1.1.	 	The Contractor’s policies and procedures related to Marketing shall ensure
compliance with the requirements described in this section.
	 
	 	5.1.2.	 	All marketing materials must be reviewed by and have the prior written approval of
DSHS prior to distribution (42 CFR 438.104(b)(1)(i)).
	 
	 	5.1.3.	 	Marketing materials shall not contain misrepresentations, or false, inaccurate or
misleading information (42 CFR 438.104(b)(2)).
	 
	 	5.1.4.	 	Marketing materials must be distributed in all service areas the Contractor serves
(42 CFR 438.104(b)(1)(ii)).
	 
	 	5.1.5.	 	Marketing materials must be in compliance with the, Equal Access for Enrollees and
Potential Enrollees with Communication Barriers provisions of this Section.






	 	5.1.5.1.	 	Marketing materials in English must give directions in the Medicaid eligible
population’s primary languages for obtaining understandable materials.
	 
	 	5.1.5.2.	 	DSHS may determine, in its sole judgment, if materials that are primarily
visual meet the requirements of this Contract.






	 	5.1.6.	 	The Contractor shall not offer anything of value as an inducement to enrollment.
	 
	 	5.1.7.	 	The Contractor shall not offer the sale of other insurance to attempt to influence
enrollment (42 CFR 438.104(b)(1)(iv)).
	 
	 	5.1.8.	 	The Contractor shall not directly or indirectly conduct door-to-door, telephonic
or other cold-call marketing of enrollment (42 CFR 438.104(b)(1)(v)).
	 
	 	5.1.9.	 	The Contractor shall not make any assertion or statement, whether written or oral,
in marketing materials that a Medicaid recipient must enroll with the Contractor in
order to obtain benefits or in order not to lose benefits (42 CFR 438.104(b)(2)(i)).
	 
	 	5.1.10.	 	The Contractor shall not make any assertion or statement, whether written or
oral, in marketing materials that the Contractor is endorsed by 




34









 






	 	 	 	CMS, the Federal or
State government or similar entity (42 CFR 438.104(b)(2)(ii)).






	 	5.2.	 	Information Requirements for Enrollees and Potential Enrollees:






	 	5.2.1.	 	The Contractor’s policies and procedures related to Information Requirements shall
ensure compliance with the requirements described in this section.






	 	5.2.1.1.	 	The Contractor shall provide sufficient, accurate oral and written
information to potential enrollees to assist them in making an informed decision
about enrollment in accord with the provisions of this Section (SSA 1932(d)(2)
and 42 CFR 438.10 and 438.104(b)(1)(iii)).
	 
	 	5.2.1.2.	 	The Contractor shall provide to potential enrollees upon request and to each
enrollee, within fifteen (15) working days of enrollment, at any time upon
request, and at least once a year, the information needed to understand benefit
coverage and obtain care in accord with the provisions of this Section (42 CFR
438.10(b)(3) and 438.10(f)(3)).
	 
	 	5.2.1.3.	 	At least thirty (30) calendar days prior to distribution, all enrollee
information shall be submitted to DSHS for written approval. DSHS may waive the
thirty day requirement if, in DSHS’ sole judgment, it is in the best interest of
DSHS and its clients.
	 
	 	5.2.1.4.	 	Changes to State or Federal law shall be reflected in information to
enrollees no more than ninety (90) calendar days after the effective date of the
change and enrollees shall be notified at least thirty (30) calendar days prior
to the effective date if, in the sole judgment of DSHS, the change is
significant in regard to the enrollees’ quality of or access to care. DSHS
shall notify the Contractor of any significant change in writing (42 CFR
438.6(i)(4) and 438.10(f)(4)).
	 
	 	5.2.1.5.	 	The Contractor shall provide to enrollees and potential enrollees written
information about:






	 	5.2.1.5.1.	 	Choosing a PCP, including general information on available PCPs and
how to obtain specific information including a list of PCPs that includes
their identity, location, languages spoken, qualifications, practice
restrictions, and availability.
	 
	 	5.2.1.5.2.	 	Changing PCPs.
	 
	 	5.2.1.5.3.	 	Accessing services outside the Contractor’s service area.




35









 












	 	5.2.1.5.4.	 	Accessing Emergency Services.
	 
	 	5.2.1.5.5.	 	Accessing hospital care and how to get a list of hospitals that are
available to enrollees.
	 
	 	5.2.1.5.6.	 	Specialists available to enrollees and how to obtain specific
information including a list of specialists that includes their identity,
location, languages spoken, qualifications, practice restrictions, and
availability.
	 
	 	5.2.1.5.7.	 	Limitations to the availability of or referral to specialists to
assist the enrollee in selecting a PCP, including any medical group
restrictions.
	 
	 	5.2.1.5.8.	 	Direct access to a Woman’s Healthcare specialist within the
Contractor’s network.
	 
	 	5.2.1.5.9.	 	Obtaining information regarding Physician Incentive Plans (42 CFR
422.208 and 422.210).
	 
	 	5.2.1.5.10.	 	Obtaining information on the Contractor’s structure and operations
(42 CFR 438.10(g)).
	 
	 	5.2.1.5.11.	 	Informed consent guidelines.
	 
	 	5.2.1.5.12.	 	Conversion rights under RCW 48.46.450 or RCW 48.44.370.
	 
	 	5.2.1.5.13.	 	Requesting a termination of enrollment.
	 
	 	5.2.1.5.14.	 	Information regarding advance directives to include (42 CFR 422.128
and 438.6(i)(1 and 3)):






	 	5.2.1.5.14.1.	 	A statement about an enrollee’s right to make decisions
concerning an enrollee’s medical care, accept or refuse surgical or
medical treatment, execute an advance directive, and revoke an advance
directive at any time.
	 
	 	5.2.1.5.14.2.	 	The Contractor’s written policies and procedures concerning
advance directives, including any policy that would preclude the
Contractor or subcontractor from honoring an enrollee’s advance
directive.
	 
	 	5.2.1.5.14.3.	 	An enrollee’s rights under state law, including the right to
file a grievance with the Contractor or DSHS regarding compliance with
advance directive requirements in accord with the Advance Directive




36









 






	 	 	 	provisions of the Enrollee Rights and Protections Section of this
Contract .






	 	5.2.1.5.15.	 	How to recommend changes in the Contractor’s policies and procedures.
	 
	 	5.2.1.5.16.	 	Health promotion, health education and preventive health services
available.
	 
	 	5.2.1.5.17.	 	Information on the Contractor’s Grievance System including (42 CFR
438.10(f)(2), 438.10(f)(6)(iv), 438.10(g)(1) and SMM2900 and 2902.2):






	 	5.2.1.5.17.1.	 	How to obtain assistance from the Contractor in using the
grievance, appeal and independent review processes (must assure enrollees
that information will be kept confidential except as needed to process
the grievance, appeal or independent review).
	 
	 	5.2.1.5.17.2.	 	The enrollees’ right to and how to initiate a grievance or file
an appeal, in accord with the Contractor’s DSHS approved policies and
procedures regarding grievances and appeals.
	 
	 	5.2.1.5.17.3.	 	The enrollees’ right to and how to request a hearing after the
Contractor’s appeal process is exhausted, how to request a hearing and
the rules that govern representation at the hearing.
	 
	 	5.2.1.5.17.4.	 	The enrollees’ right to and how to request an independent review
in accord with RCW 48.43.535 and WAC 246-305 after the hearing process is
exhausted and how to request an independent review.
	 
	 	5.2.1.5.17.5.	 	The enrollees’ right to appeal an independent review decision to
the Board of Appeals and how to request such an appeal.
	 
	 	5.2.1.5.17.6.	 	The requirements and timelines for grievances, appeals,
hearings, independent review and Board of Appeals.
	 
	 	5.2.1.5.17.7.	 	The enrollees’ rights and responsibilities, including potential
payment liability, regarding the continuation of services that are the
subject of appeal or a hearing.




37









 












	 	5.2.1.5.17.8.	 	The availability of toll-free numbers for information about
grievances and appeals and to file a grievance or appeal.






	 	5.2.1.5.18.	 	The enrollee’s rights and responsibilities with respect to receiving
covered services.
	 
	 	5.2.1.5.19.	 	Information about covered benefits and how to contact DSHS regarding
services that may be covered by DSHS, but are not covered benefits under
this Contract.
	 
	 	5.2.1.5.20.	 	Specific information regarding EPSDT and childhood immunizations as
described in the Benefits Section of this Contract.
	 
	 	5.2.1.5.21.	 	Information regarding the availability of and how to access or obtain
interpretation services and translation of written information at no cost to
the enrollee (42 CFR 438.10(c)(5)(i and ii)).
	 
	 	5.2.1.5.22.	 	How to obtain information in alternative formats (42 CFR
438.10(d)(2)).
	 
	 	5.2.1.5.23.	 	The enrollee’s right to and procedure for obtaining a second opinion
free of charge.
	 
	 	5.2.1.5.24.	 	The prohibition on charging enrollees for covered services, the
procedure for reporting charges the enrollee receives for covered services
to the Contractor and circumstances under which an enrollee might be charged
for services.
	 
	 	5.2.1.5.25.	 	Information regarding the Contractors appointment wait time
standards.






	 	5.2.1.6.	 	DSHS agrees to provide the Contractor with copies of written client
information, which DSHS intends to distribute to enrollees.






	 	5.3.	 	Equal Access for Enrollees & Potential Enrollees with Communication Barriers:
The Contractor shall assure equal access for all enrollees and potential enrollees when
oral or written language creates a barrier to such access for enrollees and potential
enrollees with communication barriers (42 CFR 438.10).






	 	5.3.1.	 	The Contractor’s policies and procedures related to Equal Access for Enrollees and
Potential Enrollees with Communication Barriers shall ensure compliance with the
requirements described in this section.
	 
	 	5.3.2.	 	Oral Information:




38









 












	 	5.3.2.1.	 	The Contractor shall assure that interpreter services are provided for
enrollees and potential enrollees with a primary language other than English,
free of charge (42 CFR 438.10(c)(4)). Interpreter services shall be provided
for all interactions between such enrollees or potential enrollees and the
Contractor or any of its providers including, but not limited to:






	 	5.3.2.1.1.	 	Customer service
	 
	 	5.3.2.1.2.	 	All appointments with any provider for any covered service
	 
	 	5.3.2.1.3.	 	Emergency services
	 
	 	5.3.2.1.4.	 	All steps necessary to file grievances and appeals.






	 	5.3.2.2.	 	The Contractor is responsible for payment for interpreter services for
Contractor administrative matters including, but not limited to handling
enrollee grievances and appeals.
	 
	 	5.3.2.3.	 	DSHS is responsible for payment for interpreter services provided by
interpreter agencies contracted with the state for outpatient medical visits and
hearings.
	 
	 	5.3.2.4.	 	Hospitals are responsible for payment for interpreter services during
inpatient stays.
	 
	 	5.3.2.5.	 	Public entities, such as Public Health Departments, are responsible for
payment for interpreter services provided at their facilities or affiliated
sites.
	 
	 	5.3.2.6.	 	Interpreter services include the provision of interpreters for enrollees and
potential enrollees who are deaf or hearing impaired at no cost to the enrollee
or potential enrollee (42 CFR 438.10(c)(4)).






	 	5.3.3.	 	Written Information:






	 	5.3.3.1.	 	The Contractor shall provide all generally available and client-specific
written materials in a language and format which may be understood by each
individual enrollee and potential enrollee (42 CFR 438.10(c)(3) and
438.10(d)(1)(ii)).






	 	5.3.3.1.1.	 	If five percent (5%) or more of the Contractor’s enrollees speak a
specific language other than English, generally available materials will be
translated into that language.




39









 












	 	5.3.3.1.2.	 	For enrollees whose primary language is not translated or whose need
cannot be addressed by translation as required by the provisions of this
Section, the Contractor may meet the requirement of this Section by doing
any one of the following:






	 	5.3.3.1.2.1.	 	Translating the material into the enrollee’s or potential
enrollee’s primary reading language.
	 
	 	5.3.3.1.2.2.	 	Providing the material on tape in the enrollee’s or potential
enrollee’s primary language.
	 
	 	5.3.3.1.2.3.	 	Having an interpreter read the material to the enrollee or
potential enrollee in the enrollee’s primary language.
	 
	 	5.3.3.1.2.4.	 	Providing the material in another alternative medium or format
acceptable to the enrollee or potential enrollee. The Contractor shall
document the enrollee’s or potential enrollee’s acceptance of the
material in an alternative medium or format (42 CFR 438.10(d)(1)(ii)).
	 
	 	5.3.3.1.2.5.	 	Providing the material in English, if the Contractor documents
the enrollee’s or potential enrollee’s preference for receiving material
in English.






	 	5.3.3.2.	 	The Contractor shall ensure that all written information provided to
enrollees or potential enrollees is accurate, is not misleading, is
comprehensible to its intended audience, designed to provide the greatest degree
of understanding, and is written at the sixth grade reading level and fulfils
other requirements of the Contract as may be applicable to the materials (42 CFR
438.10(b)(1)).
	 
	 	5.3.3.3.	 	DSHS may make exceptions to the sixth grade reading level when, in the sole
judgment of DSHS, the nature of the materials do not allow for a sixth grade
reading level or the enrollees’ needs are better served by allowing a higher
reading level. DSHS approval of exceptions to the sixth grade reading level
must be in writing.
	 
	 	5.3.3.4.	 	Disease Management materials, preventative services or other education
materials used by the Contractor for health promotion efforts that are not
developed by the Contractor or developed under contract with the Contractor are
not required to meet the
sixth grade reading level requirement.
	 
	 	5.3.3.5.	 	All written materials must have the written approval of DSHS prior to use.
For client-specific written materials, the Contractor may use templates that
have been pre-approved in writing by DSHS.





40









 





	 	 	 	The Contractor must provide DSHS
with a copy of all approved materials in final form.






	6.	 	PAYMENT AND SANCTIONS






	 	6.1.	 	Rates/Premiums:






	 	6.1.1.	 	Subject to the Sanctions provisions of this Section, DSHS shall pay a monthly
premium for each enrollee in full consideration of the work to be performed by the
Contractor under this Contract. DSHS shall pay the Contractor, on or before the
tenth (10th) working day of the month based on the DSHS list of enrollees whose
enrollment is ongoing or effective on the first day of said calendar month. Such
payment will be denied for new enrollees when, and for so long as, payment for those
enrollees is denied by the Centers for Medicare and Medicaid Services (CMS) under 42
CFR 438.726(b) or 42 CFR 438.730(e).
	 
	 	6.1.2.	 	The Contractor shall reconcile the electronic benefit enrollment file with the
premium payment information and submit a claim to DSHS for any amount due the
Contractor within three hundred sixty-five (365) calendar days of the month of
service. Any claim submitted after the 365-day period will be denied. When DSHS’
records confirm the Contractor’s claim, DSHS shall remit payment within thirty (30)
calendar days of the receipt of the claim.
	 
	 	6.1.3.	 	The statewide Base Rate, Geographical Adjustment Factors, Risk Adjustment Factors
and Age/Sex Factors are in Exhibit A, Premiums, Service Areas, and Capacity.
	 
	 	6.1.4.	 	The monthly premium payment will be calculated as follows:

	 
	 	 	 	Premium Payment = Base Rate x Age/Sex Factor x Risk Adjustment Factor x
Geographical Adjustment Factor as described herein.
	 
	 	6.1.5.	 	Following the end of the annual legislative session, DSHS will provide to the
Contractor the Base Rate, Age/Sex Factors, Risk Adjustment Factors, and Geographical
Adjustment Factors for the following calendar year. DSHS will provide rates at
least one hundred and twenty (120) calendar days prior to the first day of the
following year. If the Contractor will not continue to provide HO/SCHIP services in
the following calendar year, the Contractor shall notify DSHS no later than thirty
(30) calendar days after the publication of the rates and factors as required under
the Notices provisions of the General Terms and
Conditions Section of this Contract. If the Contractor notifies DSHS, this
Contract shall terminate, without penalty to either party, effective midnight,
December 31, of the current year. The termination will be considered a
termination for convenience under the Termination for Convenience provisions
of the General Terms and Conditions Section of 




41









 






	 	 	 	this Contract, but neither
party shall have the right to assert a claim for costs.






	 	6.1.6.	 	The Geographical Adjustment Factors will be adjusted by DSHS for the period
January 1, through December 31, of the following year for changes in utilization. In
addition, the payment for Critical Access Hospitals (CAH) as required in the
Payments to CAH provision in this Section may be prospectively updated by DSHS if,
in DSHS’ judgment, there are material changes in rates or utilization related to
CAH.
	 
	 	6.1.7.	 	The Risk Adjustment Factor will be recalculated by DSHS for the period January 1,
through December 31, of the following year based on the most currently available
enrollment and encounter data Risk Adjustment Factors may be recalculated by DSHS
if, in DSHS’ sole judgment, changes in contractor participation in HO/SCHIP require
changes to the Risk Adjustment Factors.
	 
	 	6.1.8.	 	Each year DSHS will develop a Quality Incentive based on HEDIS® measures for
childhood immunizations and well child visits. The Quality Incentive information
and amounts will be provided in writing to all HO/SCHIP contractors prior to
generating payments for the Quality Incentive at the end of the first quarter of the
year.
	 
	 	6.1.9.	 	Notwithstanding an Amendment as defined in the General Terms and Conditions
Section of this Contract, DSHS may modify Exhibit A, Premiums, Service Areas, and
Capacity to add any changes in service areas, capacity, the Base Rate, Geographical
Adjustment Factors, and Risk Adjustment Factors as needed. DSHS will provide such
modifications to the Contractor in writing. If the Contractor does not disagree in
writing with the modifications within fifteen (15) calendar days of the date the
modifications are provided, the change will amend the Contract without any further
action. If the Contractor does not accept the modifications, DSHS will terminate
this Contract for convenience as provided herein, but neither party shall have a
right to assert a claim for costs. If the modification changes the premium
payments, the update is subject to CMS approval.
	 
	 	6.1.10.	 	DSHS shall automatically generate newborn premiums whenever possible. For
newborns whose premiums DSHS does not automatically generate, the Contractor shall
submit a supplemental premium payment request to DSHS within 365 calendar days of
the month of service. The Contractor shall be responsible for reviewing monthly
data provided by DSHS of the newborn premiums to determine whether a supplemental
premium request needs to be submitted. DSHS shall pay supplemental premiums
through the end of the month in which the sixtieth (60th) day of life occurs.




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	 	6.1.11.	 	DSHS shall make a full monthly payment to the Contractor for the month in which
an enrollee’s enrollment is terminated except as otherwise provided herein.
	 
	 	6.1.12.	 	The Contractor shall be responsible for covered medical services provided to the
enrollee in any month for which DSHS paid the Contractor for the enrollee’s care
under the terms of this Contract.






	 	6.2.	 	Delivery Case Rate Payment: A one-time payment of $5,500.00 shall be made to
the Contractor for labor and delivery expenses for enrollees enrolled with the
Contractor during the month of delivery. The Delivery Case Rate shall only be paid to
the Contractor if it has incurred expenses for and paid for labor and delivery.
Delivery includes both live and stillbirths, but does not include miscarriage, induced
abortion, or other fetal demise not requiring labor and delivery to terminate the
pregnancy.
	 
	 	6.3.	 	Renegotiation of Rates: The base rate set forth herein shall be subject to
renegotiation during the Contract period only if DSHS, in its sole judgment, determines
that it is necessary due to a change in federal or state law or other material changes,
beyond the Contractor’s control, which would justify such a renegotiation.
	 
	 	6.4.	 	Reinsurance/Risk Protection: The Contractor may obtain reinsurance for
coverage of enrollees only to the extent that it obtains such reinsurance for other
groups enrolled by the Contractor, provided that the Contractor remains ultimately
liable to DSHS for the services rendered.
	 
	 	6.5.	 	Recoupments:






	 	6.5.1.	 	Unless mutually agreed by the parties in writing, DSHS shall only recoup premium
payments and retroactively terminate enrollment for individual enrollees who are:






	 	6.5.1.1.	 	Covered by the Contractor with duplicate coverage.
	 
	 	6.5.1.2.	 	Deceased prior to the month of enrollment. Premium payments shall be
recouped effective the first day of the month following the enrollee’s date of
death.
	 
	 	6.5.1.3.	 	Placed in the foster care medical program.
	 
	 	6.5.1.4.	 	Retroactively have their enrollment terminated consistent with the
Termination of Enrollment provisions of the Enrollment Section of this Contract.
	 
	 	6.5.1.5.	 	Newborns determined to have an SSI eligibility effective date within the
first sixty (60) days of life in accord with the provisions in the Enrollees
Eligible for Social Security Income (SSI) of the




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	 	 	 	Enrollment Section of this
Contract. DSHS shall recoup all premiums paid for the enrollee, but not the
birth mother or any other family member, back to the month of birth.






	 	6.5.1.6.	 	Found ineligible for enrollment with the Contractor, provided DSHS has
notified the Contractor before the first day of the month for which the premium
was paid.
	 
	 	6.5.1.7.	 	Incarcerated for any full month of enrollment.






	 	6.5.2.	 	The Contractor may recoup payments made to providers for services provided to
enrollees during the period for which DSHS recoups premiums for those enrollees. If
the Contractor recoups said payments, providers may submit appropriate claims for
payment to DSHS through its fee-for-service program.
	 
	 	6.5.3.	 	When DSHS recoups premiums and retroactively terminates the enrollment of an
enrollee, DSHS will not recoup premiums and retroactively terminate the enrollment
of any other family member, except for newborns whose mother’s enrollment is
terminated for duplicate coverage.






	 	6.6.	 	Information for Rate Setting and Methodology: For rate setting only, the
Contractor shall annually provide information regarding its cost experience related to
the provision of the services required under this Contract. The experience information
shall be provided directly to an actuary designated by DSHS. The designated actuary
will determine the timing, content, format and medium for such information. DSHS sets
actuarially-sound managed care rates.
	 
	 	6.7.	 	Payments to Critical Access Hospitals (CAH): For services provided by CAH to
enrollees, the Contractor shall pay the CAH the prospective Inpatient and Outpatient
Departmental Weighted Cost-to-Charge rates published by DSHS for the fee-for-service
program (see Attachment A for website link).
	 
	 	6.8.	 	Stop Loss for Hemophiliac Drugs: DSHS will provide stop loss protection for
the Contractor for paid claims for Factors VII, VIII and IX and the anti-inhibitor for
enrollees with a diagnosis of hemophilia as identified by diagnosis codes 286.0-286.3,
V83.01 and V83.02. DSHS will reimburse the Contractor seventy-five
percent (75%) of all verifiable paid claims for the identified hemophiliac drugs in
excess of $250,000 for any single enrollee enrolled with the Contractor during each
contract year. The Contractor must submit documentation of paid claims as required
by DSHS.
	 
	 	6.9.	 	Encounter Data: The Contractor shall comply with the required format provided
in the Encounter Data Transaction Guide published by DSHS (see Attachment A for website
link). Encounter data includes claims paid by the Contractor for services delivered to
enrollees through the Contractor during a 




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	 	 	 	specified reporting period. DSHS collects
and uses this data for many reasons such as: federal reporting (42 CFR 438.242(b)(1));
rate setting and risk adjustment; service verification, managed care quality
improvement program, utilization patterns and access to care; DSHS hospital rate
setting; and research studies.






DSHS may change the Encounter Data Transaction Guide with one hundred and fifty (150)
calendar days’ written notice to the Contractor. The Encounter Data Transaction Guide
may be changed with less than one hundred and fifty (150) calendar days’ notice by
mutual agreement of the Contractor and DSHS. The Contractor shall, upon receipt of
such notice from DSHS, provide notice of changes to subcontractors.




	 	6.10.	 	Emergency Services by Non-Contracted Providers: The Contractor shall limit
payment for emergency services furnished by any provider who does not have a contract
with the Contractor to the amount that would be paid for the services if they were
provided under DSHS’ Medicaid FFS program (Deficit Reduction Act of 2005, Public Law
No. 109-171, Section 6085).
	 
	 	6.11.	 	Data Certification Requirements: Any information and/or data required by this
Contract and submitted to DSHS shall be certified by the Contractor as follows (42 CFR
438.242(b)(2) and 438.600 through 438.606):






	 	6.11.1.	 	Source of certification: The information and/or data shall be certified by one
of the following:






	 	6.11.1.1.	 	The Contractor’s Chief Executive Officer.
	 
	 	6.11.1.2.	 	The Contractor’s Chief Financial Officer.
	 
	 	6.11.1.3.	 	An individual who has delegated authority to sign for, and who reports
directly to, the Contractor’s Chief Executive Officer or Chief Financial
Officer.






	 	6.11.2.	 	Content of certification: The Contractor’s certification shall attest, based on
best knowledge, information, and belief, to the accuracy, completeness and
truthfulness of the information and/or data.
	 
	 	6.11.3.	 	Timing of certification: The Contractor shall submit the certification
concurrently with the certified information and/or data.
	 
	 	6.11.4.	 	DSHS will identify the specific data that requires certification.






	 	6.12.	 	Sanctions:






	 	6.12.1.	 	If the Contractor fails to meet one or more of its obligations under the terms of
this Contract or other applicable law, DSHS may impose sanctions by withholding up
to five percent of its scheduled payments to




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	 	 	 	the Contractor.






	 	6.12.1.1.	 	DSHS may withhold payment from the end the cure period until the default is
cured or any resulting dispute is resolved in the Contractor’s favor.
	 
	 	6.12.1.2.	 	DSHS will notify the Contractor in writing of the basis and nature of any
sanctions, and if, applicable, provide a reasonable deadline for curing the
cause for the sanction before imposing sanctions. The Contractor may request a
dispute resolution, as described in the Disputes provisions of the General Terms
and Conditions Section of this Contract, if the Contractor disagrees with DSHS’
position.






	 	6.12.2.	 	DSHS, CMS or the Office of the Inspector General (OIG) may impose intermediate
sanctions in accord with 42 CFR 438.700, 42 CFR 438.702, 42 CFR 438.704, 45 CFR
92.36(i)(1), 42 CFR 422.208 and 42 CFR 422.210 against the Contractor for:






	 	6.12.2.1.	 	Failing to provide medically necessary services that the Contractor is
required to provide, under law or under this Contract, to an enrollee covered
under this Contract.
	 
	 	6.12.2.2.	 	Imposing on enrollees premiums or charges that are in excess of the
premiums or charges permitted under law or under this Contract.
	 
	 	6.12.2.3.	 	Acting to discriminate against enrollees on the basis of their health
status or need for health care services. This includes termination of
enrollment or refusal to reenroll an enrollee, except as permitted under law or
under this Contract, or any practice that would reasonably be expected to
discourage enrollment by enrollees whose medical condition or history indicates
probable need for substantial future medical services.
	 
	 	6.12.2.4.	 	Misrepresenting or falsifying information that it furnishes to CMS, DSHS,
an enrollee, potential enrollee or any of its subcontractors.
	 
	 	6.12.2.5.	 	Failing to comply with the requirements for physician incentive plans.
	 
	 	6.12.2.6.	 	Distributing directly or indirectly through any agent or independent
contractor, marketing materials that have not been approved by DSHS or that
contain false or materially misleading information.




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	 	6.12.2.7.	 	Violating any of the other requirements of Sections 1903(m) or 1932 of the
Social Security Act, and any implementing regulations.
	 
	 	6.12.2.8.	 	Intermediate sanctions may include:






	 	6.12.2.8.1.	 	Civil monetary penalties in the following amounts:






	 	6.12.2.8.1.1.	 	A maximum of $25,000 for each determination of failure to
provide services; misrepresentation or false statements to enrollees,
potential enrollees or healthcare providers; failure to comply with
physician incentive plan requirements; or marketing violations;
	 
	 	6.12.2.8.1.2.	 	A maximum of $100,000 for each determination of discrimination;
or misrepresentation or false statements to CMS or DSHS;
	 
	 	6.12.2.8.1.3.	 	A maximum of $15,000 for each potential enrollee DSHS determines
was not enrolled because of a discriminatory practice subject to the
$100,000 overall limit; and
	 
	 	6.12.2.8.1.4.	 	A maximum of $25,000 or double the amount of the charges,
whichever is greater, for charges to enrollees that are not allowed under
managed care. DSHS will deduct from the penalty the amount charged and
return it to the enrollee.






	 	6.12.2.8.2.	 	Appointment of temporary management for the Contractor as provided in
42 CFR 438.706. DSHS will only impose temporary management if it finds that
the Contractor has repeatedly failed to meet substantive requirements in
Sections 1903(m) or 1932 of the Social Security Act. Temporary management
will be imposed in accord with RCW 48.44.033 or other applicable law.
	 
	 	6.12.2.8.3.	 	Suspension of all new enrollments, including default enrollment,
after the effective date of the sanction. DSHS shall notify current
enrollees of the sanctions and that they may terminate enrollment at any
time.
	 
	 	6.12.2.8.4.	 	Suspension of payment for enrollees enrolled after the effective date
of the sanction and until CMS or DSHS is satisfied that the reason for
imposition of the sanction no longer exists and is not likely to recur.




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	 	7.	 	ACCESS AND CAPACITY






	 	7.1.	 	Access and Capacity Policy and Procedure Requirements: The Contractor’s
policies and procedures related to access and capacity shall ensure compliance with the
requirements described in this section.
	 
	 	7.2.	 	Network Capacity:






	 	7.2.1.	 	The Contractor shall maintain and monitor an appropriate provider network,
supported by written agreements, sufficient to serve enrollees enrolled under this
Contract (42 CFR 438.206(b)(1)).
	 
	 	7.2.2.	 	The Contractor shall provide covered services required by this Contract through
non-participating providers, at a cost to the enrollee that is no greater than if
the covered services were provided by participating providers, if its network of
participating providers is insufficient to meet the medical needs of enrollees in a
manner consistent with this Contract. The Contractor shall adequately and timely
cover these services out of network for as long as the Contractor’s network is
inadequate to provide them (42 CFR 438.206(b)(4)). This provision shall not be
construed to require the Contractor to cover such services without authorization
except as required for emergency services.
	 
	 	7.2.3.	 	The Contractor must submit documentation regarding its maintenance, monitoring and
analysis of the network to determine compliance with the requirements of this
Section, at any time upon DSHS request or when there has been a change in the
Contractor’s network or operations that, in the sole judgment of DSHS, would
adversely affect adequate capacity and/or the Contractor’s ability to provide
services (42 CFR 438.207(b & c)).
	 
	 	7.2.4.	 	With the written approval of DSHS, the Contractor may increase capacity or set its
capacity to unlimited at any time by giving written notice to DSHS. For unlimited
capacity, DSHS will set capacity at the total number of eligibles in the service
area. The Contractor shall provide evidence, as DSHS requires, demonstrating the
Contractor’s
ability to support the capacity increase. DSHS may withhold approval of a
requested capacity increase, if, in DSHS’ sole judgment, the requested
increase is not in the best interest of DSHS.
	 
	 	7.2.5.	 	The Contractor may decrease capacity by giving DSHS sixty (60) calendar days’
written notice. The decrease shall not be effective until the first day of the
month which falls after the sixty (60) calendar days has elapsed. Exhibit A,
Premiums, Service Areas, and Capacity will be updated by DSHS for increases and
decreases in capacity.






	 	7.3.	 	Service Delivery Network: In the maintenance and monitoring of its network,
the Contractor must consider the following (42 CFR 438.206(b)):




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	 	7.3.1.	 	Expected enrollment.
	 
	 	7.3.2.	 	The stated capacity in Exhibit A of this Contract.
	 
	 	7.3.3.	 	Adequate access to all services covered under this Contract.
	 
	 	7.3.4.	 	The expected utilization of services, taking into consideration the
characteristics and health care needs of the Medicaid population represented by the
Contractor’s enrollees.
	 
	 	7.3.5.	 	The number and types (in terms of training, experience and specialization) of
providers required to furnish the contracted services.
	 
	 	7.3.6.	 	The number of network providers who are not accepting new Medicaid enrollees.
	 
	 	7.3.7.	 	The geographic location of providers and enrollees, considering distance, travel
time, the means of transportation ordinarily used by potential enrollees, and
whether the location provides physical access for the Contractor’s enrollees with
disabilities.
	 
	 	7.3.8.	 	The cultural, ethnic, race and language needs of enrollees.






	 	7.4.	 	Timely Access to Care: The Contractor shall have contracts in place with all
subcontractors that meet state standards for access, taking into account the urgency of
the need for services (42 CFR 438.206(b) & (c)(1)(i))). The Contractor shall ensure
that:






	 	7.4.1.	 	Network providers offer access comparable to that offered to commercial enrollees
or comparable to Medicaid fee-for-service, if the Contractor serves only Medicaid
enrollees (42 CFR 438.206(b)(1)(iv) & (c)(1)(ii))).
	 
	 	7.4.2.	 	Mechanisms are established to ensure compliance by providers.
	 
	 	7.4.3.	 	Providers are monitored regularly to determine compliance.
	 
	 	7.4.4.	 	Corrective action is initiated and documented if there is a failure to comply.






	 	7.5.	 	Hours of Operation for Network Providers: The Contractor must require that
network providers offer hours of operation for enrollees that are no less than the
hours of operation offered to any other patient (42 CFR 438.206(c)(1)(iii)).
	 
	 	7.6.	 	24/7 Availability: The Contractor shall have the following services available
on a 24-hour-a-day, seven-day-a-week basis by telephone. These services




49









 






	 	 	 	may be
provided directly by the Contractor or may be delegated to subcontractors (42 CFR
438.206(c)(1)(iii)).






	 	7.6.1.	 	Medical advice for enrollees from licensed health care professionals.
	 
	 	7.6.2.	 	Triage concerning the emergent, urgent or routine nature of medical conditions by
licensed health care professionals.
	 
	 	7.6.3.	 	Authorization of services.
	 
	 	7.6.4.	 	Emergency drug supply, as described in the General Description of Covered Services
provisions of the Benefits Section of this Contract.






	 	7.7.	 	Appointment Standards: The Contractor shall comply with appointment standards
that are no longer than the following (42 CFR 438.206(c)(1)(i)):






	 	7.7.1.	 	Non-symptomatic (i.e., preventive care) office visits shall be available from the
enrollee’s PCP or another provider within thirty (30) calendar days. A
non-symptomatic office visit may include, but is not limited to, well/preventive
care such as physical examinations, annual gynecological examinations, or child and
adult immunizations.
	 
	 	7.7.2.	 	Non-urgent, symptomatic (i.e., routine care) office visits shall be available from
the enrollee’s PCP or another provider within ten (10) calendar days. A non-urgent,
symptomatic office visit is associated with the presentation of medical signs not
requiring immediate attention.
	 
	 	7.7.3.	 	Urgent, symptomatic office visits shall be available from the enrollee’s PCP or
another provider within forty-eight (48) hours. An urgent, symptomatic visit is
associated with the presentation of medical signs that require immediate attention,
but are not life threatening.
	 
	 	7.7.4.	 	Emergency medical care shall be available twenty-four (24) hours per day, seven
(7) days per week.






	 	7.8.	 	Integrated Provider Network Database (IPND): The Contractor shall report its
complete provider network, to include all current contracted providers, monthly to DSHS
through the designated data management contact in accord with the Provider Network
Reporting Requirements published by DSHS (see Attachment A for website link)(42 CFR
438.242(b)(1)).
	 
	 	7.9.	 	Provider Network — Distance Standards:






	 	7.9.1.	 	The Contractor network of providers shall meet the distance standards below in
every service area. The designation of a zip code in a service area as rural or
urban is in Exhibit A, Premiums, Service Areas, and Capacity.




50









 












	 	7.9.1.1.	 	PCP






Urban: 2 within 10 miles for 90% of enrollees in the Contractor’s service area.




Rural: 1 within 25 miles for 90% of enrollees in the Contractor’s service area.




	 	7.9.1.2.	 	Obstetrics






Urban: 2 within 10 miles for 90% of enrollees in the Contractor’s service area.




Rural: 1 within 25 miles for 90% of enrollees in the Contractor’s service area.




	 	7.9.1.3.	 	Pediatrician or Family Practice Physician Qualified to Provide Pediatric
Services






Urban: 2 within 10 miles for 90% of enrollees in the Contractor’s service area.




Rural: 1 within 25 miles for 90% of enrollees in the Contractor’s service area.




	 	7.9.1.4.	 	Hospital






Urban/Rural: 1 within 25 miles for 90% of enrollees in the Contractor’s service
area.




	 	7.9.1.5.	 	Pharmacy






Urban: 1 within 10 miles for 90% of enrollees in the Contractor’s service area.




Rural: 1 within 25 miles for 90% of enrollees in the Contractor’s service area.




	 	7.9.2.	 	DSHS may, in its sole discretion, grant exceptions to the distance standards.
DSHS’ approval of an exception shall be in writing. The Contractor shall request an
exception in writing and shall provide evidence as DSHS may require to support the
request. If the closest provider of the type subject to the standards in this
section is beyond the distance standard applicable to the zip code, the distance
standard defaults to the distance to that provider. The closest provider may be a
provider not participating with the Contractor.




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	 	7.10.	 	Distance Standards for High Volume Specialty Care Providers: The Contractor
shall establish and meet measurable distance standards for high volume Specialty Care
Providers to enrollees. The Contractor shall analyze performance against standards at
minimum, annually.
	 
	 	7.11.	 	Standards for the Ratio of Primary Care and Specialty Providers to Enrollees:
The Contractor shall establish and meet measurable standards for the ratio of both PCPs
and high volume Specialty Care Providers to enrollees. The Contractor shall analyze
performance against standards at minimum, annually.
	 
	 	7.12.	 	Access to Specialty Care:






	 	7.12.1.	 	The Contractor shall provide all medically necessary specialty care for enrollees
in a service area. If an enrollee needs specialty care from a type of specialist
who is not available within the Contractor’s provider network, the Contractor shall
provide the necessary services with a qualified specialist outside the Contractor’s
provider network.
	 
	 	7.12.2.	 	The Contractor shall maintain, and make readily available to providers,
up-to-date information on the Contractor available network of specialty providers
and shall provide any required assistance to providers in obtaining timely referral
to specialty care.






	 	7.13.	 	Capacity Limits and Order of Acceptance:






	 	7.13.1.	 	The Contractor shall provide care to all enrollees who voluntarily choose the
Contractor. The Contractor shall accept assignments up to the capacity limits in
Exhibit A, Premiums, Service Areas, and Capacity.
	 
	 	7.13.2.	 	Enrollees will be accepted in the order in which they apply.
	 
	 	7.13.3.	 	DSHS shall enroll all eligible clients with the contractor of their choice unless
DSHS determines, in its sole judgment, that it is in DSHS’ best interest to withhold
or limit enrollment with the Contractor.
	 
	 	7.13.4.	 	The Contractor may request in writing that DSHS temporarily suspend voluntary
enrollment in any service area. DSHS will approve the temporary suspension when the
Contractor presents evidence to DSHS, of the network limitations that demonstrate
the Contractor’s inability to accept additional enrollees.
	 
	 	7.13.5.	 	The Contractor shall accept clients who are assigned by DSHS in accord with this
Contract, WAC 388-538, and WAC 388-542, except as specifically provided in the
Enrollment Data and Requirements for Contractor’s Response provisions in the
Enrollment Section of this Contract.




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	 	7.13.6.	 	No eligible client shall be refused enrollment or re-enrollment, be terminated
from enrollment, or be discriminated against in any way because of health status,
the existence of a pre-existing physical or mental condition, including pregnancy
and/or hospitalization, or the expectation of the need for frequent or high cost
care (42 CFR 438.6(d)(1 and 3)).






	 	7.14.	 	Assignment of Enrollees:






	 	7.14.1.	 	Potential enrollees who do not select a Healthy Options/SCHIP plan shall be
assigned to a Healthy Options/SCHIP plan by DSHS as follows:






	 	7.14.1.1.	 	DSHS will identify the Contractor’s capacity in each service area, as
stated in Exhibit A, Premiums, Service Areas, and Capacity, modified by
increases and decreases in capacity made in accord with this Contract.
	 
	 	7.14.1.2.	 	DSHS will determine the total capacity of all contractors receiving
assignment in each service area.
	 
	 	7.14.1.3.	 	DSHS will determine the number of households in a service area.
	 
	 	7.14.1.4.	 	Assignments will be calculated based on the Contractor’s capacity divided
by the total capacity of a service area and then
multiplied by the total number of households in a service area. The
result of this calculation will determine the number of households to
be assigned to the Contractor in a specific service area. In any area
where the Contractor’s capacity is unlimited, DSHS will set the
Contractor’s capacity, for this calculation, at the total number of
HO/SCHIP eligible’s in the service area.






	 	7.14.2.	 	At DSHS’ sole discretion, DSHS may not make assignments of enrollees to the
Contractor in a service area if the Contractor’s enrollment, when DSHS calculates
assignments, is ninety percent (90%) or more of its capacity in that service area.
	 
	 	7.14.3.	 	The Contractor may choose not to receive assignments or limit assignments in any
service area by so notifying DSHS in writing at least sixty (60) calendar days
before the first of the month it is requesting not to receive assignment of
enrollees.
	 
	 	7.14.4.	 	DSHS reserves the right to make no assignments, or to withhold or limit
assignments to the Contractor, when, in its sole judgment, it is in the best
interest of DSHS.
	 
	 	7.14.5.	 	If either the Contractor or DSHS limits assignments as described herein, the
Contractor’s capacity shall be that limit.




53









 












	 	7.15.	 	Provider Network Changes:






	 	7.15.1.	 	The Contractor shall give DSHS a minimum of ninety (90) calendar days’ prior
written notice, in accord with the Notices provisions of the General Terms and
Conditions Section of this Contract, of the loss of a material provider. A material
provider is one whose loss would impair the Contractor’s ability to provide
continuity of and access to care for the Contractor’s current enrollees and/or the
number of enrollees the Contractor has agreed to serve in a service area.
	 
	 	7.15.2.	 	The Contractor shall make a good faith effort to provide written notification to
enrollees affected by any provider termination within fifteen (15) calendar days
after receiving or issuing a provider termination notice (42 CFR 438.10(f)(5)).
Enrollee notices shall have prior approval of DSHS. If the Contractor fails to
notify affected enrollees of a provider termination at least sixty (60) calendar
days prior to the effective date of termination, the Contractor shall allow affected
enrollees to continue to receive services from the terminating provider, at the
enrollees’ option, and administer benefits for the lesser of a period ending the
last day of the month in which sixty (60) calendar days elapses from the date the
Contractor notifies enrollees or the enrollee’s effective date of enrollment with
another plan.






	8.	 	QUALITY OF CARE






	 	8.1.	 	Quality Assessment and Performance Improvement (QAPI) Program:






	 	8.1.1.	 	The Contractor’s policies and procedures related to quality assessment and
performance improvement (QAPI) program shall ensure compliance with the requirements
described in this section.
	 
	 	8.1.2.	 	The Contractor shall have and maintain a quality assessment and performance
improvement (QAPI) program for the services it furnishes to its enrollees that meets
the provisions of 42 CFR 438.240.






	 	8.1.2.1.	 	The Contractor shall define its QAPI program structure and processes and
assign responsibility to appropriate individuals.
	 
	 	8.1.2.2.	 	The QAPI program structure shall include the following elements:






	 	8.1.2.2.1.	 	A written description of the QAPI program including identification of
designated physician and behavioral health practitioners. The QAPI program
description shall include:






	 	8.1.2.2.1.1.	 	A listing of all quality-related committee(s);
	 
	 	8.1.2.2.1.2.	 	Descriptions of committee responsibilities;




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	 	8.1.2.2.1.3.	 	Contractor staff and practicing provider committee participant
titles;
	 
	 	8.1.2.2.1.4.	 	Meeting frequency; and
	 
	 	8.1.2.2.1.5.	 	Maintenance of meeting minutes reflecting decisions made by each
committee, as appropriate.






	 	8.1.2.2.2.	 	A Quality Improvement Committee that oversees the quality functions of
the Contractor. The Quality Improvement Committee will:






	 	8.1.2.2.2.1.	 	Recommend policy decisions;
	 
	 	8.1.2.2.2.2.	 	Analyze and evaluate the results of QI activities;
	 
	 	8.1.2.2.2.3.	 	Institute actions; and
	 
	 	8.1.2.2.2.4.	 	Ensure appropriate follow-up.






	 	8.1.2.2.3.	 	An annual quality work plan.
	 
	 	8.1.2.2.4.	 	An annual evaluation of the QAPI program to include an evaluation of
performance improvement projects, trending of performance measures and
evaluation of the overall effectiveness of the QI program (42 CFR
438.240(e)(2)).






	 	8.1.3.	 	Upon request, the Contractor shall make available to providers, enrollees, or the
Department, the QAPI program description, and information on the Contractor’s
progress towards meeting its goals.
	 
	 	8.1.4.	 	The Contractor shall provide evidence of oversight of delegated entities
responsible for quality improvement. Oversight activities shall include evidence
of:






	 	8.1.4.1.	 	A delegation agreement with each delegated entity describing the
responsibilities of the Contractor and delegated entity;
	 
	 	8.1.4.2.	 	Evaluation of the delegated organization prior to delegation;
	 
	 	8.1.4.3.	 	An annual evaluation of the delegated entity;
	 
	 	8.1.4.4.	 	Evaluation of regular delegated entity reports; and
	 
	 	8.1.4.5.	 	Follow-up on issues out of compliance with delegated agreement or DSHS
contract specifications.




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	 	8.1.5.	 	The Contractor shall have in effect mechanisms to assess the quality and
appropriateness of care furnished to enrollees with special health care needs. (42
CFR 438.240 (b)(4)).






	 	8.2.	 	Performance Improvement Projects:






	 	8.2.1.	 	The Contractor’s policies and procedures related to performance improvement
projects shall ensure compliance with the requirements described in this section.
	 
	 	8.2.2.	 	The Contractor shall have an ongoing program of performance improvement projects
that focus on clinical and non-clinical areas. The Contractor shall conduct at least
two (2) Performance Improvement Projects (PIPs) of which at least one (1) is
clinical and at least one (1) is non-clinical as described in 42 CFR 438.240 (b)(1)
and as specified in the CMS protocol (see Attachment A for website link).
	 
	 	8.2.3.	 	The projects must be designed to achieve, through ongoing measurements and
intervention, significant improvement, sustained over time, in clinical and
non-clinical areas that are expected to have a favorable effect on health outcomes
and enrollee satisfaction. Through
implementation of performance improvement projects, the Contractor shall:






	 	8.2.3.1.	 	Measure performance using objective, quality indicators.
	 
	 	8.2.3.2.	 	Implement system interventions to achieve improvement in quality.
	 
	 	8.2.3.3.	 	Evaluate the effectiveness of the interventions.
	 
	 	8.2.3.4.	 	Plan and initiate activities for increasing or sustaining improvement.
	 
	 	8.2.3.5.	 	Report the status and results of each project to DSHS (42 CFR
438.240(d)(2)).
	 
	 	8.2.3.6.	 	Complete projects in a reasonable time period as to allow aggregate
information on the success of the projects to produce new information on the
quality of care every year (42 CFR 438.240(d)(2)).






	 	8.2.4.	 	Annually, the Contractor shall submit to DSHS one (1) clinical and one (1)
non-clinical performance improvement project which, in the judgment of the
Contractor, best meet the requirements of a performance improvement project. Each
project will be documented on a performance improvement project worksheet found in
the CMS protocol




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	 	 	 	entitled “Conducting Performance Improvement Projects” (see
Attachment A for website link).






	 	8.2.5.	 	If any of the Contractor’s Health Plan Employer Data and Information Set (HEDIS®)
rates on Well Child Visits in the first fifteen (15) months, six (6) or more well
child visits measure), Well Child Visits in the third (3rd), fourth
(4th), fifth (5th) and sixth (6th) years of life,
or Adolescent Well Care Visits are below a sixty percent (60%) benchmark in 2008 or
2009, the Contractor shall implement a clinical PIP designed to increase the rates.
	 
	 	8.2.6.	 	If any of the Contractor’s HEDIS® Combination 2, Childhood Immunization rates are
below a seventy percent (70%) benchmark in 2008 or below a seventy-five percent
(75%) benchmark in 2009 the Contractor shall implement a performance improvement
project designed to increase the immunization rate.
	 
	 	8.2.7.	 	If both the HEDIS® Well-Child Measure and Combination 2 Childhood Immunization
measures do not meet contractually required benchmarks, the Contractor is required
to conduct a second clinical PIP. The Contractor may count either the HEDIS®
Well-Child or Combination 2
PIPs towards meeting the one (1) required clinical PIP. Both PIPs shall be
submitted to DSHS.
	 
	 	8.2.8.	 	The Contractor may be required to conduct a CAHPS® non-clinical performance
improvement project(s) based on a correlation analysis of measures most likely to
impact enrollee satisfaction. The Contractor will be notified of the PIP in January
2008 by DSHS. The Contractor may count the PIP towards meeting the one (1) required
non-clinical PIP. The project must be initiated in 2008 and continue through the
2009 contract year.
	 
	 	8.2.9.	 	In addition to the PIPs required under this Section the Contractor shall
participate in a yearly statewide PIP.






	 	8.2.9.1.	 	The PIP will either be conducted by the Department of Health or by an
organization selected by DSHS.
	 
	 	8.2.9.2.	 	The PIP shall be designed to maximize resources and reduce cost to
contractors.
	 
	 	8.2.9.3.	 	The Contractor shall cooperate with DSHS’ designated External Quality Review
Organization (EQRO) and the organization conducting the PIP.
	 
	 	8.2.9.4.	 	The Contractor will receive copies of aggregate data and reports produced
from these projects.




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	 	8.2.9.5.	 	The Contractor shall provide financial support to the organization
conducting the PIP in the following manner:






	 	8.2.9.5.1.	 	If the Contractors enrollment is less than 10,000 the Contractor shall
provide $10,000 to support the PIP.
	 
	 	8.2.9.5.2.	 	If the Contractors enrollment is more than 10,000 but less than
100,000 the Contractor shall provide $20,000 to support the PIP.
	 
	 	8.2.9.5.3.	 	If the Contractors enrollment is more than 100,000 the Contractor
shall provide $30,000 to support the PIP.






	 	8.3.	 	Performance Measures using Health Employer Data & Information Set
(HEDISâ):






	 	8.3.1.	 	In accord with the Notices provisions of the General Terms and Conditions Section
of this Contract, the Contractor shall report to DSHS HEDISâ measures using
the current HEDISâ Technical Specifications and official corrections published
by NCQA, unless directed otherwise in
writing by DSHS. For the 2008 and 2009 HEDIS® measures listed below, the
Contractor shall use the administrative or hybrid data collection methods,
specified in the current HEDISâ Technical Specifications, unless
directed otherwise by DSHS (42 CFR 438.240(b)(2)). The Contractor shall make
its best effort to maximize data collection.
	 
	 	8.3.2.	 	No later than June 15 of each year, HEDISâ measures shall be submitted
electronically to DSHS using the NCQA Interactive Data Submission System (IDSS) or
other NCQA-approved method.
	 
	 	8.3.3.	 	The following HEDIS® measures shall be submitted to DSHS in 2008 and 2009:






	 	8.3.3.1.	 	Childhood Immunization Status (Hybrid measure required);
	 
	 	8.3.3.2.	 	Postpartum Care (Hybrid measure required);
	 
	 	8.3.3.3.	 	Well Child Visits in the First 15 Months of Life (Hybrid measure required);
	 
	 	8.3.3.4.	 	Well Child Visits in the Third, Fourth, Fifth and Sixth Years of Life
(Hybrid measure required);
	 
	 	8.3.3.5.	 	Adolescent Well Care Visits (Hybrid measure required);
	 
	 	8.3.3.6.	 	Comprehensive Diabetes Care (Hybrid measure required)
	 
	 	8.3.3.7.	 	Inpatient Utilization — Nonacute Care




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	 	8.3.3.8.	 	Ambulatory Care
	 
	 	8.3.3.9.	 	Frequency of Selected Procedures — a subset of measures to include:
myringotomy, myringotomy with adenoidectomy, hysterectomy, mastectomy,
lumpectomy
	 
	 	8.3.3.10.	 	Race/Ethnicity diversity of membership
	 
	 	8.3.3.11.	 	Language diversity of membership






	 	8.3.4.	 	The Contractor shall submit raw HEDIS® data to DSHS electronically for the
Childhood Immunization Status measure, no later than June 30 of each year. The
Contractor shall submit the raw HEDIS® data according to specifications provided by
DSHS.
	 
	 	8.3.5.	 	All HEDIS® measures, including the CAHPS® sample frame shall be audited, by a
designated certified HEDIS® Compliance Auditor, a licensed organization in accord
with methods described in the current
HEDIS® Compliance AuditTM Standards, Policies and Procedures. DSHS will fund
and the DSHS designated EQRO will conduct the audit.
	 
	 	8.3.6.	 	The Contractor shall cooperate with DSHS’ designated EQRO to validate the
Contractor’s Health Employer Data and Information Set (HEDIS®) performance measures
and CAHPS® sample frame.






	 	8.3.6.1.	 	If the Contractor does not have NCQA accreditation for Healthy Options
managed care from the National Committee for Quality Assurance (NCQA), the
Contractor shall receive a partial audit.
	 
	 	8.3.6.2.	 	If the Contractor has NCQA accreditation for Healthy Options managed care or
is seeking accreditation with a scheduled NCQA visit in 2008 or 2009, the
Contractor shall receive a full audit.
	 
	 	8.3.6.3.	 	Data collected and the methods employed for HEDISâ validation may be
supplemented by indicators and/or processes published in the Centers for
Medicare and Medicaid (CMS) Validating Performance Measures protocol identified
by the DSHS designated EQRO.






	 	8.3.7.	 	The Contractor shall provide evidence of trending of measures to assess
performance in quality and safety of clinical care and quality of non-clinical or
service-related care.
	 
	 	8.3.8.	 	The Contractor shall collect and maintain data on ethnicity, race and language
markers as established by DSHS on all enrollees. The Contractor shall record and
maintain enrollee self-identified data as




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	 	 	 	established by the Contractor and maintain
unique data fields for self-identified data.






	 	8.3.9.	 	The Contractor shall rotate HEDIS® measures only with the advance
written permission of DSHS. The Contractor may request permission to rotate
measures by making a written request to the DSHS contact named in the Notices
provisions of the General Terms and Conditions Section of this Contract. Childhood
Immunization and well-child measures shall not be rotated.






	 	8.4.	 	Consumer Assessment of Healthcare Providers and Systems (CAHPS®):






	 	8.4.1.	 	In 2008 a DSHS designated EQRO shall conduct the CAHPS® Children and Children with
Chronic Conditions survey based upon 2007 HEDISâ Specifications for Survey
Measures.






	 	8.4.1.1.	 	The Contractor shall create the sampling frame file.






	 	8.4.1.1.1.	 	The Contractor shall receive file specifications and instructions
specifying the format and other required information for the sample files
from DSHS, or the DSHS designated EQRO, by November 30, 2007.
	 
	 	8.4.1.1.2.	 	The Contractor shall submit the eligible sample frames to the DSHS
designated EQRO by January 18, 2008.
	 
	 	8.4.1.1.3.	 	The Contractor shall receive written notice of the sample frame
file(s) compliance audit certification from the DSHS designated EQRO by
January 31, 2008.






	 	8.4.1.2.	 	The Contractor will be allowed up to eight (8) Contractor—determined
supplemental questions. DSHS will notify the Contractor of DSHS-selected
supplemental questions.






	 	8.4.1.2.1.	 	The Contractor shall submit the questions to DSHS for written approval
for the amount, content, and survey placement prior to December 14, 2007.
	 
	 	8.4.1.2.2.	 	The Contractor shall receive a copy of the approved DSHS questionnaire
for informational purposes by January 31, 2008.






	 	8.4.1.3.	 	The Contractor shall provide National CAHPS® Benchmarking Database (NCBD)
submission information as determined by DSHS.






	 	8.4.1.3.1.	 	The Contractor shall submit the information to the DSHS designated
EQRO by April 14, 2008.




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	 	8.4.2.	 	In 2009, the Contractor shall conduct the CAHPS® Adult survey to Medicaid members
enrolled in Healthy Options.






	 	8.4.2.1.	 	The Contractor shall contract with an NCQA certified HEDIS® survey vendor
qualified to administer the CAHPS® survey and conduct the survey according to
NCQA protocol. The Contractor shall submit the following information to the
DSHS designated EQRO:






	 	8.4.2.1.1.	 	Contractor CAHPS® survey staff member contact, CAHPS® vendor name and
CAHPS® primary vendor contact by January 5, 2009.
	 
	 	8.4.2.1.2.	 	Timeline for implementation of vendor tasks by February 16, 2009.






	 	8.4.2.2.	 	The Contractor shall ensure the survey sample frame consists of all
non-Medicare and non-commercial adult plan members (not just subscribers) 18
(eighteen) years and older with Washington State addresses. The Contractor
shall submit the survey sample frame to DSHS by January 11, 2009. In
administering the CAHPS® the Contractor shall:






	 	8.4.2.2.1.	 	Be allowed up to eight (8) Contractor-determined supplemental
questions.
	 
	 	8.4.2.2.2.	 	Allow DSHS up to eight (8) supplemental questions.
	 
	 	8.4.2.2.3.	 	Be notified of DSHS’ selected eight (8) supplemental questions on or
before November 3, 2008.
	 
	 	8.4.2.2.4.	 	Submit their questions to DSHS for written approval prior to December
15, 2008.
	 
	 	8.4.2.2.5.	 	Submit the eligible sample frame file(s) for certification by the DSHS
designated EQRO, a Certified HEDISâ Auditor by January 11, 2009.
	 
	 	8.4.2.2.6.	 	Receive written notice of the sample frame file(s) compliance audit
certification from the DSHS designated EQRO by January 31, 2009.
	 
	 	8.4.2.2.7.	 	Receive the approved DSHS questionnaire by January 31, 2009. DSHS
EQRO shall determine the questionnaire format, questions and question
placement, using the most recent HEDIS® version of the Medicaid adult
questionnaire 




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	 	 	 	(currently 3.0H), plus approved supplemental and/or custom
questions as determined by DSHS.






	 	8.4.2.2.8.	 	Conduct the mixed methodology (mail and phone surveys) for CAHPS®
survey administration.
	 
	 	8.4.2.2.9.	 	Submit the final disposition report by June 10, 2009.
	 
	 	8.4.2.2.10.	 	Submit a copy of the Washington State adult Medicaid response data
set according to 2009 NCQA/CAHPS® standards to the DSHS designated EQRO by
June 10, 2009.






	 	8.4.2.3.	 	The Contractor shall provide NCBD data submission information as determined
by DSHS.






	 	8.4.2.3.1.	 	The Contractor shall submit the information to the DSHS designated
EQRO by April 14, 2009.
	 
	 	8.4.2.3.2.	 	The DSHS designated EQRO shall submit the data to the NCBD.






	 	8.4.2.4.	 	The Contractor is required to include performance guarantee language in
their vendor subcontracts that require a vendor to achieve at least a
thirty-five percent (35%) response rate.






	 	8.4.3.	 	The Contractor shall provide the following:






	 	8.4.3.1.	 	The Contractor shall notify DSHS in writing if the Contractor cannot conduct
the annual CAHPS® surveys (Children, Children with Chronic Conditions, or Adult)
because of limited total enrollment and/or sample size. The written statement
shall provide enrollment and/or sample size data to support the Contractor’s
inability to meet the requirement.
	 
	 	8.4.3.2.	 	The Contractor shall notify DSHS in writing whether they have a physician or
physician group at substantial financial risk in accord with the physician
incentive plan requirements under the Subcontracts Section of this Contract.






	 	8.5.	 	External Quality Review:






	 	8.5.1.	 	Validation Activities: The Contractor’s quality program shall be examined using a
series of required validation procedures. The examination shall be implemented and
conducted by DSHS, its agent, or an EQRO.




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	 	8.5.2.	 	The following required activities will be validated (42 CFR 438.358(b)(1)(2)(3)):






	 	8.5.2.1.	 	Performance improvement projects;
	 
	 	8.5.2.2.	 	Performance measures; and
	 
	 	8.5.2.3.	 	A monitoring review of standards established by DSHS and included in this
Contract to comply with 42 CFR 438.204 (g) and a comprehensive review conducted
within the previous three-year period.






	 	8.5.3.	 	The following optional activity will be validated annually:






	 	8.5.3.1.	 	Administration and/or validation of consumer or provider surveys of quality
of care, i.e., the CAHPS® survey (438.358(c)(2).






	 	8.5.4.	 	DSHS reserves the right to include additional optional activities described in 42
CFR 438.358 if additional funding becomes available and as mutually negotiated
between DSHS and the Contractor.
	 
	 	8.5.5.	 	The Contractor shall submit to annual DSHS TeaMonitor and EQRO monitoring reviews.
The monitoring review process uses standard methods and data collection tools and
methods found in the CMS EQR Managed Care Organization Protocol and assesses the
Contractor’s compliance with regulatory requirements and standards of the quality
outcomes and timeliness of, and access to, services provided by Medicaid MCOs (42
CFR 438.204).






	 	8.5.5.1.	 	The Contractor shall, during an annual monitoring review of the Contractor’s
compliance with contract standards or upon request by DSHS or its External
Quality Review Organization (EQRO) contractor(s), provide evidence of how
external quality review findings, agency audits and contract monitoring
activities, enrollee grievances, HEDIS® and CAHPS® results are used to identify
and correct problems and to improve care and services to enrollees.
	 
	 	8.5.5.2.	 	The Contractor will provide data requested by the EQRO for purposes of
completing the External Quality Review Report (EQRR). The EQRR is a detailed
technical report that describes the manner in which the data from all activities
described in External Quality Review provisions of this Section and conducted in
accord with CFR 42 438.358 were aggregated and analyzed and conclusions drawn as
to the quality, timeliness and access to the care furnished by the Contractor.




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	 	8.5.5.3.	 	DSHS will provide a copy of the EQRR to the Contractor, through print or
electronic media and to interested parties such as participating health care
providers, enrollees and potential enrollees of the Contractor, recipient
advocacy groups, and members of the general public. DSHS must make this
information available in alternative formats for persons with sensory
impairments, when requested.
	 
	 	8.5.5.4.	 	If the Contractor has had an accreditation review or visit by NCQA or
another accrediting body, the Contractor shall provide the complete report from
that organization to DSHS. If permitted by the accrediting body, the Contractor
shall allow a state representative to accompany any accreditation review team
during the site visit in an official observer status. The state representative
shall be allowed to share information with DSHS, Department of Health (DOH), and
Health Care Authority (HCA) as needed to reduce duplicated work for both the
Contractor and the state.






	 	8.6.	 	Enrollee Mortality: The Contractor shall maintain a record of known enrollee
deaths, including the enrollee’s name, date of birth, age at death, location of death,
and cause(s) of death. This information shall be available to DSHS upon request. The
Contractor shall assist DSHS in efforts to evaluate and improve the availability and
utility of selected mortality information for quality improvement purposes.
	 
	 	8.7.	 	Practice Guidelines: The Contractor’s policies and procedures related to
practice guidelines shall ensure compliance with the requirements described in this
section.






	 	8.7.1.	 	The Contractor shall adopt practice guidelines. The Contractor may develop or
adopt guidelines developed by organizations such as the American Diabetes
Association or the American Lung Association. Practice guidelines shall meet the
following requirements (42 CFR 438.236):






	 	8.7.1.1.	 	Are based on valid and reliable clinical evidence or a consensus of health
care professionals in the particular field;
	 
	 	8.7.1.2.	 	Consider the needs of enrollees and support client and family involvement in
care plans;
	 
	 	8.7.1.3.	 	Are adopted in consultation with contracting health care professionals;
	 
	 	8.7.1.4.	 	Are reviewed and updated at least every two years and as appropriate;




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	 	8.7.1.5.	 	Are disseminated to all affected providers and, upon request, to DSHS,
enrollees and potential enrollees (42 CFR 438.236(c)); and
	 
	 	8.7.1.6.	 	Are the basis for and are consistent with decisions for utilization
management, enrollee education, coverage of services, and other areas to which
the guidelines apply (42 CFR 438.236(d)).






	 	8.8.	 	Drug Formulary Review and Approval: The Contractor shall submit its drug
formulary, for use with enrollees covered under the terms of this Contract, to DSHS for
review and approval by January 31 of each year of this Contract or upon DSHS’ request.
The formulary shall be submitted to:
	 
	 	 	 	Siri Childs, Pharm D, Pharmacy Policy Manager (or her successor)

Department of Social and Health Services

Division of Medical Management

P.O. Box 45506

Olympia, WA 98504-5506

E-mail: childsa@dshs.wa.gov
	 
	 	8.9.	 	Health Information Systems: The Contractor shall maintain, and shall require
subcontractors to maintain, a health information system that complies with the
requirements of 42 CFR 438.242 and provides the information necessary to meet the
Contractor’s obligations under this Contract. The Contractor shall have in place
mechanisms to verify the health information received from subcontractors. The health
information system must:






	 	8.9.1.	 	Collect, analyze, integrate, and report data. The system must provide information
on areas including but not limited to, utilization, grievance and appeals, and
terminations of enrollment for other than loss of Medicaid eligibility.
	 
	 	8.9.2.	 	Ensure data received from providers is accurate and complete by:






	 	8.9.2.1.	 	Verifying the accuracy and timeliness of reported data;
	 
	 	8.9.2.2.	 	Screening the data for completeness, logic, and consistency; and
	 
	 	8.9.2.3.	 	Collecting service information on standardized formats to the extent
feasible and appropriate.






	 	8.9.3.	 	The Contractor shall make all collected data available to DSHS and the Center for
Medicare and Medicaid Services (CMS) upon request.






	 	8.10.	 	Technical Assistance: The Contractor may request technical assistance for any
matter pertaining to this Contract by contacting DSHS by e-mail at
healthyoptions@dshs.wa.gov.






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	9.	 	POLICIES AND PROCEDURES






	 	9.1.	 	The Contractor shall have and follow written policies and procedures related to
the requirements found in the provisions and sections in this Contract.






	 	9.1.1.	 	The provisions and sections that require policy and procedure are as follows:






	 	9.1.1.1.	 	Access, to include:






	 	9.1.1.1.1.	 	Cultural Considerations
	 
	 	9.1.1.1.2.	 	Direct access for enrollees with special health care needs
	 
	 	9.1.1.1.3.	 	General requirements
	 
	 	9.1.1.1.4.	 	Network Monitoring






	 	9.1.1.2.	 	Benefits, to include:






	 	9.1.1.2.1.	 	General requirements
	 
	 	9.1.1.2.2.	 	Pharmacy Management






	 	9.1.1.3.	 	Claims Payment
	 
	 	9.1.1.4.	 	Coordination and Continuity of Care
	 
	 	9.1.1.5.	 	Coordination of Benefits
	 
	 	9.1.1.6.	 	Coverage Authorization
	 
	 	9.1.1.7.	 	Credentialing — Provider Selection
	 
	 	9.1.1.8.	 	DCR Payment Process
	 
	 	9.1.1.9.	 	Enrollee Rights, to include:






	 	9.1.1.9.1.	 	Advance Directives
	 
	 	9.1.1.9.2.	 	Enrollee Choice of Primary Care Provider
	 
	 	9.1.1.9.3.	 	General requirements
	 
	 	9.1.1.9.4.	 	Informed Consent
	 
	 	9.1.1.9.5.	 	Member Privacy




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	 	9.1.1.9.6.	 	Provider — Enrollee Communication
	 
	 	9.1.1.9.7.	 	Prohibition on Enrollee Charges for Covered Services






	 	9.1.1.10.	 	Enrollment and ended enrollment, to include:






	 	9.1.1.10.1.	 	Termination of Enrollment — this requirement does not apply to
subcontractors or non-contracted providers.
	 
	 	9.1.1.10.2.	 	Involuntary Termination of Enrollment






	 	9.1.1.11.	 	Fraud and Abuse
	 
	 	9.1.1.12.	 	Grievance System to include:






	 	9.1.1.12.1.	 	Grievance Process
	 
	 	9.1.1.12.2.	 	Appeal Process
	 
	 	9.1.1.12.3.	 	Expedited Appeal Process
	 
	 	9.1.1.12.4.	 	Independent Review
	 
	 	9.1.1.12.5.	 	Continuation of Services






	 	9.1.1.13.	 	Health Information Systems
	 
	 	9.1.1.14.	 	Marketing and Information Requirements to include:






	 	9.1.1.14.1.	 	Material Development Requirements
	 
	 	9.1.1.14.2.	 	Equal Access Requirements
	 
	 	9.1.1.14.3.	 	Material Distribution Requirements






	 	9.1.1.15.	 	Patient Review and Restriction (PRR)
	 
	 	9.1.1.16.	 	Performance Improvement Programs
	 
	 	9.1.1.17.	 	Pharmacy Management
	 
	 	9.1.1.18.	 	Physician Incentive Plan
	 
	 	9.1.1.19.	 	Practice Guidelines
	 
	 	9.1.1.20.	 	Quality Improvement
	 
	 	9.1.1.21.	 	Subcontracts and Delegation




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	 	9.1.1.22.	 	Utilization Management






	 	9.1.2.	 	The Contractor’s policies and procedures shall include the following:






	 	9.1.2.1.	 	Direct and guide the Contractor’s employees, subcontractors and any
non-contracted providers’, compliance with all applicable federal, state and
contractual requirements.
	 
	 	9.1.2.2.	 	Fully articulate the Contractor’s understanding of the requirements.
	 
	 	9.1.2.3.	 	Have an effective training plan related to the requirements and maintain
records of the number and type of providers and staff participating in training,
including evidence of assessment of participant knowledge and satisfaction with
the training.
	 
	 	9.1.2.4.	 	Identify procedures for monitoring and auditing for compliance.
	 
	 	9.1.2.5.	 	Have procedures identifying prompt response to detected non-compliance, and
effective corrective action.






	 	9.1.3.	 	The Contractor shall submit a written copy of each policy and procedure related to
this Contract to DSHS for review and approval by September 10th of each year or
anytime there is a material change. In the event that a policy and procedure had
been approved by DSHS the previous year, and remained unchanged, the Contractor
shall not be required to resubmit the policy and procedure. The Contractor shall
certify in writing to DSHS that the policy and procedure is unchanged, in accord
with the Notices provision of the General Terms and Conditions Section of this
Contract.






	10.	 	SUBCONTRACTS






	 	10.1.	 	Subcontracts Policy and Procedure Requirements: The Contractor’s policies and
procedures related to subcontracting and delegation shall ensure compliance with the
requirements described in this section..
	 
	 	10.2.	 	Contractor Remains Legally Responsible: Subcontracts, as defined herein, may
be used by the Contractor for the provision of any service under this Contract.
However, no subcontract shall terminate the Contractor’s legal responsibility to DSHS
for any work performed under this Contract (42 CFR 434.6 (c) & 438.230(a)).
	 
	 	10.3.	 	Solvency Requirements for Subcontractors: For any subcontractor at financial
risk, as defined in the Substantial Financial Risk provision, or of the Risk provision
found in the Definitions Section of this Contract, the Contractor




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	 	 	 	shall establish, enforce and monitor solvency requirements that provide assurance of the subcontractor’s
ability to meet its obligations.
	 
	 	10.4.	 	Provider Nondiscrimination:






	 	10.4.1.	 	The Contractor shall not discriminate, with respect to participation,
reimbursement, or indemnification, against providers practicing within their
licensed scope of practice solely on the basis of the type of license or
certification they hold (42 CFR 438.12(a)(1)).
	 
	 	10.4.2.	 	If the Contractor declines to include individual or groups of providers in its
network, it shall give the affected providers written notice of the reason for its
decision (42 CFR 438.12(a)(1)).
	 
	 	10.4.3.	 	The Contractor’s provider selection policies and procedures shall not
discriminate against particular providers that serve high-risk populations or
specialize in conditions that require costly treatment (42CFR 438.214(c)).
	 
	 	10.4.4.	 	Consistent with the Contractor’s responsibilities to the enrollees, this Section
may not be construed to require the Contractor to:






	 	10.4.4.1.	 	Contract with providers beyond the number necessary to meet the needs of
its enrollees;
	 
	 	10.4.4.2.	 	Preclude the Contractor from using different reimbursement amounts for
different specialties or for different providers in the same specialty; or
	 
	 	10.4.4.3.	 	Preclude the Contractor from establishing measures that are designed to
maintain quality of services and control costs (42 CFR 438.12(b)(1)).






	 	10.5.	 	Required Provisions: Subcontracts shall be in writing, consistent with the
provisions of 42 CFR 434.6. All subcontracts shall contain the following provisions:






	 	10.5.1.	 	Identification of the parties of the subcontract and their legal basis for
operation in the State of Washington.
	 
	 	10.5.2.	 	Procedures and specific criteria for terminating the subcontract.
	 
	 	10.5.3.	 	Identification of the services to be performed by the subcontractor and which of
those services may be subcontracted by the subcontractor.
	 
	 	10.5.4.	 	Reimbursement rates and procedures for services provided under the subcontract.




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	 	10.5.5.	 	Release to the Contractor of any information necessary to perform any of its
obligations under this Contract.
	 
	 	10.5.6.	 	Reasonable access to facilities and financial and medical records for duly
authorized representatives of DSHS or DHHS for audit purposes,
and immediate access for Medicaid fraud investigators (42 CFR 438.6(g)).
	 
	 	10.5.7.	 	The requirement to completely and accurately report encounter data to the
Contractor. Contractor shall ensure that all subcontractors required to report
encounter data have the capacity to submit all DSHS required data to enable the
Contractor to meet the reporting requirements in the Encounter Data Transaction
Guide published by DSHS.
	 
	 	10.5.8.	 	The requirement to comply with the Contractor’s DSHS approved fraud and abuse
policies and procedures.
	 
	 	10.5.9.	 	No assignment of the subcontract shall take effect without the DSHS’ written
agreement.
	 
	 	10.5.10.	 	The subcontractor shall comply with the applicable state and federal rules and
regulations as set forth in this Contract, including the applicable requirements of
42 CFR 438.6(i).
	 
	 	10.5.11.	 	Subcontracts shall set forth and require the subcontractor to comply with any
term or condition of this Contract that is applicable to the services to be
performed under the subcontract (42 CFR 438.6(1)).
	 
	 	10.5.12.	 	The Contractor shall provide the following information regarding the grievance
system to all subcontractors (42 CFR 438.414 and 42 CFR 438.10(g)(1)):






	 	10.5.12.1.	 	The toll-free numbers to file oral grievances and appeals.
	 
	 	10.5.12.2.	 	The availability of assistance in filing a grievance or appeal.
	 
	 	10.5.12.3.	 	The enrollee’s right to request continuation of benefits during an appeal
or hearing and, if the Contractor’s action is upheld, the enrollee’s
responsibility to pay for the continued benefits.
	 
	 	10.5.12.4.	 	The enrollee’s right to file grievances and appeals and their requirements
and timeframes for filing.
	 
	 	10.5.12.5.	 	The enrollee’s right to a hearing, how to obtain a hearing, and
representation rules at a hearing.






	 	10.6.	 	Health Care Provider Subcontracts, including those for facilities and pharmacy
benefit management, shall also contain the following provisions:




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	 	10.6.1.	 	A quality improvement system tailored to the nature and type of services
subcontracted, which affords quality control for the health care provided, including
but not limited to the accessibility of medically necessary health care, and which
provides for a free exchange of information with the Contractor to assist the Contractor in complying with the requirements of
this Contract.
	 
	 	10.6.2.	 	A statement that primary care and specialty care provider subcontractors shall
cooperate with QI activities.
	 
	 	10.6.3.	 	A means to keep records necessary to adequately document services provided to
enrollees for all delegated activities including Quality Improvement, Utilization
Management, Member Rights and Responsibilities, and Credentialing and
Recredentialing.






	 	10.6.3.1.	 	Delegated activities are documented and agreed upon between Contractor and
subcontractor. The document must include:






	 	10.6.3.1.1.	 	Assigned responsibilities;
	 
	 	10.6.3.1.2.	 	Delegated activities;
	 
	 	10.6.3.1.3.	 	A mechanism for evaluation; and
	 
	 	10.6.3.1.4.	 	Corrective action policy and procedure.






	 	10.6.4.	 	Information about enrollees, including their medical records, shall be kept
confidential in a manner consistent with state and federal laws and regulations.
	 
	 	10.6.5.	 	The subcontractor accepts payment from the Contractor as payment in full and
shall not request payment from DSHS or any enrollee for covered services performed
under the subcontract.
	 
	 	10.6.6.	 	The subcontractor agrees to hold harmless DSHS and its employees, and all
enrollees served under the terms of this Contract in the event of non-payment by the
Contractor. The subcontractor further agrees to indemnify and hold harmless DSHS
and its employees against all injuries, deaths, losses, damages, claims, suits,
liabilities, judgments, costs and expenses which may in any manner accrue against
DSHS or its employees through the intentional misconduct, negligence, or omission of
the subcontractor, its agents, officers, employees or contractors (42 CFR
438.230(b)(2)).
	 
	 	10.6.7.	 	If the subcontract includes physician services, provisions for compliance with
the PCP requirements stated in this Contract.




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	 	10.6.8.	 	A ninety (90) day termination notice provision.
	 
	 	10.6.9.	 	A specific termination provision for termination with short notice when a
provider is excluded from participation in the Medicaid program.
	 
	 	10.6.10.	 	The subcontractor agrees to comply with the appointment wait time standards of
this Contract. The subcontract must provide for regular monitoring of timely access
and corrective action if the subcontractor fails to comply with the appointment wait
time standards (42 CFR 438.206(c)(1)).
	 
	 	10.6.11.	 	A provision for ongoing monitoring and periodic formal review that is consistent
with industry standards and OIC regulations. Formal review must be completed no
less than once every three years and must identify deficiencies or areas for
improvement and provide for corrective action (42 CFR 438.230(b)).






	 	10.7.	 	Health Care Provider Subcontracts Delegating Administrative Functions:






	 	10.7.1.	 	Subcontracts that delegate administrative functions under the terms of this
Contract shall include the following additional provisions:






	 	10.7.1.1.	 	For those subcontractors at financial risk, that the subcontractor shall
maintain the Contractor’s solvency requirements throughout the term of the
Contract.
	 
	 	10.7.1.2.	 	Clear descriptions of any administrative functions delegated by the
Contractor in the subcontract, including but not limited to utilization/medical
management, claims processing, enrollee grievances and appeals, and the
provision of data or information necessary to fulfill any of the Contractor’s
obligations under this Contract.
	 
	 	10.7.1.3.	 	How frequently and by what means the Contractor will monitor compliance
with solvency requirements and requirements related to any administrative
function delegated in the subcontract.
	 
	 	10.7.1.4.	 	Provisions for revoking delegation or imposing sanctions if the
subcontractor’s performance is inadequate (42 CFR 438.230(b)(2)).
	 
	 	10.7.1.5.	 	Whether referrals for enrollees will be restricted to providers affiliated
with the group and, if so, a description of those restrictions.




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	 	10.7.2.	 	The Contractor shall submit a report of all current delegated entities,
activities delegated and the number of enrollees assigned or serviced by the
delegated entity to DSHS for review by February 28th of each year.






	 	10.8.	 	Excluded Providers:






	 	10.8.1.	 	Pursuant to Section 1128 or Section 1128A of the Social Security Act, the
Contractor may not employ or subcontract with an individual practitioner or
provider, or an entity with an officer, director, agent, or
manager, or an individual who owns or has a controlling interest in the
entity, who has been (42 CFR 438.214(d)):






	 	10.8.1.1.	 	Convicted of crimes as specified in Section 1128 of the Social Security
Act,
	 
	 	10.8.1.2.	 	Excluded from participation in the Medicare and/or Medicaid program,
	 
	 	10.8.1.3.	 	Assessed a civil penalty under the provisions of Section 1128
	 
	 	10.8.1.4.	 	Has a contractual relationship with an entity convicted of a crime
specified in Section 1128, or
	 
	 	10.8.1.5.	 	Identified as a person described in the Debarment Certification provisions
of the General Terms and Conditions Section of this Contract.






	 	10.8.2.	 	The Contractor shall terminate subcontracts of excluded providers immediately
when the Contractor becomes aware of such exclusion or when the Contractor receives
notice from DSHS, whichever is earlier.
	 
	 	10.8.3.	 	In addition, if DSHS terminates a subcontractor from participation in any DSHS
program, the Contractor shall exclude the subcontractor from participation in
Healthy Options/SCHIP. The Contractor shall terminate subcontracts of excluded
providers immediately when the Contractor becomes aware of such exclusion or when
the Contractor receives notice from DSHS, whichever is earlier (WAC 388-502-0030).
	 
	 	10.8.4.	 	If the Contractor terminates a subcontractor for cause, the Contractor shall
notify DSHS, within ten (10) working days, in writing, after the Contractor’s
provider appeal process is concluded, as provided in the Notices provisions of the
General Terms and Conditions Section of this Contract, including an explanation of
the cause of the termination.






	 	10.9.	 	Home Health Providers: If the pending Medicaid home health agency surety bond
requirement (Section 4708(d) of the Balanced Budget Act of 1997) becomes effective
before or during the term of this Contract, beginning on the effective date of the
requirement the Contractor may not subcontract




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	 	 	 	with a home health agency unless the state has obtained a surety bond from the home health agency in the amount required by
federal law. DSHS will provide a current list of bonded home health agencies upon
request to the Contractor.
	 
	 	10.10.	 	Physician Incentive Plans: Physician incentive plans, as defined herein, are subject
to the conditions set forth in this Section in accord with federal regulations (42 CFR
438.6(h), 42 CFR 422.208 and 42 CFR 422.210). The Contractor’s policies and procedures
related to physician incentive plans shall ensure compliance with the following
requirements described in this section:






	 	10.10.1.	 	The Contractor shall make no payment to a physician or physician group, directly
or indirectly, under a physician incentive plan as an inducement to reduce or limit
medically necessary services provided to an individual enrollee.
	 
	 	10.10.2.	 	Whether the incentive plan includes referral services.
	 
	 	10.10.3.	 	If the incentive plan includes referral services:






	 	10.10.3.1.	 	The type of incentive plan (e.g. withhold, bonus, capitation).
	 
	 	10.10.3.2.	 	For incentive plans involving withholds or bonuses, the percent that is
withheld or paid as a bonus.
	 
	 	10.10.3.3.	 	Proof that stop-loss protection meets the requirements identified within
the provisions of this Section, including the amount and type of stop-loss
protection.
	 
	 	10.10.3.4.	 	The panel size and, if commercial members and enrollees are pooled, a
description of the groups pooled and the risk terms of each group. Medicaid,
Medicare, and commercial members in a physician’s or physician group’s panel may
be pooled provided the terms of risk for the pooled enrollees and commercial
members are comparable, and the incentive payments are not calculated separately
for pooled enrollees. Commercial members include military and Basic Health
members.






	 	10.10.4.	 	If the Contractor, or any subcontractor (e.g. IPA, PHO), places a physician or
physician group at substantial financial risk, the Contractor shall assure that all
physicians and physician groups have either aggregate or per member stop-loss
protection for services not directly provided by the physician or physician group.






	 	10.10.4.1.	 	If aggregate stop-loss protection is provided, it must cover ninety
percent (90%) of the costs of referral services that exceed




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	 	 	 	twenty-five percent (25%) of maximum potential payments under the subcontract.
	 
	 	10.10.4.2.	 	If stop-loss protection is based on a per-member limit, it must cover
ninety percent (90%) of the cost of referral services that exceed the limit as
indicated below based on panel size, and whether stop-loss is provided
separately for professional and institutional services or is combined for the
two.






	 	10.10.4.2.1.	 	1,000 members or fewer, the threshold is $3,000 for professional
services and $10,000 for institutional services, or $6,000 for combined
services.
	 
	 	10.10.4.2.2.	 	1,001 — 5,000 members, the threshold is $10,000 for professional
services and $40,000 for institutional services, or $30,000 for combined
services.
	 
	 	10.10.4.2.3.	 	5,001 — 8,000 members, the threshold is $15,000 for professional
services and $60,000 for institutional services, or $40,000 for combined
services.
	 
	 	10.10.4.2.4.	 	8,001 — 10,000 members, the threshold is $20,000 for professional
services and $100,000 for institutional services, or $75,000 for combined
services.
	 
	 	10.10.4.2.5.	 	10,001 — 25,000, the threshold is $25,000 for professional services
and $200,000 for institutional services, or $150,000 for combined services.
	 
	 	10.10.4.2.6.	 	25,001 members or more, there is no risk threshold.






	 	10.10.4.3.	 	For a physician or physician group at substantial financial risk, the
Contractor shall periodically conduct surveys of enrollee satisfaction with the
physician or physician group. DSHS shall require such surveys annually. DSHS
may, at its sole option, conduct enrollee satisfaction surveys that satisfy this
requirement. If the Contractors enrolled population is too small to allow a
valid survey by DSHS, the Contractor shall conduct an enrollee satisfaction
survey. . DSHS shall notify the Contractor in writing if DSHS will be conducting
the survey that satisfies the requirement for the Contractor. If the
Contractor conducts the survey it shall:






	 	10.10.4.3.1.	 	Include current enrollees, and enrollees who have terminated
enrollment within 12 months of the survey for reasons other than loss of
Medicaid eligibility or moving outside the Contractor’s service area.




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	 	10.10.4.3.2.	 	Be conducted according to commonly accepted principles of survey
design and statistical analysis.
	 
	 	10.10.4.3.3.	 	Address enrollees satisfaction with the physician or physician
groups:






	 	10.10.4.3.3.1.	 	Quality of services provided.
	 
	 	10.10.4.3.3.2.	 	Degree of access to services.






	 	10.11.	 	Payment to FQHCs/RHCs: The Contractor shall not pay a federally-qualified health
center or a rural health clinic less than the Contractor would pay non-FQHC/RHC
providers for the same services (42 USC 1396(m)(2)(A)(ix)).
	 
	 	10.12.	 	Provider Education: The Contractor will maintain records of the number and type of
providers and support staff participating in provider education, including evidence of
assessment of participant satisfaction with the training process.






	 	10.12.1.	 	The Contractor shall maintain a system for keeping participating providers
informed about:






	 	10.12.1.1.	 	Covered services for enrollees served under this Contract;
	 
	 	10.12.1.2.	 	Coordination of care requirements;
	 
	 	10.12.1.3.	 	DSHS and the Contractor’s policies and procedures as related to this
Contract;
	 
	 	10.12.1.4.	 	Interpretation of data from the quality improvement program; and
	 
	 	10.12.1.5.	 	Practice guidelines as described in the provisions of the Quality of Care
Section of this Contract.






	 	10.13.	 	Claims Payment Standards: The Contractor shall meet the timeliness of payment
standards specified for Medicaid fee-for-service in Section 1902(a)(37)(A) of the
Social Security Act and specified for health carriers in WAC 284-43-321. To be
compliant with both payment standards the Contractor shall pay or deny, and shall
require subcontractors to pay or deny, ninety-five percent (95%) of clean claims within
thirty (30) calendar days of receipt, ninety-five percent (95%) of all claims within
sixty (60) of receipt and ninety-nine percent (99%) of clean claims within ninety (90)
calendar days of receipt. The Contractor and its providers may agree to a different
payment requirement in writing on an individual claim.






	 	10.13.1.	 	A claim is a bill for services, a line item of service or all services for one
enrollee within a bill.




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	 	10.13.2.	 	A clean claim is a claim that can be processed without obtaining additional
information from the provider of the service or from a third party.
	 
	 	10.13.3.	 	The date of receipt is the date the Contractor receives the claim from the
provider.
	 
	 	10.13.4.	 	The date of payment is the date of the check or other form of payment.






	 	10.14.	 	FQHC/RHC Report: The Contractor shall provide DSHS with information related to
subcontracted federally-qualified health centers (FQHC) and rural health clinics (RHC),
as required by the DSHS Healthy Options Licensed Health Carrier Billing Instructions,
published by DSHS and incorporated by reference (see Attachment A for website link).
	 
	 	10.15.	 	Provider Credentialing: The Contractor shall follow the requirements related to the
credentialing and recredentialing of providers who have signed contracts or
participation agreements with the Contractor (42 CFR 438.12(a)(2) 438.206(a & b) and
438.214).






	 	10.15.1.	 	The Contractor’s policies and procedures related to the credentialing and
recredentialing of providers who have signed contracts or participation agreements
with the Contractor shall ensure compliance with the following requirements
described in this section:






	 	10.15.1.1.	 	The Contractor’s medical director or other designated physician’s shall
have direct responsibility and participation in the credentialing process.
	 
	 	10.15.1.2.	 	The Contractor shall have a designated Credentialing Committee to oversee
the credentialing process.
	 
	 	10.15.1.3.	 	The identification of the type of providers that are credentialed and
recredentialed;
	 
	 	10.15.1.4.	 	The verification sources used to make credentialing decisions, including
any evidence of provider sanctions; and
	 
	 	10.15.1.5.	 	Prohibition against employment or contracting with providers excluded from
participation in Federal health care programs under federal law and as described
in the Excluded Providers provisions of this Section.






	 	10.15.2.	 	The criteria used by the Contractor to credential and recredential providers
shall include (42 CFR 438.230(b)(1)):






	 	10.15.2.1.	 	Evidence of a current valid license to practice;




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	 	10.15.2.2.	 	A valid DEA or CDS certificate if applicable;
	 
	 	10.15.2.3.	 	Evidence of appropriate education and training;
	 
	 	10.15.2.4.	 	Board certification if applicable;
	 
	 	10.15.2.5.	 	An Evaluation of work history; and






	 	10.15.2.6.	 	A review of any liability claims resulting in settlements or judgments
paid on or on behalf of the provider.






	 	10.15.3.	 	The Contractor’s process for making credentialing determinations, to include a
signed, dated attestation statement from the provider that addresses:






	 	10.15.3.1.	 	The lack of present illegal drug use;
	 
	 	10.15.3.2.	 	A history of loss of license and felony convictions;
	 
	 	10.15.3.3.	 	A history of loss or limitation of privileges or disciplinary activity;
	 
	 	10.15.3.4.	 	Current malpractice coverage; and
	 
	 	10.15.3.5.	 	Accuracy and completeness of the application.






	 	10.15.4.	 	The Contractor’s process for delegation of credentialing or recredentialing.
	 
	 	10.15.5.	 	The Contractor’s provider selection policies and procedures that are consistent
with 42 CFR 438.12, and must not discriminate against particular providers that
serve high-risk populations or specialize in conditions that require costly
treatment, and any other methods for assuring nondiscrimination.
	 
	 	10.15.6.	 	The Contractor’s process for communicating findings to the provider that differ
from the provider’s submitted materials, including:






	 	10.15.6.1.	 	Communication of the provider’s right to review materials;
	 
	 	10.15.6.2.	 	Correct incorrect or erroneous information;
	 
	 	10.15.6.3.	 	Be informed of their credentialing status; and
	 
	 	10.15.6.4.	 	The ability to appeal an adverse determination by the Contractor.






	 	10.15.7.	 	The Contractor’s process for notifying providers within sixty (60) days of the
credentialing committee’s decision.





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	 	10.15.8.	 	The Contractor a process to ensure confidentiality.
	 
	 	10.15.9.	 	The Contractor’s process to ensure listings in provider directories for
enrollees are consistent with credentialing file content, including education,
training, certification and specialty designation.
	 
	 	10.15.10.	 	The Contractor’s process for recredentialing providers at minimum every
thirty-six (36) months through information verified from primary sources, unless
otherwise indicated.
	 
	 	10.15.11.	 	The Contractor’s process to ensure that offices of all primary care providers,
obstetricians/gynecologists and high volume providers meet office site standards
established by the Contractor.
	 
	 	10.15.12.	 	A system for monitoring sanctions or limitations on licensure, complaints and
quality issues or information from identified adverse events and provide evidence of
action, as appropriate based on defined methods or criteria.






	11.	 	ENROLLEE RIGHTS AND PROTECTIONS:






	 	11.1.	 	General Requirements: The written policies and procedures regarding enrollee
rights shall ensure compliance with the following requirements described in this
section:






	 	11.1.1.	 	The Contractor shall comply with any applicable Federal and State laws that
pertain to enrollee rights and ensure that its staff and affiliated providers take
those rights into account when furnishing services to enrollees (42 CFR
438.100(a)(2)).
	 
	 	11.1.2.	 	The Contractor shall guarantee each enrollee the following rights (42 CFR
438.100(b)(2)):






	 	11.1.2.1.	 	To be treated with respect and with consideration for their dignity and
privacy (42 CFR 438.100(b)(2)(ii)).
	 
	 	11.1.2.2.	 	To receive information on available treatment options and alternatives,
presented in a manner appropriate to the enrollee’s ability to understand (42
CFR 438.100(b)(2)(iii)).
	 
	 	11.1.2.3.	 	To participate in decisions regarding their health care, including the
right to refuse treatment (42 CFR 438.100(b)(2)(iv)).
	 
	 	11.1.2.4.	 	To be free from any form of restraint or seclusion used as a means of
coercion, discipline, convenience, or retaliation (42 CFR 438.100(b)(2)(iv)).




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	 	11.1.2.5.	 	To request and receive a copy of their medical records, and to request that
they be amended or corrected, as specified in 45 CFR 164 (42 CFR
438.100(b)(2)(iv)).
	 
	 	11.1.2.6.	 	Each enrollee must be free to exercise their rights, and exercise of those
rights must not adversely affect the way the Contractor or its subcontractors
treat the enrollee (42 CFR 438.100(c)).






	 	11.2.	 	Cultural Considerations: The Contractor shall participate in and cooperate
with DSHS’ efforts to promote the delivery of services in a culturally competent manner
to all enrollees, including those with limited English proficiency and diverse cultural
and ethnic backgrounds (42 CFR 438.206(c)(2)).






	 	11.3.	 	Advance Directives:






	 	11.3.1.	 	The Contractor’s policies and procedures for advance directives shall meet the
requirements of WAC 388-501-0125, 42 CFR 438.6, 438.10, 422.128, 489.100 and 489
Subpart I as described in this section including the following:
	 
	 	11.3.2.	 	The Contractor’s advance directive policies and procedure shall be disseminated
to all affected providers, enrollees, DSHS, and, upon request, potential enrollees
(42 CFR 438.6(i)(3)).
	 
	 	11.3.3.	 	The Contractor’s written policies respecting the implementation of advance
directive rights shall include a clear and precise statement of limitation if the
Contractor cannot implement an advance directive as a matter of conscience (42 CFR
422.128). At a minimum, this statement must do the following:






	 	11.3.3.1.	 	Clarify any differences between Contractor conscientious objections and
those that may be raised by individual physicians.
	 
	 	11.3.3.2.	 	Identify the state legal authority permitting such objection.
	 
	 	11.3.3.3.	 	Describe the range of medical conditions or procedures affected by the
conscience objection.






	 	11.3.4.	 	If an enrollee is incapacitated at the time of initial enrollment and is unable
to receive information (due to the incapacitating condition or a mental disorder) or
articulate whether or not he or she has executed an advance directive, the
Contractor may give advance directive information to the enrollee’s family or
surrogate in the same manner that it issues other materials about policies and
procedures to the family of the incapacitated enrollee or to a surrogate or other
concerned persons in accord with State law. The Contractor is not relieved of its
obligation to provide this information to the enrollee once he or she is no longer




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	 	 	 	incapacitated or unable to receive such information. Follow-up procedures must be
in place to ensure that the information is given to the individual directly at the
appropriate time.
	 
	 	11.3.5.	 	The Contractor’s policies and procedures must require, and the Contractor must
ensure, that the enrollee’s medical record documents, in a prominent part, whether
or not the individual has executed an advance directive.
	 
	 	11.3.6.	 	The Contractor shall not condition the provision of care or otherwise
discriminate against an enrollee based on whether or not the enrollee has executed
an advance directive.
	 
	 	11.3.7.	 	The Contractor shall ensure compliance with requirements of State and Federal law
(whether statutory or recognized by the courts of the State) regarding advance
directives.
	 
	 	11.3.8.	 	The Contractor shall provide for education of staff concerning its policies and
procedures on advance directives.
	 
	 	11.3.9.	 	The Contractor shall provide for community education regarding advance directives
that may include material required herein, either directly or in concert with other
providers or entities. Separate community education materials may be developed and
used, at the discretion of the Contractor. The same written materials are not
required for all settings, but the material should define what constitutes an
advance directive, emphasizing that an advance directive is designed to enhance an
incapacitated individual’s control over medical treatment, and describe applicable
State and Federal law concerning advance directives. The Contractor shall document
its community education efforts (42 CFR 438.6(i)(3)).
	 
	 	11.3.10.	 	The Contractor is not required to provide care that conflicts with an advance
directive; and is not required to implement an advance directive if, as a matter of
conscience, the Contractor cannot implement an advance directive and State law
allows the Contractor or any subcontractor providing services under this Contract to
conscientiously object.
	 
	 	11.3.11.	 	The Contractor shall inform enrollees that they may file a grievance with the
Contractor if the enrollee is dissatisfied with the Contractor’s advance directive
policy and procedure or the Contractor’s administration of those policies and
procedures. The Contractor shall also inform enrollees that they may file a
grievance with DSHS if they believe the Contractor is non-compliant with advance
directive requirements.






	 	11.4.	 	Enrollee Choice of PCP:






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	 	11.4.1.	 	The Contractor must implement procedures to ensure each enrollee has a source of
primary care appropriate to their needs (42 CFR 438.207(c)).






	 	11.4.2.	 	The Contractor shall allow, to the extent possible and appropriate, each new
enrollee to choose a participating PCP (42 CFR 438.6(m)).






	 	11.4.3.	 	In the case of newborns, the parent shall choose the newborn’s PCP.






	 	11.4.4.	 	If the enrollee does not make a choice at the time of enrollment, the Contractor
shall assign the enrollee to a PCP or clinic, within reasonable proximity to the
enrollee’s home, no later than fifteen (15) working days after coverage begins.






	 	11.4.5.	 	The Contractor shall allow an enrollee to change PCP or clinic at anytime with
the change becoming effective no later than the beginning of the month following the
enrollees request for the change (WAC 388-538-060 and WAC 284-43-251(1)).






	 	11.4.6.	 	The Contractor may limit enrollees’ ability to change PCP’s in accord with the
Patient Review and Restriction provisions of the Benefits Section of this Contract.






	 	11.5.	 	Direct Access for Enrollees with Special Health Care Needs: The Contractor
shall allow enrollees with special health care needs who utilize a specialist
frequently to retain the specialist as a PCP, or alternatively, be allowed direct
access to specialists for needed care. The Contractor shall also allow enrollees with
special health care needs as defined in WAC 388-538-050 to retain a specialist as a PCP
or be allowed direct access to a specialist if the assessment required under the
provisions of this Contract demonstrates a need for a course of treatment or regular
monitoring by such specialist (42 CFR 438.208(c)(4) and 438.6(m)).






	 	11.6.	 	Prohibition on Enrollee Charges for Covered Services:






	 	11.6.1.	 	Under no circumstances shall the Contractor, or any providers used to deliver
services covered under the terms of this Contract, charge enrollees for covered
services (SSA 1932(b)(6), SSA 1128B(d)(1)), 42 CFR 438.106(c), 438.6(1), 438.230,
and 438.204(a) and WAC 388-502-0160).






	 	11.6.2.	 	The Contractor shall have a separate and specific policy and procedure that fully
articulates how the Contractor will protect enrollees from being billed for covered
services.






	 	11.7.	 	Provider/Enrollee Communication: The Contractor may not prohibit, or
otherwise restrict, a health care professional acting within their lawful scope 




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	 	 	 	of practice, from advising or advocating on behalf of an enrollee who is their patient,
for the following (42 CFR 438.102(a)(1)(i)):






	 	11.7.1.	 	The enrollee’s health status, medical care, or treatment options, including any
alternative treatment that may be self-administered (42 CFR 438.102(a)(1)(i)).






	 	11.7.2.	 	Any information the enrollee needs in order to decide among all relevant
treatment options (42 CFR 438.102(a)(1)(ii)).






	 	11.7.3.	 	The risks, benefits, and consequences of treatment or non-treatment (42 CFR
438.102(a)(1)(iii)).






	 	11.7.4.	 	The enrollee’s right to participate in decisions regarding their health care,
including the right to refuse treatment, and to express preferences about future
treatment decisions (42 CFR 438.102(a)(1)(iv)).






	 	11.8.	 	Enrollee Self-Determination: The Contractor shall ensure that all providers:
obtain informed consent prior to treatment from enrollees, or persons authorized to
consent on behalf of an enrollee as described in RCW 7.70.065; comply with the
provisions of the Natural Death Act (RCW 70.122) and state and federal Medicaid rules
concerning advance directives (WAC 388-501-0125 and 42 CFR 438.6(m)); and, when
appropriate, inform enrollees of their right to make anatomical gifts (RCW 68.50.540).





12.     UTILIZATION MANAGEMENT PROGRAM AND AUTHORIZATION OF SERVICES





	 	12.1.	 	Utilization Management Program: The Contractor shall follow the Utilization
Management requirements described in this section.






	 	12.1.1.	 	The Contractor’s policies and procedures related to Utilization Management shall
comply with, and require the compliance of subcontractors with delegated authority
for Utilization Management, the requirements described in this section.






	 	12.1.2.	 	The Contractor shall have and maintain a Utilization Management Program (UMP) for
the services it furnishes its enrollees.






	 	12.1.3.	 	The Contractor shall define its UMP structure and assign responsibility for UMP
activities to appropriate individuals.






	 	12.1.4.	 	Upon request the Contractor shall provide DSHS with a written description of the
UMP that includes identification of designated physician and behavioral health
practitioners and evidence of the physician and behavioral health practitioner’s
involvement in program development and implementation.






	 	12.1.5.	 	The UMP program description shall include:




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	 	12.1.5.1.	 	A written description of all UM-related committee(s);
	 
	 	12.1.5.2.	 	Descriptions of committee responsibilities;






	 	12.1.5.3.	 	Contractor staff and practicing provider committee participant title(s);






	 	12.1.5.4.	 	Meeting frequency;
	 
	 	12.1.5.5.	 	Maintenance of meeting minutes reflecting decisions made by each committee,
as appropriate.






	 	12.1.6.	 	UMP behavioral health and non-behavioral health policies and procedures at
minimum, shall include the following content:






	 	12.1.6.1.	 	Documentation of use and periodic review of written clinical
decision-making criteria based on clinical evidence, including policies and
procedures for appropriate application of the criteria.






	 	12.1.6.2.	 	Mechanisms for providers and enrollees on how they can obtain the UM
decision-making criteria upon request, including UM action or denial
determination letter template language reflecting same.






	 	12.1.6.3.	 	Mechanisms for assessment of inter-rater reliability of all clinical
professionals and as appropriate, non-clinical staff responsible for UM
decisions.






	 	12.1.6.4.	 	Written job descriptions with qualification for providers who review
denials of care based on medical necessity that requires education, training or
professional experience in medical or clinical practice and current
non-restricted license.






	 	12.1.6.5.	 	Mechanisms to verify that claimed services were actually provided.






	 	12.1.6.6.	 	Mechanisms to detect both underutilization and over-utilization of
services, including pharmacy underutilization and over-utilization, and produce
a yearly report which identifies and reports findings on utilization measures
and includes completed or planned
interventions to address under or over-utilization patterns of care
(42 CFR 438.240(b)(3)).






	 	12.1.6.7.	 	Specify the type of personnel responsible for each level of UM
decision-making.




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	 	12.1.6.8.	 	A physician or behavioral health practitioner or pharmacist as appropriate
reviews any behavioral health denial of care based on medical necessity.






	 	12.1.6.9.	 	Use of board certified consultants to assist in making medical necessity
determinations.






	 	12.1.6.10.	 	Appeals of adverse determinations evaluated by health care providers who
were not involved in the initial decision and who have appropriate expertise in
the field of medicine that encompasses the covered person’s condition or disease
(PBOR, WAC 284-43-620(4)).






	 	12.1.6.11.	 	Documentation of timelines for appeals in accord with the Appeal Process
provisions of the Grievance System Section of this Contract.






	 	12.1.7.	 	Annually evaluate and update the UMP.






	 	12.1.8.	 	The Contractor shall not structure compensation to individuals or entities that
conduct utilization management activities so as to provide incentives for the
individual or entity to deny, limit, or discontinue medically necessary services to
any enrollee (42 CFR 438.210(e)).






	 	12.1.9.	 	The Contractor shall not penalize or threaten a provider or facility with a
reduction in future payment or termination of participating provider or
participating facility status because the provider or facility disputes the
Contractor’s determination with respect to coverage or payment for health care
service (PBOR, WAC 284-43-210(6)).






	 	12.2.	 	Authorization of Services: The Contractor shall follow the authorization of
services requirements described in this section.






	 	12.2.1.	 	The Contractor’s policies and procedures related to authorization of services
shall include the compliance with 42 CFR 438.210 and WAC 388-538, and require
compliance of subcontractors with delegated authority for authorization of services
with the requirements described in this section.






	 	12.2.2.	 	The Contractor shall have in effect mechanisms to ensure consistent application
of review criteria for authorization decisions (42 CFR 438.210(b)(1)(i)).






	 	12.2.3.	 	The Contractor shall consult with the requesting provider when appropriate (42
CFR 438.210(b)(1)(ii)).






	 	12.2.3.1.	 	The Contractor shall require that any decision to deny a service
authorization request or to authorize a service in an amount,




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	 	 	 	duration, or scope
that is less than requested, be made by a health care professional who has
appropriate clinical expertise in treating the enrollee’s condition or disease
(42 CFR 438.210(b)(3)).






	 	12.2.3.2.	 	The Contractor shall notify the requesting provider, and give the enrollee
written notice of any decision by the Contractor to deny a service authorization
request, or to authorize a service in an amount, duration, or scope that is less
than requested. The notice shall meet the following requirements, except that
the notice to the provider need not be in writing (42 CFR 438.210(c) and
438.404):






	 	12.2.3.2.1.	 	The notice to the enrollee shall be in writing and shall meet the
requirements of the, Information Requirements for Enrollees and Potential
Enrollees, provisions of the Marketing and Information Requirements Section,
of this Contract to ensure ease of understanding.






	 	12.2.3.2.2.	 	The notice shall explain the following (42 CFR 438.404(b)(1-3)(5-7)):






	 	12.2.3.2.2.1.	 	The action the Contractor has taken or intends to take.
	 
	 	12.2.3.2.2.2.	 	The reasons for the action, in easily understood language.
	 
	 	12.2.3.2.2.3.	 	A statement whether or not an enrollee has any liability for
payment.
	 
	 	12.2.3.2.2.4.	 	A toll free telephone number to call if the enrollee is billed
for services.
	 
	 	12.2.3.2.2.5.	 	The enrollee’s right to file an appeal.
	 
	 	12.2.3.2.2.6.	 	The procedures for exercising the enrollee’s rights.






	 	12.2.3.2.3.	 	The circumstances under which expedited resolution is available and
how to request it.
	 
	 	12.2.3.2.4.	 	The enrollee’s right to have benefits continue pending resolution of
the appeal, how to request that benefits be continued, and the circumstances
under which the enrollee may be required to pay for these services.






	 	12.2.4.	 	The Contractor shall provide for the following timeframes for authorization
decisions and notices:




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	 	12.2.4.1.	 	For denial of payment that may result in payment liability for the
enrollee, at the time of any action affecting the claim.
	 
	 	12.2.4.2.	 	For termination, suspension, or reduction of previously authorized
services, ten (10) calendar days prior to such termination, suspension, or
reduction, except if the criteria stated in 42 CFR 431.213 and 431.214 are met.
The notice shall be mailed within this ten (10) calendar day period by a method
that certifies receipt and assures delivery within three (3) calendar days.






	 	12.2.4.2.1.	 	For standard authorization, determinations are to be made within two
(2) business days of the receipt of necessary information, but may not
exceed fourteen (14) calendar days following receipt of the request for
services (42 CFR 438.210(d)(1)).
	 
	 	12.2.4.2.2.	 	Beyond the fourteen (14) calendar day period, a possible extension of
up to fourteen (14) additional calendar days (equal to a total of
twenty-eight (28) calendar days) is allowed under the following
circumstances (42 CFR 438.210(d)(1)(i-ii)):






	 	12.2.4.2.2.1.	 	The enrollee, or the provider, requests extension; or
	 
	 	12.2.4.2.2.2.	 	The Contractor justifies and documents a need for additional
information and how the extension is in the enrollee’s interest.
	 
	 	12.2.4.2.2.3.	 	If the Contractor extends that timeframe, it
shall(438.408(c)(2):






	 	12.2.4.2.2.3.1.	 	Give the enrollee written notice of the reason for the
decision to extend the timeframe and inform the enrollee of the right
to file a grievance if he or she disagrees with that decision; and
	 
	 	12.2.4.2.2.3.2.	 	Issue and carry out its determination as expeditiously as
the enrollee’s health condition
requires and no later than the date the extension
expires.






	 	12.2.4.2.3.	 	For standard authorization decisions, notification of the decision
shall be made to the attending physician, ordering provider, facility and
enrollee within two (2) business days (PBOR, WAC 284-43-410).






	 	12.2.4.3.	 	For cases in which a provider indicates, or the Contractor determines, that
following the timeframe for standard




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	 	 	 	authorization decisions could seriously
jeopardize the enrollee’s life or health or ability to attain, maintain, or
regain maximum function, the Contractor shall make an expedited authorization
decision and provide notice as expeditiously as the enrollee’s health condition
requires and no later than three (3) working days after receipt of the request
for service. The Contractor may extend the three (3) working days by up to
fourteen (14) calendar days under the following circumstances (42 CFR
438.210(d)(2)):






	 	12.2.4.3.1.	 	The enrollee requests the extension; or
	 
	 	12.2.4.3.2.	 	The Contractor justifies and documents a need for additional
information and how the extension is in the enrollee’s interest.






	 	12.3.	 	Fraud and Abuse Requirements: The Contractor shall have and follow the Fraud
and Abuse requirements described in this section.






	 	12.3.1.	 	The Contractor’s policies and procedures related to fraud and abuse shall include
compliance with 42 CFR 438.608(a) and section 1902(a)(68) of the Social Security Act
and include the requirement of compliance of staff and subcontractors with the
requirements described in this section.
	 
	 	12.3.2.	 	The Contractor shall have:






	 	12.3.2.1.	 	In effect a process to inform employees and subcontractors regarding the
False Claims Act.
	 
	 	12.3.2.2.	 	Administrative and management arrangements or procedures, and a mandatory
compliance plan.
	 
	 	12.3.2.3.	 	Standards of conduct that articulates the Contractor’s commitment to comply
with all applicable federal and state standards.
	 
	 	12.3.2.4.	 	The designation of a compliance officer and a compliance committee that is
accountable to senior management.
	 
	 	12.3.2.5.	 	Effective training for the compliance officer and the Contractor’s
employees and subcontractors.
	 
	 	12.3.2.6.	 	Effective lines of communication between the compliance officer and the
Contractor’s staff and subcontractors.
	 
	 	12.3.2.7.	 	Enforcement of standards through well-publicized disciplinary guidelines.




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	 	12.3.2.8.	 	Provision for internal monitoring and auditing.
	 
	 	12.3.2.9.	 	Provision for prompt response to detected offenses, and for development of
corrective action initiatives.
	 
	 	12.3.2.10.	 	Provision of detailed information to employees and subcontractors
regarding fraud and abuse policies and procedures and the False Claims Act as
identified in Section 1902(a)(68) of the Social Security Act.






	 	12.3.3.	 	The Contractor shall report in writing to DSHS all verified cases of fraud and
abuse, including fraud and abuse by the Contractor’s employees and subcontractors,
within seven (7) calendar days according to the Notices provisions of the General
Terms and Conditions Section of this Contract. The report shall include the
following information:






	 	12.3.3.1.	 	Subject(s) of complaint by name and either provider/subcontractor type or
employee position.
	 
	 	12.3.3.2.	 	Source of complaint by name and provider/subcontractor type or employee
position, if applicable.
	 
	 	12.3.3.3.	 	Nature of complaint.
	 
	 	12.3.3.4.	 	Estimate of the amount of funds involved.
	 
	 	12.3.3.5.	 	Legal and administrative disposition of case.





13.     GRIEVANCE SYSTEM





	 	13.1.	 	General Requirements: The Contractor shall have a grievance system which
complies with the requirements of 42 CFR 438 Subpart F and WACs 388-538 and 284-43,
insofar as those WACs are not in conflict with 42 CFR 438 Subpart F. The grievance
system shall include a grievance process, an appeal process, and
access to the hearing process. NOTE: Provider claim disputes initiated by the
provider are not subject to this Section.






	 	13.1.1.	 	The Contractor shall have policies and procedures addressing the grievance
system, which comply with the requirements of this Contract. DSHS must approve, in
writing, all grievance system policies and procedures and related notices to
enrollees regarding the grievance system.
	 
	 	13.1.2.	 	The Contractor shall give enrollees any assistance necessary in completing forms
and other procedural steps for grievances and appeals (42 CFR 438.406(a)(1) and WAC
284-43-615(2)(e)).




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	 	13.1.3.	 	The Contractor shall acknowledge receipt of each grievance, either orally or in
writing, and appeal, in writing, within five (5) working days (42 CFR 438.406(a)(2)
and (WAC 284-43-620).
	 
	 	13.1.4.	 	The Contractor shall ensure that decision makers on grievances and appeals were
not involved in previous levels of review or decision-making (42 CFR
438.406(a)(3)(i)).
	 
	 	13.1.5.	 	Decisions regarding grievances and appeals shall be made by health care
professionals with clinical expertise in treating the enrollee’s condition or
disease if any of the following apply (42 CFR 438.406(a)(3)(ii)):






	 	13.1.5.1.	 	If the enrollee is appealing an action concerning medical necessity.
	 
	 	13.1.5.2.	 	If an enrollee grievance concerns a denial of expedited resolution of an
appeal.
	 
	 	13.1.5.3.	 	If the grievance or appeal involves any clinical issues.






	 	13.2.	 	Grievance Process: The following requirements are specific to the grievance
process:






	 	13.2.1.	 	Only an enrollee may file a grievance with the Contractor; a provider may not
file a grievance on behalf of an enrollee (42 CFR 438.402(b)(3)).
	 
	 	13.2.2.	 	The Contractor shall accept grievances forwarded by DSHS.
	 
	 	13.2.3.	 	The Contractor shall cooperate with any representative authorized in writing by
the covered enrollee (WAC 284-43-615).
	 
	 	13.2.4.	 	The Contractor shall consider all information submitted by the covered person or
representative (WAC 284-43-615).
	 
	 	13.2.5.	 	The Contractor shall investigate and resolve all grievances (WAC 284-43-615).
	 
	 	13.2.6.	 	The Contractor shall complete the disposition of a grievance and notice to the
affected parties as expeditiously as the enrollees health condition requires, but no
later than ninety (90) calendar days from receipt of the grievance.
	 
	 	13.2.7.	 	The Contractor may notify enrollees of the disposition of grievances. The
notification may be orally or in writing for grievances not involving clinical
issues. Notices of disposition for clinical issues must be in writing.





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	 	13.2.8.	 	Enrollees do not have the right to a hearing in regard to the disposition of a
grievance.






	 	13.3.	 	Appeal Process: The following requirements are specific to the appeal
process:






	 	13.3.1.	 	An enrollee, or a provider acting on behalf of the enrollee and with the
enrollee’s written consent, may appeal a Contractor action (42 CFR 438.406(b)(1)).
	 
	 	13.3.2.	 	If DSHS receives a request to appeal an action of the Contractor, DSHS will
forward relevant information to the Contractor and the Contractor will contact the
enrollee.
	 
	 	13.3.3.	 	For appeals of standard service authorization decisions, an enrollee must file an
appeal, either orally or in writing, within ninety (90) calendar days of the date on
the Contractor’s notice of action. This also applies to an enrollee’s request for an
expedited appeal (42 CFR 438.406(b)(1)).
	 
	 	13.3.4.	 	For appeals for termination, suspension, or reduction of previously authorized
services when the enrollee requests continuation of such services, an enrollee must
file an appeal within ten (10) calendar days of the date of the Contractor’s mailing
of the notice of action. If the enrollee is notified in a timely manner and the
enrollee’s request for continuation of services is not timely, the Contractor is not
obligated to continue services and the timeframes for appeals of standard resolution
apply (42 CFR 438.408).
	 
	 	13.3.5.	 	Oral inquiries seeking to appeal an action shall be treated as appeals and be
confirmed in writing, unless the enrollee or provider requests an expedited
resolution (42 CFR 438.406(b)(1)).
	 
	 	13.3.6.	 	The appeal process shall provide the enrollee a reasonable opportunity to present
evidence, and allegations of fact or law, in person as well as in writing. The
Contractor shall inform the enrollee of the limited time
available for this in the case of expedited resolution (42 CFR 438.406(b)(2)).
	 
	 	13.3.7.	 	The appeal process shall provide the enrollee and the enrollee’s representative
opportunity, before and during the appeals process, to examine the enrollee’s case
file, including medical records, and any other documents and records considered
during the appeal process (42 CFR 438.406(b)(3)).
	 
	 	13.3.8.	 	The appeal process shall include as parties to the appeal, the enrollee and the
enrollee’s representative, or the legal representative of the deceased enrollee’s
estate (42 CFR 438.406(b)(4)).




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	 	13.3.9.	 	The Contractor shall resolve each appeal and provide notice, as expeditiously as
the enrollee’s health condition requires, within the following timeframes (42 CFR
438.408(b)(2-3):






	 	13.3.9.1.	 	For standard resolution of appeals and for appeals for termination,
suspension, or reduction of previously authorized services a decision must be
made within fourteen (14) days after receipt of the appeal, unless the
Contractor notifies the enrollee that an extension is necessary to complete the
appeal; however, the extension cannot delay the decision beyond thirty (30) days
of the request for appeal, without the informed written consent of the enrollee.
In all circumstances the appeal determination must not be extended beyond
forty-five (45) calendar days from the day the Contractor receives the appeal
request.






	 	13.3.9.2.	 	For expedited resolution of appeals, including notice to the affected
parties, no longer than three (3) calendar days after the Contractor receives
the appeal. This timeframe may not be extended.






	 	13.3.10.	 	The notice of the resolution of the appeal shall (42 CFR 438.408(d)):






	 	13.3.10.1.	 	Be in writing. For notice of an expedited resolution, the Contractor
shall also make reasonable efforts to provide oral notice.
	 
	 	13.3.10.2.	 	Include the reasons for the determination in easily understood language
and the date completed.
	 
	 	13.3.10.3.	 	A written statement of the clinical rationale for the decision, including
how the requesting provider or enrollee may obtain the Utilization Management
clinical review or decision-making criteria.
	 
	 	13.3.10.4.	 	For appeals not resolved wholly in favor of the enrollee (42 CFR
438.408(e)(2)):






	 	13.3.10.4.1.	 	Include information on the enrollee’s right to request a hearing and
how to do so.
	 
	 	13.3.10.4.2.	 	Include information on the enrollee’s right to receive services
while the hearing is pending and how to make the request.
	 
	 	13.3.10.4.3.	 	Inform the enrollee that the enrollee may be held liable for the
amount the Contractor pays for services received while the hearing is
pending, if the hearing decision upholds the Contractor’s action.




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	 	13.4.	 	Expedited Appeal Process:






	 	13.4.1.	 	The Contractor shall establish and maintain an expedited appeal review process
for appeals when the Contractor determines, for a request from the enrollee, or the
provider indicates, in making the request on the enrollee’s behalf or supporting the
enrollee’s request, that taking the time for a standard resolution could seriously
jeopardize the enrollee’s life or health or ability to attain, maintain, or regain
maximum function (42 CFR 438.410(a)).
	 
	 	13.4.2.	 	The Contractor shall make a decision on the enrollee’s request for expedited
appeal and provide notice, as expeditiously as the enrollee’s health condition
requires, within three (3) calendar days after the Contractor receives the appeal.
The Contractor shall also make reasonable efforts to provide oral notice.
	 
	 	13.4.3.	 	The Contractor shall ensure that punitive action is not taken against a provider
who requests an expedited resolution or supports an enrollee’s appeal (42 CFR
438.410(b)).
	 
	 	13.4.4.	 	If the Contractor denies a request for expedited resolution of an appeal, it
shall transfer the appeal to the timeframe for standard resolution and make
reasonable efforts to give the enrollee prompt oral notice of the denial, and follow
up within two (2) calendar days with a written notice (42 CFR 438.410(c)).
	 
	 	13.4.5.	 	The enrollee has a right to file a grievance regarding the Contractors denial of
a request for expedited resolution. The Contractor must inform the enrollee of
their right to file a grievance in the notice of denial.






	 	13.5.	 	Hearings:






	 	13.5.1.	 	A provider may not request a hearing on behalf of an enrollee.
	 
	 	13.5.2.	 	If an enrollee does not agree with the Contractor’s resolution of the appeal, the
enrollee may file a request for a hearing within the following time frames (see WAC
388-538-112 for the hearing process for enrollees):






	 	13.5.2.1.	 	For hearings regarding a standard service, within ninety (90) calendar days
of the date on the Contractor’s mailing of the notice of the resolution of the
appeal 42 CFR 438.402 (b)(2)).
	 
	 	13.5.2.2.	 	For hearings regarding termination, suspension, or reduction of a
previously authorized service, if the enrollee requests continuation of
services, within ten (10) calendar days of the date on the Contractor’s mailing
of the notice of the resolution of the




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	 	 	 	appeal. If the enrollee is notified in a
timely manner and the enrollee’s request for continuation of services is not
timely, the Contractor is not obligated to continue services and the timeframes
for a hearing regarding a standard service apply (42 CFR 438.420)






	 	13.5.3.	 	If the enrollee requests a hearing, the Contractor shall provide to DSHS upon
request and within three (3) working days, all Contractor-held documentation related
to the appeal, including but not limited to, any transcript(s), records, or written
decision(s) from participating providers or delegated entities.
	 
	 	13.5.4.	 	The Contractor is an independent party and is responsible for its own
representation in any hearing, independent review, Board of Appeals and subsequent
judicial proceedings.
	 
	 	13.5.5.	 	The Contractor’s medical director or designee shall review all cases where a
hearing is requested and any related appeals, when medical necessity is an issue.
	 
	 	13.5.6.	 	The enrollee must exhaust all levels of resolution and appeal within the
Contractor’s grievance system prior to filing a request for a hearing with DSHS (42
CFR 438.402(b)(2)(ii)).
	 
	 	13.5.7.	 	DSHS will notify the Contractor of hearing determinations. The Contractor will be
bound by the hearing determination, whether or not the hearing determination upholds
the Contractor’s decision. Implementation of such a hearing decision shall not be
the basis for termination of enrollment by the Contractor.
	 
	 	13.5.8.	 	If the hearing decision is not within the purview of this Contract, then DSHS
will be responsible for the implementation of the hearing decision.






	 	13.6.	 	Independent Review: After exhausting both the Contractor’s appeal process and
the hearing process an enrollee has a right to independent review in accord with RCW
48.43.535 and WAC 284-43-630.
	 
	 	13.7.	 	Board of Appeals: An enrollee who is aggrieved by the final decision of an
independent review may appeal the decision to the DSHS Board of Appeals in accord with
WAC ###-##-#### through ###-##-####. Notice of this right will be included in the
written determination from the Contractor or Independent Review Organization.
	 
	 	13.8.	 	Continuation of Services:






	 	13.8.1.	 	The Contractor shall continue the enrollee’s services if all of the following
apply (42 CFR 438.420):




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	 	13.8.1.1.	 	An appeal, hearing or independent review is requested on or before the
later of the following:






	 	13.8.1.1.1.	 	Within ten (10) calendar days of the Contractor mailing the notice of
action, which for actions involving services previously authorized, shall be
delivered by a method that certifies receipt and assures delivery within
three (3) calendar days.






	 	13.8.1.1.2.	 	The intended effective date of the Contractor’s proposed action.






	 	13.8.1.2.	 	The appeal involves the termination, suspension, or reduction of a
previously authorized course of treatment.
	 
	 	13.8.1.3.	 	The services were ordered by an authorized provider.
	 
	 	13.8.1.4.	 	The original period covered by the original authorization has not expired.
	 
	 	13.8.1.5.	 	The enrollee requests an extension of services.






	 	13.8.2.	 	If, at the enrollee’s request, the Contractor continues or reinstates the
enrollee’s services while the appeal, hearing, independent review or DSHS Board of
Appeals is pending, the services shall be continued until one of the following
occurs:






	 	13.8.2.1.	 	The enrollee withdraws the appeal, hearing or independent review request.
	 
	 	13.8.2.2.	 	Ten (10) calendar days pass after the Contractor mails the notice of the
resolution of the appeal and the enrollee has not requested
a hearing (with continuation of services until the hearing decision is
reached) within the ten (10) calendar days.
	 
	 	13.8.2.3.	 	Ten (10) calendar days pass after DSHS mails the notice of resolution of
the hearing and the enrollee has not requested an independent review (with
continuation of services until the independent review decision is reached)
within the ten (10) calendar days.
	 
	 	13.8.2.4.	 	Ten (10) calendar days pass after the Contractor mails the notice of the
resolution of the independent review and the enrollees has not requested a DSHS
Board of Appeals (with continuation of services until the DSHS Board of Appeals
decision is reached) within ten (10) calendar days.




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	 	13.8.2.5.	 	The time period or service limits of a previously authorized service has
been met.






	 	13.8.3.	 	If the final resolution of the appeal upholds the Contractor’s action, the
Contractor may recover from the enrollee the amount paid for the services provided
to the enrollee while the appeal was pending, to the extent that they were provided
solely because of the requirement for continuation of services.






	 	13.9.	 	Effect of Reversed Resolutions of Appeals and Hearings:






	 	13.9.1.	 	If the Contractor, DSHS Office of Administrative Hearings (OAH), independent
review organization (IRO) or DSHS Board of Appeals reverses a decision to deny,
limit, or delay services that were not provided while the appeal was pending, the
Contractor shall authorize or provide the disputed services promptly, and as
expeditiously as the enrollee’s health condition requires (42 CFR 438.424(a)(b)).






	 	13.9.2.	 	If the Contractor, OAH, IRO or DSHS Board of Appeals reverses a decision to deny
authorization of services, and the enrollee received the disputed services while the
appeal was pending, the Contractor shall pay for those services.






	 	13.10.	 	Actions, Grievances, Appeals and Independent Reviews: The Contractor shall maintain
records of all actions, grievances, appeals and independent reviews.






	 	13.10.1.	 	The records shall include actions, grievances and appeals handled by delegated
entities.
	 
	 	13.10.2.	 	The Contractor shall provide a report of complete actions, grievances, appeals
and independent reviews to DSHS in accord with the Grievance System Reporting
Requirements published by DSHS (see Attachment A for website link).
	 
	 	13.10.3.	 	The Contractor is responsible for maintenance of records for and reporting of
any grievance, actions and appeals handled by delegated entities.
	 
	 	13.10.4.	 	Delegated actions, grievances and appeals are to be integrated into the
Contractor’s report.
	 
	 	13.10.5.	 	Data shall be reported in the DSHS and Contractor agreed upon format. Reports
that do not meet the Grievance System Reporting Requirements shall be returned to
the Contractor for correction. Corrected reports will be resubmitted to DSHS within
30 calendar days.




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	 	13.10.6.	 	The report medium shall be specified by DSHS and shall be in accord with the
Grievance System Reporting Requirements published by DSHS (See Attachment A for
website link).
	 
	 	13.10.7.	 	Reporting of actions shall include all denials or limited authorization of a
requested service, including the type or level of service, and the reduction,
suspension, or termination of a previously authorized service but will not include
denials of payment to providers unless the enrollee may be liable for payment in
accord with WAC 388-502-0160 and the provisions of this Contract.
	 
	 	13.10.8.	 	The Contractor shall provide information to DSHS regarding denial of payment to
providers upon request.
	 
	 	13.10.9.	 	Reporting of grievances shall include all expressions of enrollee
dissatisfaction not related to an action. All grievances are to be recorded and
counted whether the grievance is remedied by the Contractor immediately or through
its grievance and quality of care service procedures.





14.    BENEFITS





	 	14.1.	 	Scope of Services:






	 	14.1.1.	 	The Contractor is responsible for covering medically necessary services relating
to (42 CFR 438.210(a)(4)):






	 	14.1.1.1.	 	The prevention, diagnosis, and treatment of health impairments.
	 
	 	14.1.1.2.	 	The achievement of age-appropriate growth and development.
	 
	 	14.1.1.3.	 	The attainment, maintenance, or regaining of functional capacity.






	 	14.1.2.	 	If a specific procedure or element of a covered service is covered by DSHS under
its fee-for-service program, as described in DSHS’ billing instructions,
incorporated by reference (see Attachment A for website link), the Contractor shall
cover the service subject to the specific exclusions and limitations as described in
this Contract.
	 
	 	14.1.3.	 	Except as otherwise specifically provided in this Contract, the Contractor shall
provide covered services in the amount, duration and scope described in the Medicaid
State Plan (42 CFR 438.210(a)(1 & 2)).
	 
	 	14.1.4.	 	The amount and duration of covered services that are medically necessary depends
on the enrollee’s condition (42 CFR 438.210(a)(3)(i)).




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	 	14.1.5.	 	The Contractor shall not arbitrarily deny or reduce the amount, duration or scope
of required services solely because of the enrollee’s diagnosis, type of illness or
condition (42 CFR 438.210(a)(3)(ii).
	 
	 	14.1.6.	 	Except as specifically provided in the provisions of the, Authorization of
Services Section, the requirements of this Section shall not be construed to prevent
the Contractor from establishing utilization control measures as it deems necessary
to assure that services are appropriately utilized, provided that utilization
control measures do not deny medically necessary covered services to enrollees. The
Contractor’s utilization control measures are not required to be the same as those
in the Medicaid fee-for-service program (42 CFR 438.210(a)(3)(iii).
	 
	 	14.1.7.	 	For specific covered services, the requirements of this Section shall also not be
construed as requiring the Contractor to cover the specific items covered by DSHS
under its fee-for-service program, but shall rather be construed to require the
Contractor to cover the same scope of services.
	 
	 	14.1.8.	 	Nothing in this Contract shall be construed to require or prevent the Contractor
from covering services outside of the scope of services covered under this Contract
(42 CFR 438.6(e)).
	 
	 	14.1.9.	 	The Contractor may limit coverage of services to participating providers except
as specifically provided in the Access and Capacity Section of this Contract; and
the following provisions of this Section:






	 	14.1.9.1.	 	Emergency services;
	 
	 	14.1.9.2.	 	Outside the Service Areas as necessary to provide medically necessary
services; and
	 
	 	14.1.9.3.	 	Coordination of Benefits, when an enrollee has other medical coverage as
necessary to coordinate benefits.






	 	14.1.10.	 	Within the Service Areas: Within the Contractor’s service areas, as defined in
the Service Areas provisions of the Enrollment Section of this Contract, the
Contractor shall cover enrollees for all medically necessary services included in
the scope of services covered by this Contract.
	 
	 	14.1.11.	 	Outside the Service Areas: For the enrollees still enrolled with the Contractor
who are temporarily outside of the service areas or who have moved to a service area
not served by the Contractor, the Contractor shall cover the following services:






	 	14.1.11.1.	 	Emergency and post-stabilization services.






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	 	14.1.11.2.	 	Urgent care services associated with the presentation of medical signs
that require immediate attention, but are not life threatening. The Contractor
may require prior-authorization for urgent care services as long as the wait
times specified in the, Appointment Standards, provisions of the Access and
Capacity Section of this Contract, are not exceeded.
	 
	 	14.1.11.3.	 	Services that are neither emergent nor urgent, but are medically necessary
and cannot reasonably wait until enrollee’s return to the service area. The
Contractor is not required to cover non-symptomatic (i.e., preventive care) out
of the service area. The Contractor may require pre-authorization for such
services as long as the wait times specified in the Appointment Standards
provision of the Access and Capacity Section of this Contract, are not exceeded.
	 
	 	14.1.11.4.	 	The Contractor’s obligation for services outside the service area is
limited to ninety (90) calendar days beginning with the first of the month
following the month in which the enrollee leaves the service area or changes
residence, except when the enrollee is sent out of the service area by the
Contractor to receive services.
	 
	 	14.1.11.5.	 	The Contractor is not responsible for coverage of any services when an
enrollee is outside the United States of America and its territories and
possessions.






	 	14.2.	 	Medical Necessity Determination: The Contractor shall determine which
services are medically necessary, according to utilization management requirements and
the definition of Medically Necessary Services in this Contract. The Contractor’s
determination of medical necessity in specific instances shall be final except as
specifically provided in this Contract regarding appeals, hearings and independent
review.
	 
	 	14.3.	 	Enrollee Self-Referral:






	 	14.3.1.	 	Enrollees have the right to self-refer for certain services to local health
departments and family planning clinics paid through separate arrangements with the
State of Washington.
	 
	 	14.3.2.	 	The Contractor is not responsible for the coverage of the services provided
through such separate arrangements.
	 
	 	14.3.3.	 	The enrollees also may choose to receive such services from the Contractor.
	 
	 	14.3.4.	 	The Contractor shall assure that enrollees are informed, whenever appropriate, of
all options in such a way as not to prejudice or direct the
enrollee’s choice of where to receive the services. If the Contractor in 




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	 	 	 	any
manner deprives enrollees of their free choice to receive services through the
Contractor, the Contractor shall pay the local health department or family
planning facility for services provided to enrollees up to the limits
described herein.






	 	14.3.5.	 	If the Contractor subcontracts with local health departments or family planning
clinics as participating providers or refers enrollees to them to receive services,
the Contractor shall pay the local health department or family planning facility for
services provided to enrollees up to the limits described herein.
	 
	 	14.3.6.	 	The services to which an enrollee may self-refer are:






	 	14.3.6.1.	 	Family planning services and sexually-transmitted disease screening and
treatment services provided at family planning facilities, such as Planned
Parenthood.
	 
	 	14.3.6.2.	 	Immunizations, sexually-transmitted disease screening and follow-up,
immunodeficiency virus (HIV) screening, tuberculosis screening and follow-up,
and family planning services through the local health department.






	 	14.4.	 	Women’s Health Care Services: The Contractor must provide female enrollees
with direct access to a women’s health specialist within the Contractors network for
covered care necessary to provide women’s routine and preventive health care services
in accord with the provisions of WAC 284-43-250 and 42 CFR 438.206(b)(2).
	 
	 	14.5.	 	Maternity Newborn Length of Stay: The Contractor shall ensure that hospital
delivery maternity care is provided in accord with RCW 48.43.115.
	 
	 	14.6.	 	Continuity of Care: The Contract shall ensure the Continuity of Care, as
defined herein, for enrollees in an active course of treatment for a chronic or acute
medical condition. The Contractor shall ensure that medically necessary care for
enrollees is not interrupted (42 CFR 438.208).






	 	14.6.1.	 	For changes in the Contractor’s provider network or service areas, the Contractor
shall comply with the notification requirements identified in the Service Area and
Provider Network Changes provisions found in the Enrollment and Access and Capacity
Sections of this Contract.
	 
	 	14.6.2.	 	If possible and reasonable, the Contractor shall preserve enrollee provider
relationships through transitions.
	 
	 	14.6.3.	 	Where preservation of provider relationships is not possible and reasonable, the
Contractor shall provide transition to a provider who will provide equivalent,
uninterrupted care as expeditiously as the enrollee’s medical condition requires.




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	 	14.6.4.	 	The Contractor shall allow new enrollees with the Contractor to fill
prescriptions written prior to enrollment until the first of the following occurs:






	 	14.6.4.1.	 	The enrollee’s prescription expires.
	 
	 	14.6.4.2.	 	A participating provider examines the enrollee to evaluate the continued
need for the prescription. If the enrollee refuses an evaluation by a
participating provider the Contractor may refuse to fill the prescription.






	 	14.7.	 	Coordination of Care: The Contractor shall ensure that health care services
are coordinated for enrollees as follows (42 CFR 438.208):






	 	14.7.1.	 	The Contractor shall ensure that PCPs are responsible for the provision,
coordination, and supervision of health care to meet the needs of each enrollee,
including initiation and coordination of referrals for medically necessary specialty
care.
	 
	 	14.7.2.	 	The Contractor shall ensure that enrollee health information is shared between
providers in a manner that facilitates coordination of care while protecting
confidentiality and enrollee privacy (42 CFR 438.208(b)(4) and 45 CFR 160 and 164
subparts A and E).
	 
	 	14.7.3.	 	The Contractor shall provide support services to assist PCPs in providing
coordination if it is not provided directly by the Contractor.
	 
	 	14.7.4.	 	The Contractor shall coordinate and ensure PCPs coordinate with community-based
and DSHS services/programs including but not limited to services/programs described
in this Section:






	 	14.7.4.1.	 	First Steps Maternity Services and Maternity Case Management;
	 
	 	14.7.4.2.	 	Transportation services;
	 
	 	14.7.4.3.	 	Regional Support Networks for mental health services;
	 
	 	14.7.4.4.	 	Developmental Disability services;
	 
	 	14.7.4.5.	 	Infant Toddler Early Intervention Program (ITEIP) for infants from the ages
of birth to three;
	 
	 	14.7.4.6.	 	Patient Review and Restriction (PRR) program, for enrollees who meet the
criteria identified in WAC 388-501-0135;
	 
	 	14.7.4.7.	 	Health Department services, including Title V services for children with
special health care needs;




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	 	14.7.4.8.	 	Home and Community Services for older and physically disabled individuals;
and
	 
	 	14.7.4.9.	 	Alcohol and Substance Abuse services.






	 	14.7.5.	 	The Contractor shall identify or shall ensure that providers identify enrollees
with special health care needs as defined in WAC 388-538-050. The Contractor’s
obligation for identification of enrollees with special health care needs is limited
to identification in the course of any contact or health care visit initiated by the
enrollee and any information available to the Contractor regarding an enrollee’s
special health care needs. The Contractor shall maintain a record of all enrollee’s
identified as enrollee’s with special health care needs.
	 
	 	14.7.6.	 	The Contractor shall ensure that PCPs, in consultation with other appropriate
health care professionals, assess and develop individualized treatment plans for
children with special health care needs and enrollees with special health care needs
as defined herein, which ensure integration of clinical and non-clinical disciplines
and services in the overall plan of care (42 CFR 438.208(c)(2)).






	 	14.7.6.1.	 	Documentation regarding the assessment and treatment plan shall be in the
enrollee’s case file, including enrollee participation in the development of the
treatment plan (42 CFR 438.208(c)(3)).
	 
	 	14.7.6.2.	 	If the Contractor requires approval of the treatment plan, approval must be
provided in a timely manner appropriate to the enrollee’s health condition.






	 	14.7.7.	 	The Contractor must implement procedures to share with other MCOs and RSNs
serving the enrollee the results of its identification and assessment of any
children with special health care needs and enrollee with special health care needs
so that those activities are not duplicated while protecting confidentiality and
enrollee rights (42 CFR 438.208 (b)(3)).






	 	14.8.	 	Second Opinions:






	 	14.8.1.	 	The Contractor must authorize a second opinion regarding the enrollee’s health
care from a qualified health care professional within the Contractor’s network, or
provide authorization for the enrollee to obtain a second opinion outside the
Contractor’s network, if the Contractor’s
network is unable to provide for a qualified health care professional, at no
cost to the enrollee.
	 
	 	14.8.2.	 	This Section shall not be construed to require the Contractor to cover unlimited
second opinions, nor to require the Contractor to cover any 




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	 	 	 	services other than the
professional services of the second opinion provider (42 CFR 438.206(b)(3)).






	 	14.9.	 	Sterilizations and Hysterectomies: The Contractor shall assure that all
sterilizations and hysterectomies performed under this Contract are in compliance with
42 CFR 441 Subpart F, and that the DSHS Sterilization Consent Form (DSHS 13-364(x)) or
its equivalent is used.
	 
	 	14.10.	 	Experimental and Investigational Services:






	 	14.10.1.	 	If the Contractor excludes or limits benefits for any services for one or more
medical conditions or illnesses because such services are deemed experimental or
investigational, the Contractor shall develop and follow policies and procedures for
such exclusions and limitations. The policies and procedures shall identify the
persons responsible for such decisions. The policies and procedures and any
criteria for making decisions shall be made available to DSHS upon request (WACs
284-44-043, 284-46-507 and 284-96-015).
	 
	 	14.10.2.	 	In making the determination, whether to authorize a service the Contractor shall
consider the following:






	 	14.10.2.1.	 	Evidence in peer-reviewed, medical literature, as defined herein, and
pre-clinical and clinical data reported to the National Institute of Health
and/or the National Cancer Institute, concerning the probability of the service
maintaining or significantly improving the enrollee’s length or quality of life,
or ability to function, and whether the benefits of the service or treatment are
outweighed by the risks of death or serious complications.
	 
	 	14.10.2.2.	 	Whether evidence indicates the service or treatment is likely to be as
beneficial as existing conventional treatment alternatives.
	 
	 	14.10.2.3.	 	Any relevant, specific aspects of the condition.
	 
	 	14.10.2.4.	 	Whether the service or treatment is generally used for the condition in
the State of Washington.
	 
	 	14.10.2.5.	 	Whether the service or treatment is under continuing scientific testing
and research.
	 
	 	14.10.2.6.	 	Whether the service or treatment shows a demonstrable benefit for the
condition.
	 
	 	14.10.2.7.	 	Whether the service or treatment is safe and efficacious.
	 
	 	14.10.2.8.	 	Whether the service or treatment will result in greater benefits for the
condition than another generally available service.




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	 	14.10.2.9.	 	If approval is required by a regulating agency, such as the Food and Drug
Administration, whether such approval has been given before the date of service.






	 	14.10.3.	 	Criteria to determine whether a service is experimental or investigational shall
be no more stringent for Medicaid enrollees than that applied to any other members.
	 
	 	14.10.4.	 	A service or treatment that is not experimental for one enrollee with a
particular medical condition cannot be determined to be experimental for another
enrollee with the same medical condition and similar health status.
	 
	 	14.10.5.	 	A service or treatment may not be determined to be experimental and
investigational solely because it is under clinical investigation when there is
sufficient evidence in peer-reviewed medical literature to draw conclusions, and the
evidence indicates the service or treatment will probably be of significant benefit
to enrollees.
	 
	 	14.10.6.	 	An adverse determination made by the Contractor shall be subject to appeal
through the Contractor’s appeal process, hearing process and independent review.






	 	14.11.	 	Enrollee Hospitalized at Enrollment:






	 	14.11.1.	 	If an enrollee is in an acute care hospital at the time of enrollment and was
not enrolled in Healthy Options/SCHIP on the day the enrollee is admitted to the
hospital, DSHS shall be responsible for payment of all inpatient facility and
professional services provided from the date of admission until the date the
enrollee is no longer confined to an acute care hospital.
	 
	 	14.11.2.	 	If an enrollee is enrolled in Healthy Options/SCHIP on the day the enrollee was
admitted to an acute care hospital, then the plan the enrollee is enrolled with on
the date of admission shall be responsible for payment of all covered inpatient
facility and professional services provided from the date of admission until the
date the enrollee is no longer confined to an acute care hospital.
	 
	 	14.11.3.	 	For newborns, born while their mother is hospitalized, the party responsible for
the payment of covered services for the mother’s hospitalization shall be
responsible for payment of all covered inpatient facility and professional services
provided to the newborn from the date of admission until the date the newborn is no
longer confined to an acute care hospital.




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	 	14.11.4.	 	For newborns, who are removed from the enrollment with the Contractor
retroactive to the date of birth and whose premiums are recouped as provided herein,
DSHS shall be responsible for payment of all covered inpatient facility and
professional services provided to and associated with the newborn. This provision
does not apply for services provided to and associated with the mother.
	 
	 	14.11.5.	 	If DSHS is responsible for payment of all covered inpatient facility and
professional services provided to a mother, DSHS shall not pay the Contractor a
Delivery Case Rate under the provisions of the Payment and Sanctions Section of this
Contract.






	 	14.12.	 	Enrollee Hospitalized at Termination of Enrollment: If an enrollee is in an acute
care hospital at the time of termination of enrollment and the enrollee was enrolled
with the Contractor on the date of admission, the Contractor shall be responsible for
payment of all covered inpatient facility and professional services from the date of
admission until one of the following occurs;






	 	14.12.1.	 	The enrollee is no longer confined to an acute care hospital.
	 
	 	14.12.2.	 	The Contractor’s obligation to pay for services has ended based on the
Contractor’s obligation for covering services outside the service area as identified
in this Section.
	 
	 	14.12.3.	 	The enrollee’s eligibility to receive Medicaid services ends. The Contractor’s
obligation for payment ends at the end of the month the enrollees Medicaid
eligibility ends.






	 	14.13.	 	General Description of Covered Services: This Section is a general description of
services covered under this Contract and is not intended to be exhaustive.






	 	14.13.1.	 	Medical services provided to enrollees who have a diagnosis of alcohol and/or
chemical dependency or mental health diagnosis are covered when those services are
otherwise covered services.
	 
	 	14.13.2.	 	Inpatient Services: Provided by acute care hospitals (licensed under RCW
70.41), or nursing facilities (licensed under RCW 18.51) when nursing facility
services are not covered by DSHS’ Aging and Disability
Services Administration and the Contractor determines that nursing facility
care is more appropriate than acute hospital care. Inpatient physical
rehabilitation services are included.
	 
	 	14.13.3.	 	Outpatient Hospital Services: Provided by acute care hospitals (licensed under
RCW 70.41).
	 
	 	14.13.4.	 	Emergency Services and Post-stabilization Services:




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	 	14.13.4.1.	 	Emergency Services: Emergency services are defined herein.






	 	14.13.4.1.1.	 	The Contractor will provide all inpatient and outpatient emergency
services in accord with the requirements of 42 CFR 438.114.
	 
	 	14.13.4.1.2.	 	The Contractor shall cover all emergency services provided by a
licensed provider, acting with in their scope of practice, without regard to
whether the provider is a participating or non-participating provider (42
CFR 438.114 (c)(1)(i)).
	 
	 	14.13.4.1.3.	 	The Contractor shall not refuse to cover emergency services based on
the emergency room provider, hospital, or fiscal agent not notifying the
enrollee’s primary care provider, or the Contractor of the enrollee’s
screening and treatment within 10 calendar days of presentation for
emergency services (42 CFR 438.114 (c)(1)(ii)).
	 
	 	14.13.4.1.4.	 	The only exclusions to the Contractor’s coverage of emergency
services are mental health services which are covered under separate
contract, and dental services only if provided by a dentist or an oral
surgeon to treat a dental diagnosis, covered under DSHS’ fee-for-service
program.
	 
	 	14.13.4.1.5.	 	Emergency services shall be provided without requiring prior
authorization.
	 
	 	14.13.4.1.6.	 	What constitutes an emergency medical condition may not be limited
on the basis of lists of diagnoses or symptoms (42 CFR 438.114 (d)(1)(i)).
	 
	 	14.13.4.1.7.	 	The Contractor shall cover treatment obtained under the following
circumstances:






	 	14.13.4.1.7.1.	 	An enrollee had an emergency medical condition, including cases
in which the absence of immediate medical attention would not have had
the outcomes specified in the definition of an emergency medical
condition (42 CFR 438.114(c)(1)(ii)(A)).
	 
	 	14.13.4.1.7.2.	 	A participating provider or other Contractor representative
instructs the enrollee to seek emergency services (42 CFR
438.114(c)(1)(ii)(B)).






	 	14.13.4.1.8.	 	If there is a disagreement between a hospital and the Contractor
concerning whether the patient is stable enough for discharge or transfer,
or whether the medical benefits of 




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	 	 	 	an unstabilized transfer outweigh the
risks, the judgment of the attending physician(s) actually caring for the
enrollee at the treating facility prevails and is binding on the Contractor
(42 CFR 438.114 (d)(3)).






	 	14.13.4.2.	 	Post-stabilization Services: Post-stabilization services are defined
herein.






	 	14.13.4.2.1.	 	The Contractor will provide all inpatient and outpatient
post-stabilization services in accord with the requirements of 42 CFR
438.114 and 42 CFR 422.113(c).
	 
	 	14.13.4.2.2.	 	The Contractor shall cover all post-stabilization services provided
by a licensed provider, acting with in their scope of practice, without
regard to whether the provider is a participating or non-participating
provider.
	 
	 	14.13.4.2.3.	 	The Contractor shall cover post-stabilization services under the
following circumstances (42 CFR 438.114 (e) and 42 CFR 438.113(c)(2)(iii))):






	 	14.13.4.2.3.1.	 	The services are pre-approved by a participating provider or
other Contractor representative.
	 
	 	14.13.4.2.3.2.	 	The services are not pre-approved by a participating provider
or other Contractor representative, but are administered to maintain the
enrollee’s stabilized condition within 1 hour of a request to the
Contractor for pre-approval of further post-stabilization care services.
	 
	 	14.13.4.2.3.3.	 	The services are not pre-approved by a participating provider
or other Contractor representative, but are administered to maintain,
improve, or resolve the enrollee’s stabilized condition and:






	 	14.13.4.2.3.3.1.	 	The Contractor does not respond to a request for
pre-approval within thirty (30) minutes (RCW 48.43.093(d));
	 
	 	14.13.4.2.3.3.2.	 	The Contractor cannot be contacted; or
	 
	 	14.13.4.2.3.3.3.	 	The Contractor representative and the treating physician
cannot reach an agreement concerning the enrollee’s care and a
Contractor physician is not available for consultation. In this
situation, the Contractor shall give the treating physician the
opportunity to consult with a Contractor physician 




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	 	 	 	and the treating
physician may continue with care of the enrollee until a Contractor
physician is reached or one of the criteria identified in 42 CFR
438.114(e) and 42 CFR 422.133(c)(3) is met.






	 	14.13.4.2.4.	 	The Contractor’s responsibility for post-stabilization services it
has not pre-approved ends when (42 CFR 438.114(e) and 42 CFR 422.133(c)(3)):






	 	14.13.4.2.4.1.	 	A participating provider with privileges at the treating
hospital assumes responsibility for the enrollee’s care;
	 
	 	14.13.4.2.4.2.	 	A participating provider assumes responsibility for the
enrollee’s care through transfer;
	 
	 	14.13.4.2.4.3.	 	A Contractor representative and the treating physician reach an
agreement concerning the enrollee’s care; or
	 
	 	14.13.4.2.4.4.	 	The enrollee is discharged.






	 	14.13.5.	 	Ambulatory Surgery Center: Services provided at ambulatory surgery centers.
	 
	 	14.13.6.	 	Provider Services: Services provided in an inpatient or outpatient (e.g.,
office, clinic, emergency room or home) setting by licensed professionals including,
but not limited to, physicians, physician assistants, advanced registered nurse
practitioners, midwives, podiatrists, audiologists, registered nurses, and certified
dietitians. Provider Services include, but are not limited to:






	 	14.13.6.1.	 	Medical examinations, including wellness exams for adults and EPSDT for
children
	 
	 	14.13.6.2.	 	Immunizations
	 
	 	14.13.6.3.	 	Maternity care
	 
	 	14.13.6.4.	 	Family planning services provided or referred by a participating provider
or practitioner
	 
	 	14.13.6.5.	 	Performing and/or reading diagnostic tests
	 
	 	14.13.6.6.	 	Private duty nursing
	 
	 	14.13.6.7.	 	Surgical services
	 
	 	14.13.6.8.	 	Services to correct defects from birth, illness, or trauma, or for
mastectomy reconstruction




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	 	14.13.6.9.	 	Anesthesia
	 
	 	14.13.6.10.	 	Administering pharmaceutical products
	 
	 	14.13.6.11.	 	Fitting prosthetic and orthotic devices
	 
	 	14.13.6.12.	 	Rehabilitation services
	 
	 	14.13.6.13.	 	Enrollee health education
	 
	 	14.13.6.14.	 	Nutritional counseling for specific conditions such as diabetes, high
blood pressure, and anemia
	 
	 	14.13.6.15.	 	Bio-feedback training when determined medically necessary specifically
for, perineal muscles, anorectral or urethral sphincter, including EMG and/or
manometry for incontinence.
	 
	 	14.13.6.16.	 	Genetic services when medically necessary for diagnosis of a medical
condition.






	 	14.13.7.	 	Tissue and Organ Transplants: Heart, kidney, liver, bone marrow, lung,
heart-lung, pancreas, kidney-pancreas, cornea, small bowel, and peripheral blood
stem cell.
	 
	 	14.13.8.	 	Laboratory, Radiology, and Other Medical Imaging Services: Screening and
diagnostic services and radiation therapy.
	 
	 	14.13.9.	 	Vision Care: Eye examinations for visual acuity and refraction once every
twenty-four (24) months for adults and once every twelve (12) months for children
under age twenty-one (21). These limitations do not apply to additional services
needed for medical conditions. The Contractor may restrict non-emergent care to
participating providers. Enrollees may self-refer to participating providers for
these services.
	 
	 	14.13.10.	 	Outpatient Mental Health:






	 	14.13.10.1.	 	Psychiatric and psychological testing, evaluation and diagnosis:






	 	14.13.10.1.1.	 	Once every twelve (12) months for adults twenty-one (21) and over
and children under age twenty-one when not ordered as a result of an EPSDT
exam.
	 
	 	14.13.10.1.2.	 	Unlimited for children under age twenty-one (21) when identified in
an EPSDT exam.






	 	14.13.10.2.	 	Unlimited medication management:






	 	14.13.10.2.1.	 	Provided by the PCP or by PCP referral.




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	 	14.13.10.2.2.	 	Provided in conjunction with mental health treatment covered by the
Contractor.






	 	14.13.10.3.	 	Twelve hours per calendar year for treatment for enrollees who do not
meet the RSNs access standards for receiving treatment.
	 
	 	14.13.10.4.	 	Transition to the RSN, as appropriate to the enrollee’s condition to
assure continuity of care.
	 
	 	14.13.10.5.	 	The Contractor may subcontract with RSNs to provide the outpatient mental
health services that are the responsibility of the Contractor. Such contracts
shall not be written or construed in a manner that provides less than the
services otherwise described in this Section as the Contractor’s responsibility
for outpatient mental health services.
	 
	 	14.13.10.6.	 	The DSHS Mental Health Division (MHD) and the Division of Healthcare
Services (DHS) shall each appoint a Mental Health Care Coordinator (MHCC). The
MHCCs shall be empowered to decide all Contractor and RSN issues regarding
outpatient mental health coverage that cannot be otherwise resolved between the
Contractor and the RSN. The MHCCs will also undertake training and technical
assistance activities that further coordination of care between DPS, MHD,
Healthy Options contractors, and RSNs. The Contractor shall cooperate with the
activities of the MHCCs.






	 	14.13.11.	 	Neurodevelopmental Services, Occupational Therapy, Speech Therapy, and Physical
Therapy: Services for the restoration or maintenance of a function affected by an
enrollee’s illness, disability, condition or injury, or for the amelioration of the
effects of a developmental disability when provided by a facility that is not a DSHS
recognized neurodevelopmental center. The Contractor may refer children to a DSHS
recognized neurodevelopmental center for the services as long as appointment wait
time standards and access to care standards of this Contract are met (see Attachment
A for website link).
	 
	 	14.13.12.	 	Pharmaceutical Products:






	 	14.13.12.1.	 	Prescription drug products according to a DSHS approved formulary, which
includes both legend and over-the-counter (OTC) products. The Contractor’s
formulary shall include all therapeutic classes in DSHS’ fee-for-service drug
file and a sufficient variety of drugs in each therapeutic class to meet
enrollees’ medically necessary health care needs. The Contractor shall provide
participating pharmacies and participating providers with its formulary and
information about 




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	 	 	 	how to request non-formulary drugs.
	 
	 	14.13.12.2.	 	The Contractor shall have in place a mechanism to deny prescriptions
written by excluded providers.
	 
	 	14.13.12.3.	 	The Contractor’s policies and procedures for the administration of the
pharmacy benefit shall ensure compliance with the following requirements
described in this section:






	 	14.13.12.3.1.	 	Formulary exceptions: The Contractor shall approve or deny all
requests for non-formulary drugs by the business day following the day of
request.
	 
	 	14.13.12.3.2.	 	Emergency drug supply: The Contractor shall have a process for
providing an emergency drug supply to enrollees when a delay in
authorization would interrupt a drug therapy that must be continuous or when
the delay would pose a threat to the enrollees’ health and safety. The drug
supply provided must be sufficient to bridge the time until an authorization
determination is made.






	 	14.13.12.4.	 	Covered drug products shall include:






	 	14.13.12.4.1.	 	Oral, enteral and parenteral nutritional supplements and supplies,
including prescribed infant formulas;
	 
	 	14.13.12.4.2.	 	All Food and Drug Administration (FDA) approved contraceptive
drugs, devices, and supplies; including but not limited to Depo-Provera,
Norplant, and OTC products;
	 
	 	14.13.12.4.3.	 	Antigens and allergens; and
	 
	 	14.13.12.4.4.	 	Therapeutic vitamins and iron prescribed for prenatal and postnatal
care.






	 	14.13.13.	 	Home Health Services: Home health services through state-licensed agencies.
	 
	 	14.13.14.	 	Durable Medical Equipment (DME) and Supplies: Including, but not limited to:
DME; surgical appliances; orthopedic appliances and braces;
prosthetic and orthotic devices; breast pumps; incontinence supplies for
enrollees over three (3) years of age; and medical supplies. Incontinence
supplies shall not include non-disposable diapers unless the enrollee agrees.
	 
	 	14.13.15.	 	Oxygen and Respiratory Services: Oxygen, and respiratory therapy equipment and
supplies.




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	 	14.13.16.	 	Hospice Services: When the enrollee elects hospice care. Includes facility
services.
	 
	 	14.13.17.	 	Blood, Blood Components and Human Blood Products: Administration of whole
blood and blood components as well as human blood products. In areas where there is
a charge for blood and/or blood products, the Contractor shall cover the cost of the
blood or blood products.
	 
	 	14.13.18.	 	Treatment for Renal Failure: Hemodialysis, or other appropriate procedures to
treat renal failure, including equipment needed in the course of treatment.
	 
	 	14.13.19.	 	Ambulance Transportation: The Contractor shall cover ground and air ambulance
transportation for emergency medical conditions, as defined herein, including, but
not limited to, Basic and Advanced Life Support Services, and other required
transportation costs, such as tolls and fares. In addition, the Contractor shall
cover ambulance services under two circumstances for non-emergencies:






	 	14.13.19.1.	 	When it is necessary to transport an enrollee between facilities to
receive a covered services; and,
	 
	 	14.13.19.2.	 	When it is necessary to transport an enrollee, who must be carried on a
stretcher, or who may require medical attention en route (RCW 18.73.180) to
receive a covered service.






	 	14.13.20.	 	Smoking Cessation Services: For pregnant women through sixty (60) calendar
days post pregnancy.
	 
	 	14.13.21.	 	Newborn Screenings: The Contractor shall cover all newborn screenings required
by the Department of Health.
	 
	 	14.13.22.	 	EPSDT:






	 	14.13.22.1.	 	The Contractor shall meet all requirements under the DSHS EPSDT program
policy and billing instructions, incorporated by reference (see Attachment A for
website link).
	 
	 	14.13.22.2.	 	The following services are covered when referred as a result of an EPSDT
exam.






	 	14.13.22.2.1.	 	Chiropractic services;
	 
	 	14.13.22.2.2.	 	Nutritional counseling; and
	 
	 	14.13.22.2.3.	 	Unlimited psychiatric and psychological testing evaluation and
diagnosis.




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	 	14.14.	 	Exclusions: The following services and supplies are excluded from coverage under
this Contract.






	 	14.14.1.	 	Unless otherwise required by this Contract, ancillary services resulting from
excluded services are also excluded.
	 
	 	14.14.2.	 	Complications resulting from an excluded service are also excluded for a period
of ninety (90) calendar days following the occurrence of the excluded service not
counting the date of service. Thereafter, complications resulting from an excluded
service are a covered service when they would otherwise be a covered service under
the provisions of this Contract.
	 
	 	14.14.3.	 	Services Covered By DSHS Fee-For-Service Or Through Other Contracts:






	 	14.14.3.1.	 	School Medical Services for Special Students as described in the DSHS
billing instructions for School Medical Services.
	 
	 	14.14.3.2.	 	Eyeglass Frames, Lenses, and Fabrication Services covered under DSHS’
selective contract for these services, and associated fitting and dispensing
services.
	 
	 	14.14.3.3.	 	Voluntary Termination of Pregnancy.
	 
	 	14.14.3.4.	 	Transportation Services other than Ambulance: including but not limited
to Taxi, cabulance, voluntary transportation, public transportation and common
carriers.
	 
	 	14.14.3.5.	 	Services provided by dentists and oral surgeons for dental diagnoses,
including physical exams required prior to hospital admissions for oral surgery
and anesthesia for dental care.
	 
	 	14.14.3.6.	 	Hearing Aid Devices, including fitting, follow-up care and repair.
	 
	 	14.14.3.7.	 	First Steps Child Care, Infant Case Management and Maternity Support
Services as described in the DSHS program billing instructions (see Attachment A
for website link).
	 
	 	14.14.3.8.	 	Sterilizations for enrollees under age twenty-one (21), or those that do
not meet other federal requirements (42 CFR 441 Subpart F) (see Attachment A for
website link).
	 
	 	14.14.3.9.	 	Health care services provided by a neurodevelopmental center recognized by
DSHS.
	 
	 	14.14.3.10.	 	Services provided by a health department or family planning clinic when a
client self-refers for care.




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	 	14.14.3.11.	 	Inpatient psychiatric professional services.
	 
	 	14.14.3.12.	 	Emergency mental health services.
	 
	 	14.14.3.13.	 	Pharmaceutical products prescribed by any provider related to services
provided under a separate contract with DSHS.
	 
	 	14.14.3.14.	 	Laboratory services required for medication management of drugs
prescribed by community mental health providers whose services are purchased by
the Mental Health Division.
	 
	 	14.14.3.15.	 	Protease Inhibitors
	 
	 	14.14.3.16.	 	Services ordered as a result of an EPSDT exam that are not otherwise
covered services.
	 
	 	14.14.3.17.	 	Surgical procedures for weight loss or reduction, when approved by DSHS
in accord with WAC 388-531-0200. The Contractor has no obligation to cover
surgical procedures for weight loss or reduction.
	 
	 	14.14.3.18.	 	Prenatal Diagnosis Genetic Counseling provided to enrollees to allow
enrollees and their PCPs to make informed decisions regarding current genetic
practices and testing.






	 	14.14.4.	 	Services Covered By Other Divisions In DSHS:






	 	14.14.4.1.	 	Substance abuse treatment services covered through the Division of Alcohol
and Substance Abuse (DASA).
	 
	 	14.14.4.2.	 	Community-based services (e.g., COPES and Personal Care Services) covered
through the Aging and Disability Services Administration.
	 
	 	14.14.4.3.	 	Nursing facilities covered through the Aging and Disability Services
Administration.
	 
	 	14.14.4.4.	 	Mental health services separately purchased for all Medicaid clients by
the Mental Health Division, including 24-hour crisis
intervention, outpatient mental health treatment services, Club House,
respite care, Supported Employment and inpatient services.
	 
	 	14.14.4.5.	 	Health care services covered through the Division of Developmental
Disabilities for institutionalized clients.
	 
	 	14.14.4.6.	 	Infant formula for oral feeding provided by the Women, Infants and
Children (WIC) program in the Department of Health.





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	 	 	 	Medically necessary
nutritional supplements for infants are covered under the pharmacy benefit.






	 	14.14.5.	 	Services Not Covered by Either DSHS or the Contractor in accord with WAC
388-501-070:






	 	14.14.5.1.	 	Any ancillary services provided in association with services not covered
by either DSHS or the Contractor.
	 
	 	14.14.5.2.	 	Medical examinations for Social Security Disability.
	 
	 	14.14.5.3.	 	Services for which plastic surgery or other services are indicated
primarily for cosmetic reasons.
	 
	 	14.14.5.4.	 	Physical examinations required for obtaining continuing employment,
insurance or governmental licensing.
	 
	 	14.14.5.5.	 	Sports physicals
	 
	 	14.14.5.6.	 	Experimental and Investigational Treatment or Services, determined in
accord with the Experimental and Investigational Services, provision of this
Section and services associated with experimental or investigational treatment
or services.
	 
	 	14.14.5.7.	 	Reversal of voluntary induced sterilization.
	 
	 	14.14.5.8.	 	Personal Comfort Items, including but not limited to guest trays,
television and telephone charges.
	 
	 	14.14.5.9.	 	Massage Therapy
	 
	 	14.14.5.10.	 	Acupuncture
	 
	 	14.14.5.11.	 	TMJ for Adults
	 
	 	14.14.5.12.	 	Diagnosis and treatment of infertility, impotence, and sexual
dysfunction.
	 
	 	14.14.5.13.	 	Orthoptic (eye training) care for eye conditions
	 
	 	14.14.5.14.	 	Naturopathy
	 
	 	14.14.5.15.	 	Tissue or organ transplants that are not specifically listed as covered.
	 
	 	14.14.5.16.	 	Immunizations required for international travel purposes only.
	 
	 	14.14.5.17.	 	Court-ordered services




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	 	14.14.5.18.	 	Gender dysphoria surgery and other services not covered by DSHS for
gender dysphoria.
	 
	 	14.14.5.19.	 	Any service provided to an incarcerated enrollee, beginning when a law
enforcement officer takes the enrollee into legal custody and ending when the
enrollee is no longer in legal custody.
	 
	 	14.14.5.20.	 	Pharmaceutical products prescribed by any provider related to a service
not covered by either DSHS or the Contractor.
	 
	 	14.14.5.21.	 	Any non covered product, service or supply under DSHS’ fee-for-service
program.






	 	14.15.	 	Coordination of Benefits and Subrogation of Rights of Third Party Liability:






	 	14.15.1.	 	Coordination of Benefits:






	 	14.15.1.1.	 	Until DSHS ends the enrollment of an enrollee who has comparable coverage
as described in the Enrollment Section of this Contract, the services and
benefits available under this Contract shall be secondary to any other medical
coverage.
	 
	 	14.15.1.2.	 	Nothing in this Section negates any of the Contractor’s responsibilities
under this Contract including, but not limited to, the requirement described in
the Prohibition on Enrollee Charges for Covered Services provisions of the
Enrollee Rights and Protections Section of this Contract. The Contractor shall:






	 	14.15.1.2.1.	 	Not refuse or reduce services provided under this Contract solely
due to the existence of similar benefits provided under any other health
care contracts (RCW 48.21.200), except in accord with applicable
coordination of benefits rules in WAC 284-51.
	 
	 	14.15.1.2.2.	 	Attempt to recover any third-party resources available to enrollees
(42 CFR 433 Subpart D) and shall make all
records pertaining to coordination of benefits collections for
enrollees available for audit and review.
	 
	 	14.15.1.2.3.	 	Pay claims for prenatal care and preventive pediatric care and then
seek reimbursement from third parties (42 CFR 433.139(b)(3)).
	 
	 	14.15.1.2.4.	 	Pay claims for covered services when probable third party liability
has not been established or the third party benefits 




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	 	 	 	are not available to
pay a claim at the time it is filed (42 CFR 433.139(c)).
	 
	 	14.15.1.2.5.	 	Communicate the requirements of this Section to subcontractors that
provide services under the terms of this Contract, and assure compliance
with them.






	 	14.15.2.	 	Subrogation Rights of Third-Party Liability:






	 	14.15.2.1.	 	Injured person means an enrollee covered by this Contract who sustains
bodily injury.
	 
	 	14.15.2.2.	 	Contractor’s medical expense means the expense incurred by the Contractor
for the care or treatment of the injury sustained computed in accord with the
Contractor’s fee-for-service schedule.
	 
	 	14.15.2.3.	 	If an enrollee requires medical services from the Contractor as a result
of an alleged act or omission by a third-party giving rise to a claim of legal
liability against the third-party, the Contractor shall have the right to obtain
recovery of its cost of providing benefits to the injured person from the
third-party.
	 
	 	14.15.2.4.	 	DSHS specifically assigns to the Contractor the DSHS’ rights to such third
party payments for medical care provided to an enrollee on behalf of DSHS, which
the enrollee assigned to DSHS as provided in WAC 388-505-0540.
	 
	 	14.15.2.5.	 	DSHS also assigns to the Contractor its statutory lien under RCW
43.20B.060. The Contractor shall be subrogated to the DSHS’ rights and remedies
under RCW 74.09.180 and RCW 43.20B.040 through RCW 43.20B.070 with respect to
medical benefits provided to enrollees on behalf of DSHS under RCW 74.09.
	 
	 	14.15.2.6.	 	The Contractor may obtain a signed agreement from the enrollee in which
the enrollee agrees to fully cooperate in effecting collection from persons
causing the injury. The agreement may provide that if an injured party settles
a claim without protecting the Contractor’s interest, the injured party shall be
liable to the
Contractor for the full cost of medical services provided by the
Contractor.
	 
	 	14.15.2.7.	 	The Contractor shall notify DSHS of the name, address, and other
identifying information of any enrollee and the enrollee’s attorney who settles
a claim without protecting the Contractor’s interest in contravention of RCW
43.20B.050.






	 	14.16.	 	Patient Review and Restriction (PRR):




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	 	14.16.1.	 	The Contractor’s policies and procedures related to a Patient Review and
Restriction (PRR) program, shall ensure compliance with the requirements described
in this section
	 
	 	14.16.2.	 	The Contractor shall have a PRR program that meets the requirements of WAC
388-501-0135. PRR is authorized by 42 USC 1396n (a)(2) and 42 CFR 431.54.
	 
	 	14.16.3.	 	If either the Contractor or DSHS places an enrollee into the PRR program, both
parties will honor that placement.
	 
	 	14.16.4.	 	The Contractor’s placement of an enrollee into the PRR program shall be
considered an action, which shall be subject to appeal under the provisions of the
Grievance System section of this Contract. If the enrollee appeals the PRR
placement the Contractor will notify DSHS of the appeal and the outcome.
	 
	 	14.16.5.	 	When an enrollee is placed in the Contractor’s PRR program, the Contractor shall
send the enrollee a written notice of the enrollee’s PRR placement, or any change of
status, in accord with the requirements of WAC 388-501-0135.
	 
	 	14.16.6.	 	The Contractor shall send DSHS a written notice of the enrollee’s PRR placement,
or any change of status, in accord with the required format provided in the Patient
Review and Restriction Program Guide published by DSHS (See Attachment A for website
link.)
	 
	 	14.16.7.	 	In accord with WAC 388-501-0135, DSHS will limit the ability of an enrollee
placed in the PRR program to change their enrolled contractor for twelve months
after the enrollee is in the PRR program by DSHS or the Contractor unless the PRR
enrollee moves to a residence outside the Contractor’s service areas.
	 
	 	14.16.8.	 	If DSHS limits the ability of an enrollee to change their enrolled contractor
family members may still change enrollment as provided in this Contract.






118












 





	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Adams	 	Benton	 	Chelan	 	Clallam	 	Clark	 	Columbia	 	Cowlitz	 	Douglas	 	Ferry	 	Franklin	 	Garfield
	CITY	 	ZIP	 	CITY	 	ZIP	 	CITY	 	ZIP	 	CITY	 	ZIP	 	CITY	 	ZIP	 	CITY	 	ZIP	 	CITY	 	ZIP	 	CITY	 	ZIP	 	CITY	 	ZIP	 	CITY	 	ZIP	 	CITY	 	ZIP
	Benge (50)

	 	 	99105	 	 	Benton City
	 	 	99320	 	 	Ardenvoir
	 	 	98811	 	 	Beaver
	 	 	98305	 	 	Amboy
	 	 	98601	 	 	Dayton
	 	 	99328	 	 	Ariel (50)
	 	 	98603	 	 	Bridgeport
	 	 	98813	 	 	Boyd
	 	 	99107	 	 	Connell
	 	 	99326	 	 	Pomeroy
	 	 	99347	 
	Cunningham

	 	 	99327	 	 	Kennewick (U)
	 	 	99336	 	 	Cashmere
	 	 	98815	 	 	Carlsborg
	 	 	98324	 	 	Battle Ground
	 	 	98604	 	 	Starbuck
	 	 	99359	 	 	Carrolls
	 	 	98609	 	 	East Wenatchee
	 	 	98802	 	 	Curlew (50)
	 	 	99118	 	 	Eltopia
	 	 	99330	 	 	 	 	 	 	 
	Hatton

	 	 	99332	 	 	Kennewick
	 	 	99337	 	 	Chelan
	 	 	98816	 	 	Clallam Bay
	 	 	98326	 	 	Bush Prairie
	 	 	98606	 	 	 	 	 	 	 	 	Castle Rock
	 	 	98611	 	 	Mansfield
	 	 	98830	 	 	Danville (50)
	 	 	99121	 	 	Kahlotus
	 	 	99335	 	 	 	 	 	 	 
	Lind

	 	 	99341	 	 	Kennewick
	 	 	99338	 	 	Chelan Falls
	 	 	98817	 	 	Forks
	 	 	98331	 	 	Camas
	 	 	98607	 	 	 	 	 	 	 	 	Cougar (50)
	 	 	98616	 	 	Orondo
	 	 	98843	 	 	Inchelium (50)
	 	 	99138	 	 	Mesa
	 	 	99343	 	 	 	 	 	 	 
	Othello

	 	 	99344	 	 	Paterson
	 	 	99345	 	 	Dryden
	 	 	98821	 	 	Joyce
	 	 	98343	 	 	Heison
	 	 	98622	 	 	 	 	 	 	 	 	Kalama
	 	 	98625	 	 	Palisades
	 	 	98845	 	 	Keller
	 	 	99140	 	 	Pasco
	 	 	99301	 	 	 	 	 	 	 
	Washtucna (50)

	 	 	99371	 	 	Plymouth (50)
	 	 	99346	 	 	Entiat
	 	 	98822	 	 	La Push
	 	 	98350	 	 	La Center
	 	 	98629	 	 	 	 	 	 	 	 	Kelso
	 	 	98626	 	 	Rock Island
	 	 	98850	 	 	Laurier (50)
	 	 	99146	 	 	Pasco
	 	 	99302	 	 	 	 	 	 	 
	Ritzville

	 	 	99169	 	 	Prosser
	 	 	99350	 	 	Leavenworth
	 	 	98826	 	 	Neah Bay (50)
	 	 	98357	 	 	Ridgefield
	 	 	98642	 	 	 	 	 	 	 	 	Longview
	 	 	98632	 	 	Waterville
	 	 	98858	 	 	Malo
	 	 	99150	 	 	 	 	 	 	 	 	 	 	 	 	 
	 

	 	 	 	 	 	Richland
	 	 	99352	 	 	Malaga
	 	 	98828	 	 	Port Angeles
	 	 	98362	 	 	Vancouver
	 	 	98660	 	 	 	 	 	 	 	 	Ryderwood
	 	 	98581	 	 	 	 	 	 	 	 	Orient
	 	 	99160	 	 	 	 	 	 	 	 	 	 	 	 	 
	 

	 	 	 	 	 	West Richland
	 	 	99353	 	 	Manson
	 	 	98831	 	 	Port Angeles
	 	 	98363	 	 	Vancouver (U)
	 	 	98661	 	 	 	 	 	 	 	 	Silverlake
	 	 	98645	 	 	 	 	 	 	 	 	Republic
	 	 	99166	 	 	 	 	 	 	 	 	 	 	 	 	 
	 

	 	 	 	 	 	Richland
	 	 	98354	 	 	Monitor
	 	 	98836	 	 	Sekiu (50)
	 	 	98381	 	 	Vancouver
	 	 	98662	 	 	 	 	 	 	 	 	Toutle
	 	 	98649	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 

	 	 	 	 	 	 	 	 	 	 	 	Peshastin
	 	 	98847	 	 	Sequim
	 	 	98382	 	 	Vancouver (U)
	 	 	98663	 	 	 	 	 	 	 	 	Woodland
	 	 	98674	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 

	 	 	 	 	 	 	 	 	 	 	 	Stehekin (CP 65)
	 	 	98852	 	 	 	 	 	 	 	 	Vancouver (U)
	 	 	98664	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 

	 	 	 	 	 	 	 	 	 	 	 	Wenatchee
	 	 	98801	 	 	 	 	 	 	 	 	Vancouver
	 	 	98665	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 

	 	 	 	 	 	 	 	 	 	 	 	Wenatchee
	 	 	98807	 	 	 	 	 	 	 	 	Vancouver
	 	 	98666	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Vancouver
	 	 	98667	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Vancouver
	 	 	98668	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Vancouver
	 	 	98682	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Vancouver
	 	 	98683	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Vancouver (U)
	 	 	98684	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Vancouver
	 	 	98685	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Vancouver
	 	 	98686	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Vancouver
	 	 	98687	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Yacolt
	 	 	98675	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Washougal
	 	 	98671	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 






 









 






	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Grant	 	Grays Harbor	 	Island	 	Jefferson	 	King	 	Kitsap	 	Kittitas	 	Klickitat
	CITY	 	ZIP	 	CITY	 	ZIP	 	CITY	 	ZIP	 	CITY	 	ZIP	 	CITY	 	ZIP	 	CITY	 	ZIP	 	CITY	 	ZIP	 	CITY	 	ZIP	 	CITY	 	ZIP	 	CITY	 	ZIP	 	CITY	 	ZIP
	Beverly

	 	 	99321	 	 	Aberdeen
	 	 	98520	 	 	Clinton
	 	 	98236	 	 	Brinnon
	 	 	98320	 	 	Auburn
	 	 	98001	 	 	Kent
	 	 	98042	 	 	Seattle (U)
	 	 	98111	 	 	Seattle
	 	 	98166	 	 	Bainbridge Is.
	 	 	98110	 	 	CleElum
	 	 	98922	 	 	Appleton
	 	 	98602	 
	Coulee City

	 	 	99115	 	 	Amanda Park
	 	 	98526	 	 	Coupeville
	 	 	98239	 	 	Chimacum
	 	 	98325	 	 	Auburn (U)
	 	 	98002	 	 	Kent
	 	 	98064	 	 	Seattle (U)
	 	 	98112	 	 	Seattle
	 	 	98168	 	 	Bremerton (U)
	 	 	98310	 	 	Easton
	 	 	98925	 	 	Bickleton (50)
	 	 	99322	 
	Electric City

	 	 	99123	 	 	Copalis Bch.
	 	 	98535	 	 	Freeland
	 	 	98249	 	 	Port Hadlock
	 	 	98339	 	 	Auburn
	 	 	98071	 	 	Kirkland (U)
	 	 	98033	 	 	Seattle (U)
	 	 	98114	 	 	Seattle (U)
	 	 	98170	 	 	Bremerton
	 	 	98311	 	 	Ellensburg
	 	 	98926	 	 	Bingen
	 	 	98605	 
	Ephrata

	 	 	98823	 	 	Copalis Cros
	 	 	98536	 	 	Greenbank
	 	 	98253	 	 	Nordland
	 	 	98358	 	 	Auburn
	 	 	98092	 	 	Kirkland (U)
	 	 	98034	 	 	Seattle (U)
	 	 	98115	 	 	Seattle (U)
	 	 	98171	 	 	Bremerton
	 	 	98312	 	 	Kittitas
	 	 	98934	 	 	Centerville
	 	 	98613	 
	George

	 	 	98824	 	 	Cosmopolis
	 	 	98537	 	 	Langley
	 	 	98260	 	 	Port Ludlow
	 	 	98365	 	 	Baring (50)
	 	 	98224	 	 	Kirkland
	 	 	98083	 	 	Seattle (U)
	 	 	98116	 	 	Seattle (U)
	 	 	98174	 	 	Bremerton (U)
	 	 	98314	 	 	Ronald
	 	 	98940	 	 	Dallesport
	 	 	98617	 
	Grand Coulee

	 	 	99133	 	 	Elma
	 	 	98541	 	 	Oak Harbor
	 	 	98277	 	 	Port Townsend
	 	 	98368	 	 	Bellevue
	 	 	98004	 	 	Maple Valley
	 	 	98038	 	 	Seattle (U)
	 	 	98117	 	 	Seattle (U)
	 	 	98177	 	 	Bremerton
	 	 	98337	 	 	Roslyn
	 	 	98941	 	 	Glenwood (50)
	 	 	98619	 
	Hartline

	 	 	99135	 	 	Grayland
	 	 	98547	 	 	Oak Harbor
	 	 	98278	 	 	Quilcene
	 	 	98376	 	 	Bellevue (U)
	 	 	98005	 	 	Medina
	 	 	98039	 	 	Seattle (U)
	 	 	98118	 	 	Seattle (U)
	 	 	98178	 	 	Bremerton
	 	 	98322	 	 	S. CleElum
	 	 	98943	 	 	Goldendale
	 	 	98620	 
	Marlin

	 	 	98832	 	 	Hoquiam
	 	 	98550	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Bellevue
	 	 	98006	 	 	Mercer Is. (U)
	 	 	98040	 	 	Seattle (U)
	 	 	98119	 	 	Seattle (U)
	 	 	98181	 	 	Hansville
	 	 	98340	 	 	Thorp
	 	 	98946	 	 	Husum
	 	 	98623	 
	Mattawa (50)

	 	 	99349	 	 	Humptuliips
	 	 	98552	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Bellevue (U)
	 	 	98007	 	 	North Bend
	 	 	98045	 	 	Seattle (U)
	 	 	98121	 	 	Seattle (U)
	 	 	98184	 	 	Indianola
	 	 	98342	 	 	Vantage
	 	 	98950	 	 	Klickitat
	 	 	98628	 
	Moses Lake

	 	 	98837	 	 	Malone
	 	 	98559	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Bellevue (U)
	 	 	98008	 	 	Pacific (U)
	 	 	98047	 	 	Seattle (U)
	 	 	98122	 	 	Seattle (U)
	 	 	98185	 	 	Keyport
	 	 	98345	 	 	 	 	 	 	 	 	Lyle
	 	 	98635	 
	Quincy

	 	 	98848	 	 	McCleary
	 	 	98557	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Bellevue
	 	 	98009	 	 	Preston
	 	 	98050	 	 	Seattle (U)
	 	 	98124	 	 	Seattle
	 	 	98188	 	 	Kingston
	 	 	98346	 	 	 	 	 	 	 	 	Roosevelt (50)
	 	 	99356	 
	Royal City

	 	 	99357	 	 	Moclips
	 	 	98562	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Bellevue
	 	 	98015	 	 	Ravensdale
	 	 	98051	 	 	Seattle (U)
	 	 	98125	 	 	Seattle (U)
	 	 	98190	 	 	Manchester
	 	 	98353	 	 	 	 	 	 	 	 	Trout Lake
	 	 	98650	 
	Soap Lake

	 	 	98851	 	 	Montesano
	 	 	98563	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Black Diamond
	 	 	98010	 	 	Redmond
	 	 	98052	 	 	Seattle (U)
	 	 	98126	 	 	Seattle (U)
	 	 	98191	 	 	Ollala
	 	 	98359	 	 	 	 	 	 	 	 	Wahkiacus
	 	 	98670	 
	Stratford

	 	 	98853	 	 	Neilton
	 	 	98566	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Bothell (U)
	 	 	98011	 	 	Redmond
	 	 	98053	 	 	Seattle (U)
	 	 	98129	 	 	Seattle (U)
	 	 	98195	 	 	Port Gamble
	 	 	98364	 	 	 	 	 	 	 	 	White Salmon
	 	 	98672	 
	Warden

	 	 	98857	 	 	Oakville
	 	 	98568	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Bothell
	 	 	98041	 	 	Redmond
	 	 	98073	 	 	Seattle (U)
	 	 	98131	 	 	Seattle
	 	 	98198	 	 	Port Orchard
	 	 	98366	 	 	 	 	 	 	 	 	Wishram
	 	 	98673	 
	Wilson Creek

	 	 	98860	 	 	Ocean Shores
	 	 	98569	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Burton
	 	 	98013	 	 	Redmond
	 	 	98074	 	 	Seattle (U)
	 	 	98132	 	 	Seattle (U)
	 	 	98199	 	 	Port Orchard
	 	 	98367	 	 	 	 	 	 	 	 	 	 	 	 	 
	 

	 	 	 	 	 	Pacific Bch.
	 	 	98571	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Carnation
	 	 	98014	 	 	Redondo
	 	 	98054	 	 	Seattle (U)
	 	 	98133	 	 	Skykomish (50)
	 	 	98288	 	 	Poulsbo
	 	 	98370	 	 	 	 	 	 	 	 	 	 	 	 	 
	 

	 	 	 	 	 	Quinault
	 	 	98575	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Duvall
	 	 	98019	 	 	Renton
	 	 	98055	 	 	Seattle (U)
	 	 	98134	 	 	Snoqualmie
	 	 	98065	 	 	Retsil
	 	 	98378	 	 	 	 	 	 	 	 	 	 	 	 	 
	 

	 	 	 	 	 	Satsop
	 	 	98583	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Enumclaw (50)
	 	 	98022	 	 	Renton (U)
	 	 	98056	 	 	Seattle (U)
	 	 	98136	 	 	Vashon
	 	 	98070	 	 	Rollingbay
	 	 	98061	 	 	 	 	 	 	 	 	 	 	 	 	 
	 

	 	 	 	 	 	Taholah
	 	 	98587	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Fall City
	 	 	98024	 	 	Renton
	 	 	98057	 	 	Seattle (U)
	 	 	98138	 	 	Woodinville
	 	 	98072	 	 	Seabeck
	 	 	98380	 	 	 	 	 	 	 	 	 	 	 	 	 
	 

	 	 	 	 	 	Westport
	 	 	98595	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Federal Way (U)
	 	 	98003	 	 	Renton
	 	 	98058	 	 	Seattle (U)
	 	 	98144	 	 	Snoqualmie Pass (50)
	 	 	98068	 	 	Silverdale
	 	 	98315	 	 	 	 	 	 	 	 	 	 	 	 	 
	 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Federal Way (U)
	 	 	98023	 	 	Renton
	 	 	98059	 	 	Seattle (U)
	 	 	98145	 	 	 	 	 	 	 	 	Silverdale
	 	 	98383	 	 	 	 	 	 	 	 	 	 	 	 	 
	 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Federal Way
	 	 	98063	 	 	Seahurst
	 	 	98062	 	 	Seattle (U)
	 	 	98146	 	 	 	 	 	 	 	 	SouthColby
	 	 	98384	 	 	 	 	 	 	 	 	 	 	 	 	 
	 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Federal Way
	 	 	98093	 	 	Seattle (U)
	 	 	98101	 	 	Seattle
	 	 	98148	 	 	 	 	 	 	 	 	Southworth
	 	 	98386	 	 	 	 	 	 	 	 	 	 	 	 	 
	 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Hobart
	 	 	98025	 	 	Seattle (U)
	 	 	98102	 	 	Seattle (U)
	 	 	98151	 	 	 	 	 	 	 	 	Suquamish
	 	 	98392	 	 	 	 	 	 	 	 	 	 	 	 	 
	 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Issaquah
	 	 	98027	 	 	Seattle (U)
	 	 	98103	 	 	Seattle (U)
	 	 	98154	 	 	 	 	 	 	 	 	Tracyton
	 	 	98393	 	 	 	 	 	 	 	 	 	 	 	 	 
	 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Issaquah
	 	 	98029	 	 	Seattle (U)
	 	 	98104	 	 	Seattle (U)
	 	 	98155	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Kent
	 	 	98030	 	 	Seattle (U)
	 	 	98105	 	 	SeaTac (U)
	 	 	98158	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Issaquah
	 	 	98075	 	 	Seattle (U)
	 	 	98106	 	 	Seattle (U)
	 	 	98160	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Kenmore
	 	 	98028	 	 	Seattle (U)
	 	 	98107	 	 	Seattle (U)
	 	 	98161	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Kent (U)
	 	 	98031	 	 	Seattle (U)
	 	 	98108	 	 	Seattle (U)
	 	 	98164	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Kent
	 	 	98032	 	 	Seattle (U)
	 	 	98109	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Kent
	 	 	98035	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 






 









 






	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Lewis	 	Lincoln	 	Mason	 	Okanogan	 	Pacific	 	Pend Oreille	 	Pierce	 	San Juan	 	Skagit
	CITY	 	ZIP	 	CITY	 	ZIP	 	CITY	 	ZIP	 	CITY	 	ZIP	 	CITY	 	ZIP	 	CITY	 	ZIP	 	CITY	 	ZIP	 	CITY	 	ZIP	 	CITY	 	ZIP	 	CITY	 	ZIP	 	CITY	 	ZIP
	Adna

	 	 	98522	 	 	Almira
	 	 	99103	 	 	Allyn
	 	 	98524	 	 	Brewster
	 	 	98812	 	 	Bay Center
	 	 	98527	 	 	Cusick (50)
	 	 	99119	 	 	Anderson Is.
	 	 	98303	 	 	South Prairie
	 	 	98385	 	 	Tacoma (U)
	 	 	98455	 	 	Deer Harbor
	 	 	98243	 	 	Anacortes
	 	 	98221	 
	Centralia

	 	 	98531	 	 	Creston
	 	 	99117	 	 	Belfair
	 	 	98528	 	 	Carlton
	 	 	98814	 	 	Chinook
	 	 	98614	 	 	Ione (50)
	 	 	99139	 	 	Ashford (50)
	 	 	98304	 	 	Spanaway
	 	 	98387	 	 	Tacoma (U)
	 	 	98460	 	 	Eastsound
	 	 	98245	 	 	Bow
	 	 	98232	 
	Chehalis

	 	 	98532	 	 	Davenport
	 	 	99122	 	 	Grapeview
	 	 	98546	 	 	Conconully
	 	 	98819	 	 	Illwaco
	 	 	98624	 	 	Metaline (50)
	 	 	99152	 	 	Buckley
	 	 	98321	 	 	Steilacoom
	 	 	98388	 	 	University Place (U)
	 	 	98464	 	 	Friday Harbor
	 	 	98250	 	 	Bow
	 	 	98246	 
	Cinnabar

	 	 	98533	 	 	Edwall
	 	 	99008	 	 	Hoodsport
	 	 	98548	 	 	Coulee Dam
	 	 	99116	 	 	Lebam
	 	 	98554	 	 	Metaline Falls (50)
	 	 	99153	 	 	Camp Murray
	 	 	98430	 	 	Sumner
	 	 	98352	 	 	Tacoma (U)
	 	 	98465	 	 	Lopez Is.
	 	 	98261	 	 	Burlington
	 	 	98233	 
	Curtis

	 	 	98538	 	 	Harrington
	 	 	99134	 	 	Lilliwaup
	 	 	98555	 	 	Elmer City
	 	 	99124	 	 	Long Beach
	 	 	98631	 	 	Newport
	 	 	99156	 	 	Carbonado
	 	 	98323	 	 	Sumner
	 	 	98390	 	 	Tacoma (U)
	 	 	98466	 	 	Olga
	 	 	98279	 	 	Clear Lake
	 	 	98235	 
	Doty

	 	 	98539	 	 	Odessa
	 	 	99144	 	 	Matlock
	 	 	98560	 	 	Loomis
	 	 	98827	 	 	Menlo
	 	 	98561	 	 	Usk
	 	 	99180	 	 	Dupont
	 	 	98327	 	 	Tacoma (U)
	 	 	98401	 	 	Tacoma
	 	 	98471	 	 	Orcas
	 	 	98280	 	 	Concrete (50)
	 	 	98237	 
	Ethel

	 	 	98542	 	 	Lincoln
	 	 	99147	 	 	Shelton
	 	 	98584	 	 	Malott
	 	 	98829	 	 	Nahcotta
	 	 	98637	 	 	 	 	 	 	 	 	Eatonville
	 	 	98328	 	 	Tacoma (U)
	 	 	98402	 	 	Tacoma
	 	 	98477	 	 	Shaw Is.
	 	 	98286	 	 	Conway
	 	 	98238	 
	Galvin

	 	 	98544	 	 	Mohler
	 	 	99154	 	 	Tahuya
	 	 	98588	 	 	Mazama (50)
	 	 	98833	 	 	Naselle
	 	 	98638	 	 	 	 	 	 	 	 	Elbe
	 	 	98330	 	 	Tacoma (U)
	 	 	98403	 	 	Tacoma
	 	 	98481	 	 	Waldron
	 	 	98297	 	 	Hamilton
	 	 	98255	 
	Glennoma

	 	 	98336	 	 	Odessa
	 	 	99159	 	 	Union
	 	 	98592	 	 	Methow
	 	 	98834	 	 	Ocean Park
	 	 	98640	 	 	 	 	 	 	 	 	Fox Island
	 	 	98333	 	 	Tacoma (U)
	 	 	98404	 	 	Tacoma
	 	 	98493	 	 	Blakley Island
	 	 	98222	 	 	La Conner
	 	 	98257	 
	Mineral

	 	 	98355	 	 	Reardan
	 	 	99029	 	 	 	 	 	 	 	 	Nespelem
	 	 	99155	 	 	Oysterville
	 	 	98641	 	 	 	 	 	 	 	 	Gig Harbor
	 	 	98329	 	 	Tacoma (U)
	 	 	98405	 	 	University Place
	 	 	98467	 	 	 	 	 	 	 	 	Lyman
	 	 	98263	 
	Morton

	 	 	98356	 	 	Sprague (50)
	 	 	99032	 	 	 	 	 	 	 	 	Okanogan
	 	 	98840	 	 	Raymond
	 	 	98577	 	 	 	 	 	 	 	 	Gig Harbor
	 	 	98332	 	 	Tacoma (U)
	 	 	98406	 	 	Vaughn
	 	 	98394	 	 	 	 	 	 	 	 	Marble Mount (50)
	 	 	98267	 
	Mossyrock

	 	 	98564	 	 	Wilbur
	 	 	99185	 	 	 	 	 	 	 	 	Omak
	 	 	98841	 	 	Seaview
	 	 	98644	 	 	 	 	 	 	 	 	Gig Harbor
	 	 	98335	 	 	Tacoma (U)
	 	 	98407	 	 	Wauna
	 	 	98395	 	 	 	 	 	 	 	 	Mt. Vernon
	 	 	98273	 
	Napavine

	 	 	98565	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Oroville
	 	 	98844	 	 	South Bend
	 	 	98586	 	 	 	 	 	 	 	 	Graham
	 	 	98338	 	 	Tacoma (U)
	 	 	98408	 	 	Wilkeson
	 	 	98396	 	 	 	 	 	 	 	 	Mt. Vernon
	 	 	98274	 
	Onalaska

	 	 	98570	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Pateros
	 	 	98846	 	 	Tokeland
	 	 	98590	 	 	 	 	 	 	 	 	Kapowsin
	 	 	98344	 	 	Tacoma (U)
	 	 	98409	 	 	Paradise Inn
	 	 	98398	 	 	 	 	 	 	 	 	Rockport (50)
	 	 	98283	 
	Packwood (50)

	 	 	98361	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Riverside
	 	 	98849	 	 	 	 	 	 	 	 	 	 	 	 	 	 	La Grande
	 	 	98348	 	 	Tacoma (U)
	 	 	98411	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Sedro Wooley
	 	 	98284	 
	Pe Ell

	 	 	98572	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Tonasket
	 	 	98855	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Lake Bay
	 	 	98349	 	 	Tacoma (U)
	 	 	98412	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Randle (50)

	 	 	98377	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Twisp (50)
	 	 	98856	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Lakewood
	 	 	98439	 	 	Tacoma (U)
	 	 	98413	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Salkum

	 	 	98582	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Wauconda (50)
	 	 	98859	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Lakewood
	 	 	98492	 	 	Tacoma (U)
	 	 	98415	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Silver Creek

	 	 	98585	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Winthrop (50)
	 	 	98862	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Lakewood
	 	 	98497	 	 	Tacoma (U)
	 	 	98416	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Toledo

	 	 	98591	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Lakewood
	 	 	98498	 	 	Tacoma (U)
	 	 	98418	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Vader

	 	 	98593	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Lakewood
	 	 	98499	 	 	Tacoma
	 	 	98421	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Winlock

	 	 	98596	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Longbranch
	 	 	98351	 	 	Tacoma
	 	 	98422	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Longmire
	 	 	98397	 	 	Tacoma
	 	 	98424	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	McChord AFB
	 	 	98438	 	 	Tacoma
	 	 	98431	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	McKenna
	 	 	98558	 	 	Tacoma
	 	 	98433	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Milton
	 	 	98354	 	 	Tacoma
	 	 	98442	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Orting
	 	 	98360	 	 	Tacoma
	 	 	98443	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Puyallup
	 	 	98371	 	 	Tacoma (U)
	 	 	98444	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Puyallup
	 	 	98372	 	 	Tacoma (U)
	 	 	98445	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Puyallup (U)
	 	 	98373	 	 	Tacoma
	 	 	98446	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Puyallup
	 	 	98374	 	 	Tacoma (U)
	 	 	98447	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Puyallup
	 	 	98375	 	 	Tacoma (U)
	 	 	98450	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Roy
	 	 	98580	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 







 











 







	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Skamania	 	Snohomish	 	Spokane	 	Stevens	 	Thurston	 	Wahkiakum	 	Walla Walla	 	Whatcom	 	Whitman	 	Yakima
	CITY	 	ZIP	 	CITY	 	ZIP	 	CITY	 	ZIP	 	CITY	 	ZIP	 	CITY	 	ZIP	 	CITY	 	ZIP	 	CITY	 	ZIP	 	CITY	 	ZIP	 	CITY	 	ZIP	 	CITY	 	ZIP	 	CITY	 	ZIP
	Carson
	 	98610	 	Arlington	 	98223	 	Airway Hts.	 	99001	 	Spokane	 	99210	 	Addy	 	99101	 	Bucoda	 	98530	 	Cathlamet	 	98612	 	Burbank	 	99323	 	Acme	 	98220	 	Albion	 	99102	 	Brownstown	 	98920
	N. Bonneville
	 	98639	 	Bothell (U)	 	98021	 	Chattaroy	 	99003	 	Spokane	 	99211	 	Chewelah	 	99109	 	East Olympia	 	98540	 	Grays River	 	98621	 	College Place	 	99324	 	Bellingham (U)	 	98225	 	Belmont	 	99104	 	Buena	 	98921
	Stevenson
	 	98648	 	Bothell (U)	 	98012	 	Cheney	 	99004	 	Spokane	 	99212	 	Clayton	 	99110	 	Lacey	 	98503	 	Rosburg	 	98643	 	Dixie	 	99329	 	Bellingham	 	98226	 	Colfax	 	99111	 	Cowiche	 	98923
	Underwood
	 	98651	 	Bothell (U)	 	98082	 	Colbert	 	99005	 	Spokane	 	99213	 	Colville	 	99114	 	Lacey	 	98509	 	Skamokawa	 	98647	 	Prescott (50)	 	99348	 	Bellingham	 	98227	 	Colton	 	99113	 	Goose Prairie	 	98929
	 
	 	 	 	Darrington (50)	 	98241	 	Deer Park	 	99006	 	Spokane	 	99214	 	Evans	 	99126	 	Littlerock	 	98556	 	 	 	 	 	Touchet	 	99360	 	Bellingham	 	98228	 	Endicott	 	99125	 	Grandview	 	98930
	 
	 	 	 	Edmonds (U)	 	98020	 	Elk	 	99009	 	Spokane	 	99215	 	Ford	 	99013	 	Olympia	 	98501	 	 	 	 	 	Walla Walla	 	99362	 	Bellingham	 	98229	 	Farmington	 	99128	 	Granger	 	98932
	 
	 	 	 	Edmonds (U)	 	98026	 	Fairchild AFB	 	99011	 	Spokane	 	99216	 	Fruitland	 	99129	 	Olympia	 	98502	 	 	 	 	 	Wallula	 	99363	 	Blaine	 	98230	 	Garfield	 	99130	 	Harrah	 	98933
	 
	 	 	 	Everett	 	98201	 	Fairfield	 	99012	 	Spokane	 	99217	 	Gifford	 	99131	 	Olympia	 	98504	 	 	 	 	 	Waitsburg	 	99361	 	Blaine	 	98231	 	Hay	 	99136	 	Mabton	 	98935
	 
	 	 	 	Everett	 	98203	 	Four Lakes	 	99014	 	Spokane (U)	 	99218	 	Hunters (50)	 	99137	 	Olympia	 	98505	 	 	 	 	 	 	 	 	 	Custer	 	98240	 	Hooper	 	99333	 	Moxee	 	98936
	 
	 	 	 	Everett	 	98204	 	Freeman	 	99015	 	Spokane	 	99219	 	Kettle Falls (50)	 	99141	 	Olympia	 	98506	 	 	 	 	 	 	 	 	 	Deming	 	98244	 	LaCross	 	99143	 	Naches (50)	 	98937
	 
	 	 	 	Everett	 	98205	 	Greenacres	 	99016	 	Spokane	 	99220	 	Loon Lake	 	99148	 	Olympia	 	98507	 	 	 	 	 	 	 	 	 	Everson	 	98247	 	Lamont	 	99017	 	Outlook	 	98938
	 
	 	 	 	Everett	 	98206	 	Latah	 	99018	 	Spokane	 	99223	 	Marcus	 	99151	 	Olympia	 	98508	 	 	 	 	 	 	 	 	 	Ferndale	 	98248	 	Malden	 	99149	 	Parker	 	98939
	 
	 	 	 	Everett	 	98207	 	Liberty Lake	 	99019	 	Spokane	 	99224	 	Northport (50)	 	99157	 	Olympia	 	98512	 	 	 	 	 	 	 	 	 	Lummi Is.	 	98262	 	Oakesdale	 	99158	 	Selah	 	98942
	 
	 	 	 	Everett	 	98208	 	Marshall	 	99020	 	Spokane	 	99228	 	Rice	 	99167	 	Olympia	 	98513	 	 	 	 	 	 	 	 	 	Lynden	 	98264	 	Palouse	 	99161	 	Sunnyside	 	98944
	 
	 	 	 	Gold Bar	 	98251	 	Mead	 	99021	 	Spokane	 	99251	 	Springdale	 	99173	 	Olympia	 	98516	 	 	 	 	 	 	 	 	 	Maple Falls	 	98266	 	Pullman	 	99163	 	Tieton	 	98947
	 
	 	 	 	Granite Falls	 	98252	 	Medical Lake	 	99022	 	Spokane	 	99252	 	Tumtum	 	99034	 	Olympia	 	98599	 	 	 	 	 	 	 	 	 	Nooksack	 	98276	 	Pullman	 	99164	 	Toppenish	 	98948
	 
	 	 	 	Index	 	98256	 	Mica	 	99023	 	Spokane	 	99256	 	Valley	 	99181	 	Rainier	 	98576	 	 	 	 	 	 	 	 	 	Pt. Roberts	 	98281	 	Pullman	 	99165	 	Wapato	 	98951
	 
	 	 	 	Lake Stevens	 	98258	 	Newman Lake	 	99025	 	Spokane	 	99258	 	Wellpinit	 	99040	 	Rochester	 	98579	 	 	 	 	 	 	 	 	 	Sumas	 	98295	 	Rosalia	 	99170	 	White Swan	 	98952
	 
	 	 	 	Lynnwood (U)	 	98036	 	Nine Miles Falls	 	99026	 	Spokane	 	99260	 	 	 	 	 	Tenino	 	98589	 	 	 	 	 	 	 	 	 	 	 	 	 	St John	 	99127	 	Yakima	 	98901
	 
	 	 	 	Lynnwood (U)	 	98037	 	Otis Orchards	 	99027	 	Spokane	 	99299	 	 	 	 	 	Tumwater	 	98511	 	 	 	 	 	 	 	 	 	 	 	 	 	St. John	 	99171	 	Yakima (U)	 	98902
	 
	 	 	 	Lynnwood (U)	 	98046	 	Rockford	 	99030	 	Valleyford	 	99036	 	 	 	 	 	Yelm	 	98597	 	 	 	 	 	 	 	 	 	 	 	 	 	Steptoe	 	99174	 	Yakima	 	98903
	 
	 	 	 	Marysville	 	98270	 	Spangle	 	99031	 	Veradale	 	99037	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Tekoa	 	99033	 	Yakima	 	98904
	 
	 	 	 	Marysville	 	98271	 	Spokane (U)	 	99201	 	Waverly	 	99039	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Thornton	 	99176	 	Yakima	 	98907
	 
	 	 	 	Monroe	 	98272	 	Spokane (U)	 	99202	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Uniontown	 	99179	 	Yakima	 	98908
	 
	 	 	 	Mountlake Terrace (U)	 	98043	 	Spokane (U)	 	99203	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Yakima	 	98909
	 
	 	 	 	Mukilteo	 	98275	 	Spokane (U)	 	99204	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Zillah	 	98953
	 
	 	 	 	N. Lakewood	 	98259	 	Spokane (U)	 	99205	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	Silvana	 	98287	 	Spokane	 	99206	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	Snohomish	 	98290	 	Spokane (U)	 	99207	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	Snohomish	 	98291	 	Spokane	 	99208	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	Snohomish	 	98296	 	Spokane	 	99209	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	Stanwood	 	98282	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	Stanwood	 	98292	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	Startup	 	98293	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	Sultan	 	98294	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 






 









 






2006 — 2007 HO & SCHIP Contract

Exhibit A Premiums, Service Areas and Capacity

Exhibit A-1 Premiums

Contractor: Molina

Effective: January 1 — June 30, 2008




	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	Contractor: Molina	 
	MMIS	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Adjustment Factors	 
	Region	 	Reg	 	 	Service Area	 	Base Rate	 	 	Geo	 	 	Risk	 	 	 	 	 	 	M&F <1	 	 	M&F 1-2	 	 	M&F 3-14	 	 	M 15-18	 	 	F 15-18	 	 	M 19-34	 	 	F 19-34	 	 	M 35-64	 	 	F 35-64	 	 	M&F 65+	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	2.698	 	 	 	0.873	 	 	 	0.455	 	 	 	0.516	 	 	 	1.818	 	 	 	0.823	 	 	 	2.259	 	 	 	1.592	 	 	 	1.998	 	 	 	4.126	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Prem. 
before
 Age/Sex	 	Premiums with Age/Sex
	1
	 	 	A	 	 	King	 	 	157.99	 	 	 	0.948	 	 	 	1.019	 	 	 	152.62	 	 	 	411.77	 	 	 	133.24	 	 	 	69.44	 	 	 	78.75	 	 	 	277.46	 	 	 	125.61	 	 	 	344.77	 	 	 	242.97	 	 	 	304.93	 	 	 	629.71	 
	1
	 	 	A	 	 	Walla Walla	 	 	157.99	 	 	 	0.948	 	 	 	1.019	 	 	 	152.62	 	 	 	411.77	 	 	 	133.24	 	 	 	69.44	 	 	 	78.75	 	 	 	277.46	 	 	 	125.61	 	 	 	344.77	 	 	 	242.97	 	 	 	304.93	 	 	 	629.71	 
	1
	 	 	A	 	 	Yakima	 	 	157.99	 	 	 	0.948	 	 	 	1.019	 	 	 	152.62	 	 	 	411.77	 	 	 	133.24	 	 	 	69.44	 	 	 	78.75	 	 	 	277.46	 	 	 	125.61	 	 	 	344.77	 	 	 	242.97	 	 	 	304.93	 	 	 	629.71	 
	2
	 	 	B	 	 	Asotin	 	 	 	 	 	 	 	 	 	 	 	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 
	2
	 	 	B	 	 	Columbia	 	 	157.99	 	 	 	0.973	 	 	 	0.997	 	 	 	153.26	 	 	 	413.50	 	 	 	133.80	 	 	 	69.73	 	 	 	79.08	 	 	 	278.63	 	 	 	126.13	 	 	 	346.21	 	 	 	243.99	 	 	 	306.21	 	 	 	632.35	 
	2
	 	 	B	 	 	Garfield	 	 	157.99	 	 	 	0.973	 	 	 	0.997	 	 	 	153.26	 	 	 	413.50	 	 	 	133.80	 	 	 	69.73	 	 	 	79.08	 	 	 	278.63	 	 	 	126.13	 	 	 	346.21	 	 	 	243.99	 	 	 	306.21	 	 	 	632.35	 
	2
	 	 	B	 	 	Grays Harbor	 	 	157.99	 	 	 	0.973	 	 	 	0.997	 	 	 	153.26	 	 	 	413.50	 	 	 	133.80	 	 	 	69.73	 	 	 	79.08	 	 	 	278.63	 	 	 	126.13	 	 	 	346.21	 	 	 	243.99	 	 	 	306.21	 	 	 	632.35	 
	2
	 	 	B	 	 	Klickitat	 	 	 	 	 	 	 	 	 	 	 	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 
	2
	 	 	B	 	 	San Juan	 	 	157.99	 	 	 	0.973	 	 	 	0.997	 	 	 	153.26	 	 	 	413.50	 	 	 	133.80	 	 	 	69.73	 	 	 	79.08	 	 	 	278.63	 	 	 	126.13	 	 	 	346.21	 	 	 	243.99	 	 	 	306.21	 	 	 	632.35	 
	2
	 	 	B	 	 	Skagit	 	 	157.99	 	 	 	0.973	 	 	 	0.997	 	 	 	153.26	 	 	 	413.50	 	 	 	133.80	 	 	 	69.73	 	 	 	79.08	 	 	 	278.63	 	 	 	126.13	 	 	 	346.21	 	 	 	243.99	 	 	 	306.21	 	 	 	632.35	 
	2
	 	 	B	 	 	Whatcom	 	 	157.99	 	 	 	0.973	 	 	 	0.997	 	 	 	153.26	 	 	 	413.50	 	 	 	133.80	 	 	 	69.73	 	 	 	79.08	 	 	 	278.63	 	 	 	126.13	 	 	 	346.21	 	 	 	243.99	 	 	 	306.21	 	 	 	632.35	 
	2
	 	 	B	 	 	Whitman	 	 	157.99	 	 	 	0.973	 	 	 	0.997	 	 	 	153.26	 	 	 	413.50	 	 	 	133.80	 	 	 	69.73	 	 	 	79.08	 	 	 	278.63	 	 	 	126.13	 	 	 	346.21	 	 	 	243.99	 	 	 	306.21	 	 	 	632.35	 
	3
	 	 	C	 	 	Adams	 	 	157.99	 	 	 	0.993	 	 	 	1.027	 	 	 	161.12	 	 	 	434.70	 	 	 	140.66	 	 	 	73.31	 	 	 	83.14	 	 	 	292.92	 	 	 	132.60	 	 	 	363.97	 	 	 	256.50	 	 	 	321.92	 	 	 	664.78	 
	3
	 	 	C	 	 	Benton	 	 	157.99	 	 	 	0.993	 	 	 	1.027	 	 	 	161.12	 	 	 	434.70	 	 	 	140.66	 	 	 	73.31	 	 	 	83.14	 	 	 	292.92	 	 	 	132.60	 	 	 	363.97	 	 	 	256.50	 	 	 	321.92	 	 	 	664.78	 
	3
	 	 	C	 	 	Clallam	 	 	157.99	 	 	 	0.993	 	 	 	1.027	 	 	 	161.12	 	 	 	434.70	 	 	 	140.66	 	 	 	73.31	 	 	 	83.14	 	 	 	292.92	 	 	 	132.60	 	 	 	363.97	 	 	 	256.50	 	 	 	321.92	 	 	 	664.78	 
	3
	 	 	C	 	 	Franklin	 	 	157.99	 	 	 	0.993	 	 	 	1.027	 	 	 	161.12	 	 	 	434.70	 	 	 	140.66	 	 	 	73.31	 	 	 	83.14	 	 	 	292.92	 	 	 	132.60	 	 	 	363.97	 	 	 	256.50	 	 	 	321.92	 	 	 	664.78	 
	3
	 	 	C	 	 	Pacific	 	 	157.99	 	 	 	0.993	 	 	 	1.027	 	 	 	161.12	 	 	 	434.70	 	 	 	140.66	 	 	 	73.31	 	 	 	83.14	 	 	 	292.92	 	 	 	132.60	 	 	 	363.97	 	 	 	256.50	 	 	 	321.92	 	 	 	664.78	 
	3
	 	 	C	 	 	Spokane	 	 	157.99	 	 	 	0.993	 	 	 	1.027	 	 	 	161.12	 	 	 	434.70	 	 	 	140.66	 	 	 	73.31	 	 	 	83.14	 	 	 	292.92	 	 	 	132.60	 	 	 	363.97	 	 	 	256.50	 	 	 	321.92	 	 	 	664.78	 
	4
	 	 	D	 	 	Ferry	 	 	157.99	 	 	 	1.023	 	 	 	1.030	 	 	 	166.47	 	 	 	449.14	 	 	 	145.33	 	 	 	75.74	 	 	 	85.90	 	 	 	302.64	 	 	 	137.00	 	 	 	376.06	 	 	 	265.02	 	 	 	332.61	 	 	 	686.86	 
	4
	 	 	D	 	 	Jefferson	 	 	 	 	 	 	 	 	 	 	 	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 
	4
	 	 	D	 	 	Kittitas	 	 	157.99	 	 	 	1.023	 	 	 	1.030	 	 	 	166.47	 	 	 	449.14	 	 	 	145.33	 	 	 	75.74	 	 	 	85.90	 	 	 	302.64	 	 	 	137.00	 	 	 	376.06	 	 	 	265.02	 	 	 	332.61	 	 	 	686.86	 
	4
	 	 	D	 	 	Snohomish	 	 	157.99	 	 	 	1.023	 	 	 	1.030	 	 	 	166.47	 	 	 	449.14	 	 	 	145.33	 	 	 	75.74	 	 	 	85.90	 	 	 	302.64	 	 	 	137.00	 	 	 	376.06	 	 	 	265.02	 	 	 	332.61	 	 	 	686.86	 
	4
	 	 	D	 	 	Thurston	 	 	157.99	 	 	 	1.023	 	 	 	1.030	 	 	 	166.47	 	 	 	449.14	 	 	 	145.33	 	 	 	75.74	 	 	 	85.90	 	 	 	302.64	 	 	 	137.00	 	 	 	376.06	 	 	 	265.02	 	 	 	332.61	 	 	 	686.86	 
	5
	 	 	E	 	 	Chelan	 	 	157.99	 	 	 	1.043	 	 	 	1.030	 	 	 	169.73	 	 	 	457.93	 	 	 	148.17	 	 	 	77.23	 	 	 	87.58	 	 	 	308.57	 	 	 	139.69	 	 	 	383.42	 	 	 	270.21	 	 	 	339.12	 	 	 	700.31	 
	5
	 	 	E	 	 	Clark	 	 	 	 	 	 	 	 	 	 	 	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 
	5
	 	 	E	 	 	Cowlitz	 	 	157.99	 	 	 	1.043	 	 	 	1.030	 	 	 	169.73	 	 	 	457.93	 	 	 	148.17	 	 	 	77.23	 	 	 	87.58	 	 	 	308.57	 	 	 	139.69	 	 	 	383.42	 	 	 	270.21	 	 	 	339.12	 	 	 	700.31	 
	5
	 	 	E	 	 	Grant	 	 	157.99	 	 	 	1.043	 	 	 	1.030	 	 	 	169.73	 	 	 	457.93	 	 	 	148.17	 	 	 	77.23	 	 	 	87.58	 	 	 	308.57	 	 	 	139.69	 	 	 	383.42	 	 	 	270.21	 	 	 	339.12	 	 	 	700.31	 
	5
	 	 	E	 	 	Island	 	 	 	 	 	 	 	 	 	 	 	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 
	5
	 	 	E	 	 	Lewis	 	 	157.99	 	 	 	1.043	 	 	 	1.030	 	 	 	169.73	 	 	 	457.93	 	 	 	148.17	 	 	 	77.23	 	 	 	87.58	 	 	 	308.57	 	 	 	139.69	 	 	 	383.42	 	 	 	270.21	 	 	 	339.12	 	 	 	700.31	 
	5
	 	 	E	 	 	Lincoln	 	 	157.99	 	 	 	1.043	 	 	 	1.030	 	 	 	169.73	 	 	 	457.93	 	 	 	148.17	 	 	 	77.23	 	 	 	87.58	 	 	 	308.57	 	 	 	139.69	 	 	 	383.42	 	 	 	270.21	 	 	 	339.12	 	 	 	700.31	 
	5
	 	 	E	 	 	Mason	 	 	157.99	 	 	 	1.043	 	 	 	1.030	 	 	 	169.73	 	 	 	457.93	 	 	 	148.17	 	 	 	77.23	 	 	 	87.58	 	 	 	308.57	 	 	 	139.69	 	 	 	383.42	 	 	 	270.21	 	 	 	339.12	 	 	 	700.31	 
	5
	 	 	E	 	 	Okanogan	 	 	157.99	 	 	 	1.043	 	 	 	1.030	 	 	 	169.73	 	 	 	457.93	 	 	 	148.17	 	 	 	77.23	 	 	 	87.58	 	 	 	308.57	 	 	 	139.69	 	 	 	383.42	 	 	 	270.21	 	 	 	339.12	 	 	 	700.31	 
	5
	 	 	E	 	 	Pend Orielle	 	 	157.99	 	 	 	1.043	 	 	 	1.030	 	 	 	169.73	 	 	 	457.93	 	 	 	148.17	 	 	 	77.23	 	 	 	87.58	 	 	 	308.57	 	 	 	139.69	 	 	 	383.42	 	 	 	270.21	 	 	 	339.12	 	 	 	700.31	 
	5
	 	 	E	 	 	Pierce	 	 	157.99	 	 	 	1.043	 	 	 	1.030	 	 	 	169.73	 	 	 	457.93	 	 	 	148.17	 	 	 	77.23	 	 	 	87.58	 	 	 	308.57	 	 	 	139.69	 	 	 	383.42	 	 	 	270.21	 	 	 	339.12	 	 	 	700.31	 
	5
	 	 	E	 	 	Skamania	 	 	 	 	 	 	 	 	 	 	 	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 
	5
	 	 	E	 	 	Stevens	 	 	157.99	 	 	 	1.043	 	 	 	1.030	 	 	 	169.73	 	 	 	457.93	 	 	 	148.17	 	 	 	77.23	 	 	 	87.58	 	 	 	308.57	 	 	 	139.69	 	 	 	383.42	 	 	 	270.21	 	 	 	339.12	 	 	 	700.31	 
	6
	 	 	F	 	 	Douglas	 	 	157.99	 	 	 	1.063	 	 	 	1.026	 	 	 	172.31	 	 	 	464.89	 	 	 	150.43	 	 	 	78.40	 	 	 	88.91	 	 	 	313.26	 	 	 	141.81	 	 	 	389.25	 	 	 	274.32	 	 	 	344.28	 	 	 	710.95	 
	6
	 	 	F	 	 	Kitsap	 	 	157.99	 	 	 	1.063	 	 	 	1.026	 	 	 	172.31	 	 	 	464.89	 	 	 	150.43	 	 	 	78.40	 	 	 	88.91	 	 	 	313.26	 	 	 	141.81	 	 	 	389.25	 	 	 	274.32	 	 	 	344.28	 	 	 	710.95	 
	6
	 	 	F	 	 	Wahkiakum	 	 	 	 	 	 	 	 	 	 	 	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 





Note: Shaded areas are those not currently served.




 









 







2006 — 2007 HO & SCHIP Contract

Exhibit A Premiums, Service Areas and Capacity

Exhibit A-1 Premiums

Contractor: Molina

Effective: July 1 — December 31, 2008




	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	Contractor: Molina	 
	MMIS	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Adjustment Factors	 
	Region	 	Reg	 	 	Service Area	 	 	Base Rate	 	 	Geo	 	 	Risk	 	 	 	 	 	 	M&F <1	 	 	M&F 1-2	 	 	M&F 3-14	 	 	M 15-18	 	 	F 15-18	 	 	M 19-34	 	 	F 19-34	 	 	M 35-64	 	 	F 35-64	 	 	M&F 65+	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	2.698	 	 	 	0.873	 	 	 	0.455	 	 	 	0.516	 	 	 	1.818	 	 	 	0.823	 	 	 	2.259	 	 	 	1.592	 	 	 	1.998	 	 	 	4.126	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Prem. 
before
 Age/Sex	 	Premiums with Age/Sex
	1
	 	 	A	 	 	King	 	 	 	 	 	 	 	 	 	 	 	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 
	1
	 	 	A	 	 	Walla Walla	 	 	 	 	 	 	 	 	 	 	 	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 
	1
	 	 	A	 	 	Yakima	 	 	 	 	 	 	 	 	 	 	 	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 
	2
	 	 	B	 	 	Asotin	 	 	 	 	 	 	 	 	 	 	 	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 
	2
	 	 	B	 	 	Columbia	 	 	 	 	 	 	 	 	 	 	 	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 
	2
	 	 	B	 	 	Garfield	 	 	 	 	 	 	 	 	 	 	 	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 
	2
	 	 	B	 	 	Grays Harbor	 	 	 	 	 	 	 	 	 	 	 	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 
	2
	 	 	B	 	 	Klickitat	 	 	 	 	 	 	 	 	 	 	 	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 
	2
	 	 	B	 	 	San Juan	 	 	 	 	 	 	 	 	 	 	 	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 
	2
	 	 	B	 	 	Skagit	 	 	 	 	 	 	 	 	 	 	 	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 
	2
	 	 	B	 	 	Whatcom	 	 	 	 	 	 	 	 	 	 	 	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 
	2
	 	 	B	 	 	Whitman	 	 	 	 	 	 	 	 	 	 	 	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 
	3
	 	 	C	 	 	Adams	 	 	 	 	 	 	 	 	 	 	 	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 
	3
	 	 	C	 	 	Benton	 	 	 	 	 	 	 	 	 	 	 	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 
	3
	 	 	C	 	 	Clallam	 	 	 	 	 	 	 	 	 	 	 	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 
	3
	 	 	C	 	 	Franklin	 	 	 	 	 	 	 	 	 	 	 	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 
	3
	 	 	C	 	 	Pacific	 	 	 	 	 	 	 	 	 	 	 	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 
	3
	 	 	C	 	 	Spokane	 	 	 	 	 	 	 	 	 	 	 	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 
	4
	 	 	D	 	 	Ferry	 	 	 	 	 	 	 	 	 	 	 	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 
	4
	 	 	D	 	 	Jefferson	 	 	 	 	 	 	 	 	 	 	 	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 
	4
	 	 	D	 	 	Kittitas	 	 	 	 	 	 	 	 	 	 	 	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 
	4
	 	 	D	 	 	Snohomish	 	 	 	 	 	 	 	 	 	 	 	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 
	4
	 	 	D	 	 	Thurston	 	 	 	 	 	 	 	 	 	 	 	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 
	5
	 	 	E	 	 	Chelan	 	 	 	 	 	 	 	 	 	 	 	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 
	5
	 	 	E	 	 	Clark	 	 	 	 	 	 	 	 	 	 	 	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 
	5
	 	 	E	 	 	Cowlitz	 	 	 	 	 	 	 	 	 	 	 	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 
	5
	 	 	E	 	 	Grant	 	 	 	 	 	 	 	 	 	 	 	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 
	5
	 	 	E	 	 	Island	 	 	 	 	 	 	 	 	 	 	 	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 
	5
	 	 	E	 	 	Lewis	 	 	 	 	 	 	 	 	 	 	 	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 
	5
	 	 	E	 	 	Lincoln	 	 	 	 	 	 	 	 	 	 	 	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 
	5
	 	 	E	 	 	Mason	 	 	 	 	 	 	 	 	 	 	 	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 
	5
	 	 	E	 	 	Okanogan	 	 	 	 	 	 	 	 	 	 	 	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 
	5
	 	 	E	 	 	Pend Orielle	 	 	 	 	 	 	 	 	 	 	 	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 
	5
	 	 	E	 	 	Pierce	 	 	 	 	 	 	 	 	 	 	 	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 
	5
	 	 	E	 	 	Skamania	 	 	 	 	 	 	 	 	 	 	 	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 
	5
	 	 	E	 	 	Stevens	 	 	 	 	 	 	 	 	 	 	 	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 
	6
	 	 	F	 	 	Douglas	 	 	 	 	 	 	 	 	 	 	 	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 
	6
	 	 	F	 	 	Kitsap	 	 	 	 	 	 	 	 	 	 	 	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 
	6
	 	 	F	 	 	Wahkiakum	 	 	 	 	 	 	 	 	 	 	 	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 	 	 	0.00	 






Note: Shaded areas are those not currently served.