RCW 74.09.871
Behavioral health services
—
Contracting process.
(1) Any agreement or contract by the authority to provide behavioral health services as defined under RCW 71.24.025
to persons eligible for benefits under medicaid, Title XIX of the social security act, and to persons not eligible for medicaid must include the following:
(a) Contractual provisions consistent with the intent expressed in RCW 71.24.015
and
71.36.005
;
(b) Standards regarding the quality of services to be provided, including increased use of evidence-based, research-based, and promising practices, as defined in RCW 71.24.025
;
(c) Accountability for the client outcomes established in RCW 71.24.435, 70.320.020, and
71.36.025
and performance measures linked to those outcomes;
(d) Standards requiring behavioral health administrative services organizations and managed care organizations to maintain a network of appropriate providers that is supported by written agreements sufficient to provide adequate access to all services covered under the contract with the authority and to protect essential behavioral health system infrastructure and capacity, including a continuum of substance use disorder services;
(e) Provisions to require that medically necessary substance use disorder and mental health treatment services be available to clients;
(f) Standards requiring the use of behavioral health service provider reimbursement methods that incentivize improved performance with respect to the client outcomes established in RCW 71.24.435
and
71.36.025, integration of behavioral health and primary care services at the clinical level, and improved care coordination for individuals with complex care needs;
(g) Standards related to the financial integrity of the contracting entity. This subsection does not limit the authority of the authority to take action under a contract upon finding that a contracting entity's financial status jeopardizes the contracting entity's ability to meet its contractual obligations;
(h) Mechanisms for monitoring performance under the contract and remedies for failure to substantially comply with the requirements of the contract including, but not limited to, financial deductions, termination of the contract, receivership, reprocurement of the contract, and injunctive remedies;
(i) Provisions to maintain the decision-making independence of designated crisis responders; and
(j) Provisions stating that public funds appropriated by the legislature may not be used to promote or deter, encourage, or discourage employees from exercising their rights under Title 29, chapter 7, subchapter II, United States Code or chapter
41.56
RCW.
(2) At least six months prior to releasing a medicaid integrated managed care procurement, but no later than January 1, 2025, the authority shall adopt statewide network adequacy standards that are assessed on a regional basis for the behavioral health provider networks maintained by managed care organizations pursuant to subsection (1)(d) of this section. The standards shall require a network that ensures access to appropriate and timely behavioral health services for the enrollees of the managed care organization who live within the regional service area. At a minimum, these standards must address each behavioral health services type covered by the medicaid integrated managed care contract. This includes, but is not limited to: Outpatient, inpatient, and residential levels of care for adults and youth with a mental health disorder; outpatient, inpatient, and residential levels of care for adults and youth with a substance use disorder; crisis and stabilization services; providers of medication for opioid use disorders; specialty care; other facility-based services; and other providers as determined by the authority through this process. The authority shall apply the standards regionally and shall incorporate behavioral health system needs and considerations as follows:
(a) Include a process for an annual review of the network adequacy standards;
(b) Provide for participation from counties and behavioral health providers in both initial development and subsequent updates;
(c) Account for the regional service area's population; prevalence of behavioral health conditions; types of minimum behavioral health services and service capacity offered by providers in the regional service area; number and geographic proximity of providers in the regional service area; an assessment of the needs or gaps in the region; and availability of culturally specific services and providers in the regional service area to address the needs of communities that experience cultural barriers to health care including but not limited to communities of color and the LGBTQ+ community;
(d) Include a structure for monitoring compliance with provider network standards and timely access to the services;
(e) Consider how statewide services, such as residential treatment facilities, are utilized cross-regionally; and
(f) Consider how the standards would impact requirements for behavioral health administrative service organizations.
(3) Before releasing a medicaid integrated managed care procurement, the authority shall identify options that minimize provider administrative burden, including the potential to limit the number of managed care organizations that operate in a regional service area.
(4) The following factors must be given significant weight in any medicaid integrated managed care procurement process under this section:
(a) Demonstrated commitment and experience in serving low-income populations;
(b) Demonstrated commitment and experience serving persons who have mental illness, substance use disorders, or co-occurring disorders;
(c) Demonstrated commitment to and experience with partnerships with county and municipal criminal justice systems, housing services, and other critical support services necessary to achieve the outcomes established in RCW 71.24.435, 70.320.020, and
71.36.025
;
(d) The ability to provide for the crisis service needs of medicaid enrollees, consistent with the degree to which such services are funded;
(e) Recognition that meeting enrollees' physical and behavioral health care needs is a shared responsibility of contracted behavioral health administrative services organizations, managed care organizations, service providers, the state, and communities;
(f) Consideration of past and current performance and participation in other state or federal behavioral health programs as a contractor;
(g) The ability to meet requirements established by the authority;
(h) The extent to which a managed care organization's approach to contracting simplifies billing and contracting burdens for community behavioral health provider agencies, which may include but is not limited to a delegation arrangement with a provider network that leverages local, federal, or philanthropic funding to enhance the effectiveness of medicaid-funded integrated care services and promote medicaid clients' access to a system of services that addresses additional social support services and social determinants of health as defined in RCW 43.20.025
;
(i) Demonstrated prior national or in-state experience with a full continuum of behavioral health services that are substantially similar to the behavioral health services covered under the Washington medicaid state plan, including evidence through past and current data on performance, quality, and outcomes;
(j) Demonstrated commitment by managed care organizations to the use of alternative pricing and payment structures between a managed care organization and its behavioral health services providers, including provider networks described in subsection (b) of this section, and between a managed care organization and a behavioral administrative service organization, in any of their agreements or contracts under this section, which may include but are not limited to:
(i) Value-based purchasing efforts consistent with the authority's value-based purchasing strategy, such as capitated payment arrangements, comprehensive population-based payment arrangements, or case rate arrangements; or
(ii) Payment methods that secure a sufficient amount of ready and available capacity for levels of care that require staffing 24 hours per day, 365 days per year, to serve anyone in the regional service area with a demonstrated need for the service at all times, regardless of fluctuating utilization; and
(k) The accessibility of peer services, as demonstrated in the application through a required comprehensive analysis of access to peer services in the managed care organization's network. The analysis must evaluate the availability of certified peer counselors and peer support specialists certified under chapter
18.420
RCW who are:
(i) Adults in recovery from a mental health condition;
(ii) Adults in recovery from a substance use disorder;
(iii) Youth and young adults in recovery from a mental condition;
(iv) Youth and young adults in recovery from a substance use disorder; and
(v) The parent or legal guardian of a youth who is receiving or has received behavioral health services.
(5) The authority may use existing cross-system outcome data such as the outcomes and related measures under subsection (4)(c) of this section and chapter 338, Laws of 2013, to determine that the alternative pricing and payment structures referenced in subsection (4)(j) of this section have advanced community behavioral health system outcomes more effectively than a fee-for-service model may have been expected to deliver.
(6)(a) The authority shall urge managed care organizations to establish, continue, or expand delegation arrangements with a provider network that exists on July 23, 2023, and that leverages local, federal, or philanthropic funding to enhance the effectiveness of medicaid-funded integrated care services and promote medicaid clients' access to a system of services that addresses additional social support services and social determinants of health as defined in RCW 43.20.025
. Such delegation arrangements must meet the requirements of the integrated managed care contract and the national committee for quality assurance accreditation standards.
(b) The authority shall recognize and support, and may not limit or restrict, a delegation arrangement that a managed care organization and a provider network described in (a) of this subsection have agreed upon, provided such arrangement meets the requirements of the integrated managed care contract and the national committee for quality assurance accreditation standards. The authority may periodically review such arrangements for effectiveness according to the requirements of the integrated managed care contract and the national committee for quality assurance accreditation standards.
(c) Managed care organizations and the authority may evaluate whether to establish or support future delegation arrangements with any additional provider networks that may be created after July 23, 2023, based on the requirements of the integrated managed care contract and the national committee for quality assurance accreditation standards.
(7) The authority shall expand the types of behavioral health crisis services that can be funded with medicaid to the maximum extent allowable under federal law, including seeking approval from the centers for medicare and medicaid services for amendments to the medicaid state plan or medicaid state directed payments that support the 24 hours per day, 365 days per year capacity of the crisis delivery system when necessary to achieve this expansion.
(8) The authority shall, in consultation with managed care organizations, review reports and recommendations of the involuntary treatment act work group established pursuant to section 103, chapter 302, Laws of 2020 and develop a plan for adding contract provisions that increase managed care organizations' accountability when their enrollees require long-term involuntary inpatient behavioral health treatment and shall explore opportunities to maximize medicaid funding as appropriate.
(9) In recognition of the value of community input and consistent with past procurement practices, the authority shall include county and behavioral health provider representatives in the development of any medicaid integrated managed care procurement process. This shall include, at a minimum, two representatives identified by the association of county human services and two representatives identified by the Washington council for behavioral health to participate in the review and development of procurement documents.
(10) For purposes of purchasing behavioral health services and medical care services for persons eligible for benefits under medicaid, Title XIX of the social security act and for persons not eligible for medicaid, the authority must use regional service areas. The regional service areas must be established by the authority as provided in RCW 74.09.870
.
(11) Consideration must be given to using multiple-biennia contracting periods.
(12) Each behavioral health administrative services organization operating pursuant to a contract issued under this section shall serve clients within its regional service area who meet the authority's eligibility criteria for mental health and substance use disorder services within available resources.
[
2025 c 360 s 1
;
2023 c 292 s 2
;
2019 c 325 s 4006
;
2018 c 201 s 2007
;
2014 c 225 s 3
. Formerly RCW 43.20A.894
.]
NOTES:
Findings
—
Intent
—
2023 c 292:
"(1) The legislature finds that:
(a) Medicaid enrollees in Washington are challenged with accessing needed behavioral health care. According to the Washington state department of social and health services, as of 2021, among medicaid enrollees with an identified mental health need, only 50 percent of adults and 66 percent of youth received treatment, while among medicaid enrollees with an identified substance use disorder need, only 37 percent of adults and 23 percent of youth received treatment. Furthermore, the national council for mental wellbeing's 2022 access to care survey found that 43 percent of adults in the United States who say they need mental health or substance use care did not receive that care, and they face numerous barriers to receiving needed treatment. Lack of necessary care can cause behavioral health conditions to deteriorate and crises to escalate, driving increasing use of intensive services such as inpatient care and involuntary treatment. As a result, the behavioral health system is reaching a crisis point in communities across the state.
(b) As of December 2022, 1,953,153 Washington residents rely on apple health managed care organizations to provide for their physical and behavioral health needs. During the integration of physical and behavioral health care pursuant to chapter 225, Laws of 2014, the health care authority most recently procured managed care services in 2018 and selected five managed care organizations to serve as Washington's apple health plans to provide for the physical and behavioral health care needs of medicaid enrollees. The health care authority has begun considering when to conduct a new procurement for managed care organizations, including an allowance for possible new entrants that do not currently serve Washington's medicaid population.
(c) Medicaid managed care procurement presents a need and an opportunity for the state to reset expectations for managed care organizations related to behavioral health services to ensure that Washington residents are being served by qualified and experienced health plans that can deliver on the access to care and quality of care that residents need and deserve. (2) It is the intent of the legislature to seize this opportunity to address ongoing challenges Washington's medicaid enrollees face in accessing behavioral health care. The legislature intends to establish robust new standards defining the levels of medicaid-funded behavioral health service capacity and resources that are adequate to meet medicaid enrollees' treatment needs; to ensure that managed care organizations that serve Washington's medicaid enrollees have a track record of success in delivering a broad range of behavioral health care services to safety net populations; and to advance payment structures and provider network delivery models that improve equitable access, promote integration of care, and deliver on outcomes.
(3) The legislature finds that increased access to behavioral health services for American Indians and Alaska Natives, children in foster care, and the aged, blind, and disabled through the preservation and enhancement of the fee-for-service system is also critical to reducing health disparities among these vulnerable populations. The legislature also intends to increase access to timely and robust behavioral health services for American Indians and Alaska Natives, children in foster care, and the aged, blind, and disabled, in the fee-for-service system they access." [
2023 c 292 s 1
.]
Effective date
—
2019 c 325:
See note following RCW 71.24.011
.
Findings
—
Intent
—
Effective date
—
2018 c 201:
See notes following RCW 41.05.018
.
RCW 74.09.875
Reproductive health care services
—
Prohibited discrimination.
(1) In the provision of reproductive health care services through programs under this chapter, the authority, managed care plans, and providers that administer or deliver such services may not discriminate in the delivery of a service provided through a program of the authority based on the covered person's gender identity or expression.
(2) The authority and any managed care plans delivering or administering services purchased or contracted for by the authority, may not issue automatic initial denials of coverage for reproductive health care services that are ordinarily or exclusively available to individuals of one gender, based on the fact that the individual's gender assigned at birth, gender identity, or gender otherwise recorded in one or more government-issued documents, is different from the one to which such health services are ordinarily or exclusively available.
(3) Denials as described in subsection (2) of this section are prohibited discrimination under chapter
49.60
RCW.
(4) The definitions in this subsection apply throughout this section unless the context clearly requires otherwise.
(a) "Gender expression" means a person's gender-related appearance and behavior, whether or not stereotypically associated with the person's gender assigned at birth.
(b) "Gender identity" means a person's internal sense of the person's own gender, regardless of the person's gender assigned at birth.
(c) "Reproductive health care services" means any medical services or treatments, including pharmaceutical and preventive care service or treatments, directly involved in the reproductive system and its processes, functions, and organs involved in reproduction, in all stages of life. Reproductive health care services does not include infertility treatment.
(d) "Reproductive system" includes, but is not limited to: Genitals, gonads, the uterus, ovaries, fallopian tubes, and breasts.
(5) This section must not be construed to authorize discrimination on the basis of a covered person's gender identity or expression in the administration of any other medical assistance programs administered by the authority.
[
2019 c 399 s 2
.]
NOTES:
Effective dates
—
2019 c 399 ss 2 and 3:
"(1) Section 2 of this act takes effect January 1, 2020.
(2) Section 3 of this act takes effect January 1, 2021." [
2019 c 399 s 9
.]
Findings
—
2019 c 399:
"The legislature finds and declares:
(1) It is the public policy of this state to provide the maximum access to reproductive health care and reproductive health care coverage for all people in Washington state.
(2) In 2018, the legislature passed Substitute Senate Bill No. 6219. Along with reproductive health care coverage requirements, the bill mandated a literature review of barriers to reproductive health care. As documented by the report submitted to the legislature on January 1, 2019, young people, immigrants, people living in rural communities, transgender and gender nonconforming people, and people of color still face significant barriers to getting the reproductive health care they need.
(3) Washingtonians who are transgender and gender nonconforming have important reproductive health care needs as well. These needs go unmet when, in the process of seeking care, transgender and gender nonconforming people are stigmatized or are denied critical health services because of their gender identity or expression.
(4) The literature review mandated by Substitute Senate Bill No. 6219 found that, "[a]ccording to 2015 U.S. Transgender Survey data, thirty-two percent of transgender respondents in Washington State reported that in the previous year they did not see a doctor when needed because they could not afford it."
(5) Existing state law should be enhanced to ensure greater coverage of and timely access to reproductive health care for the benefit of all Washingtonians, regardless of gender identity or expression.
(6) Because stigma is also a key barrier to access to reproductive health care, all Washingtonians, regardless of gender identity, should be free from discrimination in the provision of health care services, health care plan coverage, and in access to publicly funded health coverage.
(7) All people should have access to robust reproductive health services to maintain and improve their reproductive health." [
2019 c 399 s 1
.]
Short title
—
2019 c 399:
"This act may be known and cited as the reproductive health care access for all act." [
2019 c 399 s 8
.]
Recommendations
—
Preexposure and postexposure prophylaxis financial support awareness
—
2019 c 399:
See note following RCW 48.43.072
.
RCW 74.09.880
Z code collection
—
Incentives and funding.
To improve health outcomes and address health inequities, the authority shall evaluate incentive approaches and recommend funding options to increase the collection of Z codes on individual medicaid claims, in accordance with standard billing guidance and regulations.
[
2022 c 215 s 5
.]
NOTES:
Finding
—
Intent
—
2022 c 215:
See note following RCW 70.320.020
.
RCW 74.09.885
Apple health and homes program
—
Definitions.
The definitions in this section apply throughout RCW 74.09.886
and
74.09.888
unless the context clearly requires otherwise.
(1) "Community support services" means active search and promotion of access to, and choice of, appropriate, safe, and affordable housing and ongoing supports to assure ongoing successful tenancy. The term includes, but is not limited to, services to medical assistance clients who are homeless or at risk of becoming homeless through outreach, engagement, and coordination of services with shelter and housing. The term includes benefits offered through the foundational community supports program established pursuant to the authority's federal waiver, entitled "medicaid transformation project," as amended and reauthorized.
(2) "Community support services provider" means a local entity that contracts with a coordinating entity to provide community support services. A community support services provider may also separately perform the functions of a housing provider.
(3) "Coordinating entity" means one or more organizations, including medicaid managed care organizations, under contract with the authority to coordinate community support services as required under RCW 74.09.886
and
74.09.888
. There may only be one coordinating entity per regional service area.
(4) "Department" means the department of commerce.
(5) "Homeless person" has the same meaning as in RCW 43.185C.010
.
(6) "Housing provider" means a public or private organization that supplies permanent supportive housing units consistent with RCW 36.70A.030
to meet the housing needs of homeless persons. A housing provider may supply permanent supportive housing in a site-based or scattered site arrangement using a variety of public, private, philanthropic, or tenant-based sources of funds to cover operating costs or rent. A housing provider may also perform the functions of a community support services provider.
(7) "Office" means the office of apple health and homes created in RCW 43.330.181
.
(8) "Program" means the apple health and homes program established in RCW 74.09.886
.
(9) "Permanent supportive housing" has the same meaning as in RCW 36.70A.030
.
[
2022 c 216 s 2
.]
NOTES:
Findings
—
Intent
—
2022 c 216:
"(1) The legislature finds that:
(a) The epidemic of homelessness apparent in communities throughout Washington is creating immense suffering. It is threatening the health of homeless families and individuals, sapping their human potential, eroding public confidence, and undermining the shared values that have driven our state's prosperity, including public safety and access to public streets, parks, and facilities;
(b) In seeking to identify the causes of this epidemic, a large proportion of those unsheltered also suffer from serious behavioral health or physical health conditions that will inevitably grow worse without timely and effective health care;
(c) Housing is an indispensable element of effective health care. Stable housing is a prerequisite to addressing behavioral health needs and lack of housing is a precursor to poor health outcomes;
(d) A home, health care, and wellness are fundamental for Washington residents;
(e) Reducing homelessness is a priority of the people of Washington state and that reducing homelessness through policy alignment and reform lessens fiscal impact to the state and improves the economic vitality of our businesses;
(f) The impact of this epidemic is falling most heavily on those communities that already suffer the most serious health disparities: Black, indigenous, people of color, and historically marginalized and underserved communities. It is a moral imperative to shelter chronically homeless populations; and
(g) Washington state has many of the tools needed to address this challenge, including a network of safety net health and behavioral health care providers in both urban and rural areas, an effective system of health care coverage through apple health, and excellent public and nonprofit affordable housing providers. Yet far too many homeless families and individuals are going without the housing and health care resources they need because these tools have yet to be combined in an effective way across the state.
(2) It is the intent of the legislature to treat chronic homelessness as a medical condition and that the apple health and homes act address the needs of chronically homeless populations by pairing a health care problem with a health care solution." [
2022 c 216 s 1
.]
Short title
—
2022 c 216:
"This act may be known and cited as the apple health and homes act." [
2022 c 216 s 10
.]
RCW 74.09.886
Apple health and homes program
—
Establishment
—
Eligibility
—
Services.
(1) Subject to the availability of amounts appropriated for this specific purpose, the apple health and homes program is established to provide a permanent supportive housing benefit and a community support services benefit through a network of community support services providers for persons assessed with specific health needs and risk factors.
(a) The program shall operate through the collaboration of the department, the authority, the department of social and health services, local governments, the coordinating entity or entities, community support services providers, local housing providers, local health care entities, and community-based organizations in contact with potentially eligible individuals, to assure seamless integration of community support services, stable housing, and health care services.
(b) The entities operating the program shall coordinate resources, technical assistance, and capacity building efforts to help match eligible individuals with community support services, health care, including behavioral health care and long-term care services, and stable housing.
(2) To be eligible for community support services and permanent supportive housing under subsection (3) of this section, a person must:
(a) Be 18 years of age or older;
(b)(i) Be enrolled in a medical assistance program under this chapter and eligible for community support services;
(ii)(A) Have a countable income that is at or below 133 percent of the federal poverty level, adjusted for family size, and determined annually by the federal department of health and human services; and
(B) Not be eligible for categorically needy medical assistance, as defined in the social security Title XIX state plan; or
(iii) Be assessed as likely eligible for, but not yet enrolled in, a medical assistance program under this chapter due to the severity of behavioral health symptom acuity level which creates barriers to accessing and receiving conventional services;
(c) Have been assessed:
(i) By a licensed behavioral health agency to have a behavioral health need which is defined as meeting one or both of the following criteria:
(A) Having mental health needs, including a need for improvement, stabilization, or prevention of deterioration of functioning resulting from the presence of a mental illness; or
(B) Having substance use disorder needs indicating the need for outpatient substance use disorder treatment which may be determined by an assessment using the American society of addiction medicine criteria or a similar assessment tool approved by the authority;
(ii) By the department of social and health services as needing either assistance with at least three activities of daily living or hands-on assistance with at least one activity of daily living and have the preliminary determination confirmed by the department of social and health services through an in-person assessment conducted by the department of social and health services; or
(iii) To be a homeless person with a long-continuing or indefinite physical condition requiring improvement, stabilization, or prevention of deterioration of functioning, including the ability to live independently without support; and
(d) Have at least one of the following risk factors:
(i)(A) Be a homeless person at the time of the eligibility determination for the program and have been homeless for 12 months prior to the eligibility determination; or
(B) Have been a homeless person on at least four separate occasions in the three years prior to the eligibility determination for the program, as long as the combined occasions equal at least 12 months;
(ii) Have a history of frequent or lengthy institutional contact, including contact at institutional care facilities such as jails, substance use disorder or mental health treatment facilities, hospitals, or skilled nursing facilities; or
(iii) Have a history of frequent stays at adult residential care facilities or residential treatment facilities.
(3) Once a coordinating entity verifies that a person has met the eligibility criteria established in subsection (2) of this section, it must connect the eligible person with a community support services provider. The community support services provider must:
(a) Deliver pretenancy support services to determine the person's specific housing needs and assist the person in identifying permanent supportive housing options that are appropriate and safe for the person;
(b) Fully incorporate the eligible person's available community support services into the case management services provided by the community support services provider; and
(c) Deliver ongoing tenancy-sustaining services to support the person in maintaining successful tenancy.
(4) Housing options offered to eligible participants may vary, subject to the availability of housing and funding.
(5) The community support services benefit must be sustained or renewed in accordance with the eligibility standards in subsection (2) of this section, except that the standards related to homelessness shall be replaced with an assessment of the person's likelihood to become homeless in the event that the community support services benefit is terminated. The coordinating entity must adopt procedures to conduct community support services benefit renewals, according to authority standards.
[
2022 c 216 s 3
.]
NOTES:
Findings
—
Intent
—
Short title
—
2022 c 216:
See notes following RCW 74.09.885
.
RCW 74.09.888
Apple health and homes program
—
Authority duties
—
Funding
—
Reports to legislature.
(1) To establish and administer RCW 74.09.886, the authority shall:
(a)(i) Establish or amend a contract with a coordinating entity to:
(A) Assure the availability of access to eligibility determinations services for community support services benefits and permanent supportive housing benefits;
(B) Verify that persons meet the eligibility standards of RCW 74.09.886
(2);
(C) Coordinate enrollment in medical assistance programs for persons who meet the eligibility standards of RCW 74.09.886
(2), except for actual enrollment in a medical assistance program under this chapter; and
(D) Coordinate with a network of community support services providers to arrange with local housing providers for the placement of an eligible person in permanent supportive housing appropriate to the person's needs and assure that community support services are provided to the person by a community support services provider.
(ii) The primary role of the coordinating entity or entities is administrative and operational, while the authority shall establish the general policy parameters for the work of the coordinating entity or entities.
(iii) In selecting the coordinating entity or entities, the authority shall: Choose one or more organizations that are capable of coordinating access to both community support services and permanent supportive housing services to eligible persons under RCW 74.09.886
; and select no more than one coordinating entity per region which is served by medicaid managed care organizations;
(b) Report to the office for the ongoing monitoring of the program; and
(c) Adopt any rules necessary to implement the program.
(2) The authority shall establish a work group to provide feedback to the agency on its foundational community supports program as it aligns with the work of the housing benefit. The work group may include representatives of state agencies, behavioral health administrative services organizations, the coordinating entity or entities, and contracted agencies providing foundational community supports services. Topics may include, but are not limited to, best practices in eligibility screening processes and case rate billing for foundational community supports housing, regional cost differentials, costs consistent with specialized needs, improved data access and data sharing with foundational community supports providers, and requirements related to the use of a common practice tool among community support services providers to integrate social determinants of health into service delivery. The authority, in consultation with foundational community supports providers and their stakeholders, shall engage each region on case management tools and programs, evaluate effectiveness, and inform the appropriate committees of the legislature on the use of case management tools. Case management shall also be a regular item of engagement in the work group. The authority shall convene the work group at least once each quarter and may expand upon, but not duplicate, existing work groups or advisory councils at the authority or other state agencies.
(3) To support the goals of the program and the goals of other statewide initiatives to identify and address social needs, including efforts within the 1115 waiver renewal to advance health equity and health-related supports, the authority shall work with the office and the department of social and health services to research, identify, and implement statewide universal measures to identify and consider social determinants of health domains, including housing, food security, transportation, financial strain, and interpersonal safety. The authority shall select an accredited or nationally vetted tool, including criteria for prioritization, for the community support services provider to use when making determinations about housing options and other support services to offer individuals eligible for the program. This screening and prioritization process may not exclude clients transitioning from inpatient or other behavioral health residential treatment settings. The authority shall inform the governor and the appropriate committees of the legislature on progress to this end.
(4)(a) The authority and the department may seek and accept funds from private and federal sources to support the purposes of the program.
(b) The authority shall seek approval from the federal department of health and human services to:
(i) Receive federal matching funds for administrative costs and services provided under the program to persons enrolled in medicaid;
(ii) Align the eligibility and benefit standards of the foundational community supports program established pursuant to the waiver, entitled "medicaid transformation project" and initially approved November 2017, between the authority and the federal centers for medicare and medicaid services, as amended and reauthorized, with the standards of the program, including extending the duration of the benefits under the foundational community supports program to not less than 12 months; and
(iii) Implement a medical and psychiatric respite care benefit for certain persons enrolled in medicaid.
(5)(a) By December 1, 2022, the authority and the office shall report to the governor and the legislature on preparedness for the first year of program implementation, including the estimated enrollment, estimated program costs, estimated supportive housing unit availability, funding availability for the program from all sources, efforts to improve billing and administrative burdens for foundational community supports providers, efforts to streamline continuity of care and system connection for persons who are potentially eligible for foundational community supports, and any statutory or budgetary needs to successfully implement the first year of the program.
(b) By December 1, 2023, the authority and the office shall report to the governor and the legislature on the progress of the first year of program implementation and preparedness for the second year of program implementation.
(c) By December 1, 2024, the authority and the office shall report to the governor and the legislature on the progress of the first two years of program implementation and preparedness for ongoing housing acquisition and development.
(d) By December 1, 2026, the authority and the office shall report to the governor and the legislature on the full implementation of the program, including the number of persons served by the program, available permanent supportive housing units, estimated unmet demand for the program, ongoing funding requirements for the program, and funding availability for the program from all sources. Beginning December 1, 2027, the authority and the office shall provide annual updates to the governor and the legislature on the status of the program.
[
2022 c 216 s 4
.]
NOTES:
Findings
—
Intent
—
Short title
—
2022 c 216:
See notes following RCW 74.09.885
.
RCW 74.09.890
Medicaid program integrity
—
Administrative oversight
—
Strategic plan
—
Best practices.
(1) The authority shall provide administrative oversight for all funds received under the medical assistance program, as codified in Title XIX of the federal social security act, the state children's health insurance program, as codified in Title XXI of the federal social security act, and any other federal medicaid funding to ensure that:
(a) All funds are spent according to federal and state laws and regulations;
(b) Delivery of services aligns with federal statutes and regulations;
(c) Corrective action plans are put in place if expenditures or services do not align with federal requirements; and
(d) Sound fiscal stewardship of medicaid funding in all agencies where medicaid funding is provided.
(2) The authority shall develop a strategic plan and performance measures for medicaid program integrity. The strategic plan must include stated strategic goals, agreed-upon objectives, performance measures, and a system to monitor progress and hold responsible parties accountable. In developing the strategic plan, the authority shall create a management information and reporting strategy with performance measures and management reports.
(3) The authority shall oversee the medicaid program resources of any state agency expending medicaid funding, including but not limited to:
(a) Regularly reviewing delegated work;
(b) Jointly reviewing required reports on terminated or sanctioned providers, compliance data, and application data;
(c) Requiring assurances that operational functions have been implemented;
(d) Reviewing audits performed on the sister state agency; and
(e) Assisting with risk assessments, setting goals, and developing policies and procedures.
(4) The authority shall develop and maintain a single, statewide medicaid fraud and abuse prevention plan consistent with the national medicaid fraud and abuse initiative or current federal best practice as recognized by the centers for medicare and medicaid services.
(5) The authority must follow best practices for identifying improper medicaid spending when implementing its program integrity activities, including but not limited to:
(a) Conducting risk assessments or evaluating leads with established risk factors;
(b) Relying on data analytics to generate leads;
(c) Conducting a preliminary review of incoming leads, which includes analyzing data about the lead and may include reviewing records such as billing histories;
(d) Determining the credibility of all allegations of potential fraud prior to referral to the state's medicaid fraud control unit;
(e) Analyzing all leads under review by the state's managed care organizations;
(f) Working with federally recognized experts that help state integrity programs improve their data analytics and identify potential fraud across medicare and medicaid such as unified program integrity contractors; and
(g) Maintaining a current fraud and abuse detection system.
[
2023 c 439 s 3
.]
NOTES:
Intent
—
Finding
—
2023 c 439:
See note following RCW 74.04.050
.
RCW 74.09.892
Medicaid program integrity
—
Managed care organizations
—
Contracts
—
Best practices.
(1) Beginning January 1, 2024, the authority's contracts with managed care organizations must clearly detail each party's requirements for maintaining program integrity and the consequences the managed care organizations face if they do not meet the requirements. The contract must ensure the penalties are adequate to ensure compliance.
(2) The authority shall follow leading program integrity practices as recommended by the centers for medicare and medicaid services, including but not limited to:
(a) Monthly reporting and quarterly meetings with managed care organizations to discuss program integrity issues and findings as well as trends in fraud and other improper payments;
(b) Financial penalties for failure to fulfill program integrity requirements, including liquidated damages and sanctions;
(c) Directly auditing providers and:
(i) Recovering overpayments from the providers; or
(ii) Assessing liquidated damages against the managed care organizations;
(d) Ensuring recoveries and liquidated damages resulting from overpayments are properly accounted for and applied to managed care encounters to ensure accurate future rate setting; and
(e) Ensuring all contracts with managed care organizations are updated as appropriate to reflect program integrity requirements.
[
2023 c 439 s 4
.]
NOTES:
Intent
—
Finding
—
2023 c 439:
See note following RCW 74.04.050
.
RCW 74.09.900
Other laws applicable.
All the provisions of Title
74
RCW, not otherwise inconsistent herewith, shall apply to the provisions of this chapter.
[
1959 c 26 s 74.09.900
. Prior:
1955 c 273 s 22
.]
RCW 74.09.920
Construction
—
Chapter applicable to state registered domestic partnerships
—
2009 c 521.
For the purposes of this chapter, the terms spouse, marriage, marital, husband, wife, widow, widower, next of kin, and family shall be interpreted as applying equally to state registered domestic partnerships or individuals in state registered domestic partnerships as well as to marital relationships and married persons, and references to dissolution of marriage shall apply equally to state registered domestic partnerships that have been terminated, dissolved, or invalidated, to the extent that such interpretation does not conflict with federal law. Where necessary to implement chapter 521, Laws of 2009, gender-specific terms such as husband and wife used in any statute, rule, or other law shall be construed to be gender neutral, and applicable to individuals in state registered domestic partnerships.
[
2009 c 521 s 175
.]
NOTES:
Effective dates
—
2009 c 521 ss 5-8, 79, 87-103, 107, 151, 165, 166, 173-175, and 190-192:
See note following RCW 2.10.900
.