Source: https://apps.leg.wa.gov/wac/default.aspx?cite=182-538&full=true
Timestamp: 2020-08-14 20:38:14
Document Index: 602741107

Matched Legal Cases: ['§ 182', '§ 182', '§ 388', '§ 388', '§ 201', '§ 201', '§ 388', '§ 182', '§ 182', '§ 182', '§ 209', '§ 388', '§ 388', '§ 388', '§ 209', '§ 388', '§ 182', '§ 182', '§ 388', '§ 201', '§ 201', '§ 388', '§ 388', '§ 388', '§ 182', '§ 388', '§ 388', '§ 201', '§ 201', '§ 388', '§ 388', '§ 388', '§ 182', 'arts 431', '§ 182', '§ 182', '§ 182', 'arts 431', '§ 182', '§ 182', '§ 182', '§ 182', '§ 388', '§ 388', '§ 201', '§ 201', '§ 388', '§ 388', '§ 388', '§ 388', '§ 388', '§ 388', '§ 182', '§ 182', '§ 182', '§ 182', '§ 388', '§ 388', '§ 201', '§ 201', '§ 388', '§ 388', '§ 388', '§ 388', '§ 388', '§ 388', '§ 388', '§ 182', '§ 182', '§ 182', '§ 182', '§ 388', '§ 388', '§ 201', '§ 201', '§ 388', '§ 388', '§ 388', '§ 182', '§ 182', '§ 182', '§ 182', '§ 388', '§ 388', '§ 388', '§ 182', '§ 182', '§ 182', 'arts 431', '§ 182', '§ 182', '§ 182', '§ 182', '§ 388', '§ 388', '§ 388', '§ 388', '§ 388', '§ 388', '§ 388', '§ 388', '§ 388', '§ 182', '§ 182', '§ 182', '§ 182', '§ 388', '§ 388', '§ 388', '§ 182', '§ 182', '§ 388', '§ 388', '§ 201', '§ 201', '§ 388', '§ 388', '§ 388', '§ 388', '§ 388', '§ 182', '§ 182', '§ 182', '§ 182', '§ 182', '§ 388', '§ 388', '§ 388', '§ 388', '§ 388', '§ 388', '§ 388', '§ 388', '§ 182', '§ 182', '§ 182']

Chapter 182-538 WAC:
WACs > Title 182 > Chapter 182-538
Chapter 182-538 WAC
HTMLPDF 182-538-040 Introduction.
HTMLPDF 182-538-050 Definitions.
HTMLPDF 182-538-060 Managed care choice and assignment.
HTMLPDF 182-538-067 Qualifications to become a managed care organization (MCO) in integrated managed care.
HTMLPDF 182-538-068 Qualifications to become a primary care case management (PCCM) provider in integrated managed care regional service areas.
HTMLPDF 182-538-070 Payments and sanctions for managed care organizations (MCOs) in integrated managed care regional service areas.
HTMLPDF 182-538-071 Payments for primary care case management (PCCM) providers in the integrated managed care for regional service areas.
HTMLPDF 182-538-095 Scope of care for integrated managed care enrollees and managed care organization benefit administration requirements.
HTMLPDF 182-538-096 Scope of service for PCCM enrollees.
HTMLPDF 182-538-100 Managed care emergency services.
HTMLPDF 182-538-110 The grievance and appeal system and agency administrative hearing for managed care organization (MCO) enrollees.
HTMLPDF 182-538-111 The administrative hearing process for primary care case management (PCCM).
HTMLPDF 182-538-120 Enrollee request for a second medical opinion.
HTMLPDF 182-538-130 Exemptions and ending enrollment in managed care.
HTMLPDF 182-538-140 Quality of care.
HTMLPDF 182-538-150 Apple health foster care program.
HTMLPDF 182-538-170 Notice requirements.
HTMLPDF 182-538-180 Rights and protections.
HTMLPDF 182-538-190 Behavioral health services only (BHSO).
182-538-061 Voluntary enrollment into managed care—Washington medicaid integration partnership (WMIP). [Statutory Authority: RCW 41.05.021, 42 C.F.R. 438. WSR 13-02-010, § 182-538-061, filed 12/19/12, effective 2/1/13. WSR 11-14-075, recodified as § 182-538-061, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.09.522. WSR 08-15-110, § 388-538-061, filed 7/18/08, effective 8/18/08; WSR 06-03-081, § 388-538-061, filed 1/12/06, effective 2/12/06. Statutory Authority: RCW 74.08.090, 74.09.522, 2003 E1 c 25 § 201(4), 2004 c 276 § 201(4), 42 U.S.C. 1396N (section 1915 (b) and (c) of the Social Security Act of 1924). WSR 05-01-066, § 388-538-061, filed 12/8/04, effective 1/8/05.] Repealed by WSR 15-24-098, filed 12/1/15, effective 1/1/16. Statutory Authority: RCW 41.05.021 and 41.05.160.
182-538-063 Managed care for medical care services clients. [Statutory Authority: RCW 41.05.021, 42 C.F.R. 438. WSR 13-02-010, § 182-538-063, filed 12/19/12, effective 2/1/13. Statutory Authority: RCW 41.05.021, 74.09.035, and 2011 1st sp.s. c 36. WSR 12-19-051, § 182-538-063, filed 9/13/12, effective 10/14/12. WSR 11-14-075, recodified as § 182-538-063, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 2007 c 522 § 209 (13)-(14). WSR 08-10-048, § 388-538-063, filed 5/1/08, effective 6/1/08. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. WSR 06-24-036, § 388-538-063, filed 11/30/06, effective 1/1/07. Statutory Authority: RCW 74.08.090 and 74.09.522. WSR 06-03-081, § 388-538-063, filed 1/12/06, effective 2/12/06. Statutory Authority: RCW 74.08.090, 74.09.035, 74.09.522, and 2003 1st sp.s. c 25 § 209(15). WSR 04-15-003, § 388-538-063, filed 7/7/04, effective 8/7/04.] Repealed by WSR 15-24-098, filed 12/1/15, effective 1/1/16. Statutory Authority: RCW 41.05.021 and 41.05.160.
182-538-065 Medicaid-eligible basic health (BH) enrollees. [Statutory Authority: RCW 41.05.021, 42 C.F.R. 438. WSR 13-02-010, § 182-538-065, filed 12/19/12, effective 2/1/13. WSR 11-14-075, recodified as § 182-538-065, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.09.522. WSR 06-03-081, § 388-538-065, filed 1/12/06, effective 2/12/06. Statutory Authority: RCW 74.08.090, 74.09.522, 2003 E1 c 25 § 201(4), 2004 c 276 § 201(4), 42 U.S.C. 1396N (section 1915 (b) and (c) of the Social Security Act of 1924). WSR 05-01-066, § 388-538-065, filed 12/8/04, effective 1/8/05. Statutory Authority: RCW 74.09.080, 74.08.510, [74.08.]522, 74.09.450, 1115 Waiver, 42 U.S.C. 1396. WSR 02-01-075, § 388-538-065, filed 12/14/01, effective 1/14/02. Statutory Authority: RCW 74.08.090, 74.09.510 and [74.09.]522 and 1115 Federal Waiver, 42 U.S.C. 1396 (a), (e), (p), 42 U.S.C. 1396r-6(b), 42 U.S.C. 1396u-2. WSR 00-04-080, § 388-538-065, filed 2/1/00, effective 3/3/00.] Repealed by WSR 15-24-098, filed 12/1/15, effective 1/1/16. Statutory Authority: RCW 41.05.021 and 41.05.160.
182-538-112 The department of social and health services' (DSHS) hearing process for enrollee appeals of managed care organization (MCO) actions. [WSR 11-14-075, recodified as § 182-538-112, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.09.522. WSR 08-15-110, § 388-538-112, filed 7/18/08, effective 8/18/08; WSR 06-03-081, § 388-538-112, filed 1/12/06, effective 2/12/06. Statutory Authority: RCW 74.08.090, 74.09.522, 2003 E1 c 25 § 201(4), 2004 c 276 § 201(4), 42 U.S.C. 1396N (section 1915 (b) and (c) of the Social Security Act of 1924). WSR 05-01-066, § 388-538-112, filed 12/8/04, effective 1/8/05. Statutory Authority: RCW 74.08.090, 74.09.522, and 74.09.450. WSR 04-13-002, § 388-538-112, filed 6/2/04, effective 7/3/04. Statutory Authority: RCW 74.08.090, 74.09.522. WSR 03-18-110, § 388-538-112, filed 9/2/03, effective 10/3/03.] Repealed by WSR 13-02-010, filed 12/19/12, effective 2/1/13. Statutory Authority: RCW 41.05.021, 42 C.F.R. 438.
PDF182-538-040
(1) This chapter governs services provided under the Washington apple health integrated managed care (IMC) contract.
[Statutory Authority: RCW 41.05.021, 41.05.160, 2019 c 325, 2014 c 225, and 2018 c 201. WSR 19-24-063, § 182-538-040, filed 11/27/19, effective 1/1/20. Statutory Authority: RCW 41.05.021, 41.05.160 and 42 C.F.R. Parts 431, 433, 438, 440, 457, and 495. WSR 17-23-199, § 182-538-040, filed 11/22/17, effective 12/23/17. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-24-098, § 182-538-040, filed 12/1/15, effective 1/1/16.]
PDF182-538-050
The following definitions and abbreviations and those found in chapter 182-500 WAC apply to this chapter. If conflict exists, this chapter takes precedence.
"Administrative hearing" means an evidentiary adjudicative proceeding before an administrative law judge or presiding officer that is available to an enrollee under chapter 182-526 WAC according to RCW 74.09.741.
"Client" - See WAC 182-500-0020.
[Statutory Authority: RCW 41.05.021, 41.05.160, 2019 c 325, 2014 c 225, and 2018 c 201. WSR 19-24-063, § 182-538-050, filed 11/27/19, effective 1/1/20. Statutory Authority: RCW 41.05.021, 41.05.160 and 42 C.F.R. Parts 431, 433, 438, 440, 457, and 495. WSR 17-23-199, § 182-538-050, filed 11/22/17, effective 12/23/17. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-24-098, § 182-538-050, filed 12/1/15, effective 1/1/16. Statutory Authority: RCW 41.05.021, 42 C.F.R. 438. WSR 13-02-010, § 182-538-050, filed 12/19/12, effective 2/1/13. WSR 11-14-075, recodified as § 182-538-050, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.09.522. WSR 08-15-110, § 388-538-050, filed 7/18/08, effective 8/18/08; WSR 06-03-081, § 388-538-050, filed 1/12/06, effective 2/12/06. Statutory Authority: RCW 74.08.090, 74.09.522, 2003 E1 c 25 § 201(4), 2004 c 276 § 201(4), 42 U.S.C. 1396N (section 1915 (b) and (c) of the Social Security Act of 1924). WSR 05-01-066, § 388-538-050, filed 12/8/04, effective 1/8/05. Statutory Authority: RCW 74.08.090, 74.09.522. WSR 03-18-109, § 388-538-050, filed 9/2/03, effective 10/3/03. Statutory Authority: RCW 74.09.080, 74.08.510, [74.08.]522, 74.09.450, 1115 Waiver, 42 U.S.C. 1396. WSR 02-01-075, § 388-538-050, filed 12/14/01, effective 1/14/02. Statutory Authority: RCW 74.08.090, 74.09.510 and [74.09.]522 and 1115 Federal Waiver, 42 U.S.C. 1396 (a), (e), (p), 42 U.S.C. 1396r-6(b), 42 U.S.C. 1396u-2. WSR 00-04-080, § 388-538-050, filed 2/1/00, effective 3/3/00. Statutory Authority: RCW 74.08.090 and 1995 2nd sp.s. c 18. WSR 95-18-046 (Order 3886), § 388-538-050, filed 8/29/95, effective 9/1/95. Statutory Authority: RCW 74.08.090. WSR 93-17-039 (Order 3621), § 388-538-050, filed 8/11/93, effective 9/11/93.]
PDF182-538-060
Managed care choice and assignment.
(1) The medicaid agency requires a client to enroll in integrated managed care (IMC) when that client:
(c) Is not exempt from IMC enrollment and the agency has not ended the client's managed care enrollment, consistent with WAC 182-538-130.
(c) Go to the ProviderOne client portal at https://www.waproviderone.org/client and follow the instructions.
(4) An enrollee in IMC must enroll with an MCO available in the regional service area where the enrollee resides.
(6) An enrollee may be placed into the PRC program by the MCO or the agency. An enrollee placed in the PRC program must follow the enrollment requirements of the program as stated in WAC 182-501-0135.
(i) If a client who is not AI/AN does not choose an MCO, the agency assigns the client to an MCO available in the area where the client resides. The MCO is responsible for primary care provider (PCP) choice and assignment.
(9) An MCO enrollee's selection of a PCP or assignment to a PCP occurs as follows:
[Statutory Authority: RCW 41.05.021, 41.05.160, 2019 c 325, 2014 c 225, and 2018 c 201. WSR 19-24-063, § 182-538-060, filed 11/27/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-24-098, § 182-538-060, filed 12/1/15, effective 1/1/16. Statutory Authority: RCW 41.05.021, 42 C.F.R. 438. WSR 13-02-010, § 182-538-060, filed 12/19/12, effective 2/1/13. WSR 11-14-075, recodified as § 182-538-060, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.09.522. WSR 08-15-110, § 388-538-060, filed 7/18/08, effective 8/18/08; WSR 06-03-081, § 388-538-060, filed 1/12/06, effective 2/12/06. Statutory Authority: RCW 74.08.090, 74.09.522, 2003 E1 c 25 § 201(4), 2004 c 276 § 201(4), 42 U.S.C. 1396N (section 1915 (b) and (c) of the Social Security Act of 1924). WSR 05-01-066, § 388-538-060, filed 12/8/04, effective 1/8/05. Statutory Authority: RCW 74.08.090, 74.09.522. WSR 03-18-109, § 388-538-060, filed 9/2/03, effective 10/3/03. Statutory Authority: RCW 74.09.080, 74.08.510, [74.08.]522, 74.09.450, 1115 Waiver, 42 U.S.C. 1396. WSR 02-01-075, § 388-538-060, filed 12/14/01, effective 1/14/02. Statutory Authority: RCW 74.08.090, 74.09.510 and [74.09.]522 and 1115 Federal Waiver, 42 U.S.C. 1396 (a), (e), (p), 42 U.S.C. 1396r-6(b), 42 U.S.C. 1396u-2. WSR 00-04-080, § 388-538-060, filed 2/1/00, effective 3/3/00. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057 and 74.08.090. WSR 98-16-044, § 388-538-060, filed 7/31/98, effective 9/1/98. Statutory Authority: RCW 74.08.090 and 1995 2nd sp.s. c 18. WSR 95-18-046 (Order 3886), § 388-538-060, filed 8/29/95, effective 9/1/95. Statutory Authority: RCW 74.08.090. WSR 93-17-039 (Order 3621), § 388-538-060, filed 8/11/93, effective 9/11/93.]
PDF182-538-067
Qualifications to become a managed care organization (MCO) in integrated managed care.
(3) At its discretion, the agency awards a contract to an MCO through a competitive process or an application process available to all qualified providers.
[Statutory Authority: RCW 41.05.021, 41.05.160, 2019 c 325, 2014 c 225, and 2018 c 201. WSR 19-24-063, § 182-538-067, filed 11/27/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-24-098, § 182-538-067, filed 12/1/15, effective 1/1/16. Statutory Authority: RCW 41.05.021, 42 C.F.R. 438. WSR 13-02-010, § 182-538-067, filed 12/19/12, effective 2/1/13. WSR 11-14-075, recodified as § 182-538-067, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.09.522. WSR 08-15-110, § 388-538-067, filed 7/18/08, effective 8/18/08; WSR 06-03-081, § 388-538-067, filed 1/12/06, effective 2/12/06. Statutory Authority: RCW 74.08.090, 74.09.522, 2003 E1 c 25 § 201(4), 2004 c 276 § 201(4), 42 U.S.C. 1396N (section 1915 (b) and (c) of the Social Security Act of 1924). WSR 05-01-066, § 388-538-067, filed 12/8/04, effective 1/8/05. Statutory Authority: RCW 74.08.090, 74.09.522. WSR 03-18-112, § 388-538-067, filed 9/2/03, effective 10/3/03. Statutory Authority: RCW 74.09.080, RCW 74.08.510, [74.08.]522, 74.09.450, 1115 Waiver, 42 U.S.C. 1396. WSR 02-01-075, § 388-538-067, filed 12/14/01, effective 1/14/02.]
PDF182-538-068
Qualifications to become a primary care case management (PCCM) provider in integrated managed care regional service areas.
[Statutory Authority: RCW 41.05.021, 41.05.160, 2019 c 325, 2014 c 225, and 2018 c 201. WSR 19-24-063, § 182-538-068, filed 11/27/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-24-098, § 182-538-068, filed 12/1/15, effective 1/1/16. Statutory Authority: RCW 41.05.021, 42 C.F.R. 438. WSR 13-02-010, § 182-538-068, filed 12/19/12, effective 2/1/13. WSR 11-14-075, recodified as § 182-538-068, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.09.522. WSR 08-15-110, § 388-538-068, filed 7/18/08, effective 8/18/08; WSR 06-03-081, § 388-538-068, filed 1/12/06, effective 2/12/06. Statutory Authority: RCW 74.09.080, 74.08.510, [74.08.]522, 74.09.450, 1115 Waiver, 42 U.S.C. 1396. WSR 02-01-075, § 388-538-068, filed 12/14/01, effective 1/14/02.]
PDF182-538-070
PDF182-538-071
Payments for primary care case management (PCCM) providers in the integrated managed care for regional service areas.
[Statutory Authority: RCW 41.05.021, 41.05.160, 2019 c 325, 2014 c 225, and 2018 c 201. WSR 19-24-063, § 182-538-071, filed 11/27/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-24-098, § 182-538-071, filed 12/1/15, effective 1/1/16.]
PDF182-538-095
PDF182-538-096
PDF182-538-100
PDF182-538-110
The grievance and appeal system and agency administrative hearing for managed care organization (MCO) enrollees.
(f) An MCO must allow enrollees and their authorized representatives to file grievances and appeals orally as well as in writing.
(g) Methods to file either a grievance or appeal include, but are not limited to, U.S. mail, commercial delivery services, hand delivery, fax, telephone, and email.
(h) MCOs may not require enrollees to provide written follow-up for a grievance the MCO received orally.
(i) The MCO must resolve each grievance and appeal and provide notice of the resolution as expeditiously as the enrollee's health condition requires, and within the time frames identified in this section.
(j) The MCO must ensure that the people who make decisions on grievances and appeals:
[Statutory Authority: RCW 41.05.021, 41.05.160, 2019 c 325, 2014 c 225, and 2018 c 201. WSR 19-24-063, § 182-538-110, filed 11/27/19, effective 1/1/20. Statutory Authority: RCW 41.05.021, 41.05.160 and 42 C.F.R. Parts 431, 433, 438, 440, 457, and 495. WSR 17-23-199, § 182-538-110, filed 11/22/17, effective 12/23/17. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-24-098, § 182-538-110, filed 12/1/15, effective 1/1/16. Statutory Authority: RCW 41.05.021, 42 C.F.R. 438. WSR 13-02-010, § 182-538-110, filed 12/19/12, effective 2/1/13. WSR 11-14-075, recodified as § 182-538-110, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.09.522. WSR 08-15-110, § 388-538-110, filed 7/18/08, effective 8/18/08; WSR 06-03-081, § 388-538-110, filed 1/12/06, effective 2/12/06; WSR 03-18-110, § 388-538-110, filed 9/2/03, effective 10/3/03. Statutory Authority: RCW 74.09.080, 74.08.510, [74.08.]522, 74.09.450, 1115 Waiver, 42 U.S.C. 1396. WSR 02-01-075, § 388-538-110, filed 12/14/01, effective 1/14/02. Statutory Authority: RCW 74.08.090, 74.09.510 and [74.09.]522 and 1115 Federal Waiver, 42 U.S.C. 1396 (a), (e), (p), 42 U.S.C. 1396r-6(b), 42 U.S.C. 1396u-2. WSR 00-04-080, § 388-538-110, filed 2/1/00, effective 3/3/00. Statutory Authority: RCW 74.08.090. WSR 97-04-004, § 388-538-110, filed 1/24/97, effective 2/24/97. Statutory Authority: RCW 74.08.090 and 1995 2nd sp.s. c 18. WSR 95-18-046 (Order 3886), § 388-538-110, filed 8/29/95, effective 9/1/95. Statutory Authority: RCW 74.08.090. WSR 94-04-038 (Order 3701), § 388-538-110, filed 1/26/94, effective 2/26/94; WSR 93-17-039 (Order 3621), § 388-538-110, filed 8/11/93, effective 9/11/93.]
PDF182-538-111
The administrative hearing process for primary care case management (PCCM).
PCCM enrollees follow the same administrative hearing rules and processes as fee-for-service clients under chapter 182-526 WAC.
[Statutory Authority: RCW 41.05.021, 41.05.160, 2019 c 325, 2014 c 225, and 2018 c 201. WSR 19-24-063, § 182-538-111, filed 11/27/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-24-098, § 182-538-111, filed 12/1/15, effective 1/1/16. Statutory Authority: RCW 41.05.021, 42 C.F.R. 438. WSR 13-02-010, § 182-538-111, filed 12/19/12, effective 2/1/13. WSR 11-14-075, recodified as § 182-538-111, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.09.522. WSR 08-15-110, § 388-538-111, filed 7/18/08, effective 8/18/08; WSR 06-03-081, § 388-538-111, filed 1/12/06, effective 2/12/06; WSR 03-18-110, § 388-538-111, filed 9/2/03, effective 10/3/03.]
PDF182-538-120
Enrollee request for a second medical opinion.
(1) A managed care enrollee has the right to a timely referral for a second opinion upon request when:
(3) Primary care case management (PCCM) enrollees have a right to a timely referral for a second opinion by another provider who has a core provider agreement with the agency.
[Statutory Authority: RCW 41.05.021, 42 C.F.R. 438. WSR 13-02-010, § 182-538-120, filed 12/19/12, effective 2/1/13. WSR 11-14-075, recodified as § 182-538-120, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.09.522. WSR 08-15-110, § 388-538-120, filed 7/18/08, effective 8/18/08; WSR 06-03-081, § 388-538-120, filed 1/12/06, effective 2/12/06. Statutory Authority: RCW 74.08.090, 74.09.522, 2003 E1 c 25 § 201(4), 2004 c 276 § 201(4), 42 U.S.C. 1396N (section 1915 (b) and (c) of the Social Security Act of 1924). WSR 05-01-066, § 388-538-120, filed 12/8/04, effective 1/8/05. Statutory Authority: RCW 74.09.080, 74.08.510, [74.08.]522, 74.09.450, 1115 Waiver, 42 U.S.C. 1396. WSR 02-01-075, § 388-538-120, filed 12/14/01, effective 1/14/02. Statutory Authority: RCW 74.08.090, 74.09.510 and [74.09.]522 and 1115 Federal Waiver, 42 U.S.C. 1396 (a), (e), (p), 42 U.S.C. 1396r-6(b), 42 U.S.C. 1396u-2. WSR 00-04-080, § 388-538-120, filed 2/1/00, effective 3/3/00. Statutory Authority: RCW 74.08.090 and 1995 2nd sp.s. c 18. WSR 95-18-046 (Order 3886), § 388-538-120, filed 8/29/95, effective 9/1/95. Statutory Authority: RCW 74.08.090. WSR 93-17-039 (Order 3621), § 388-538-120, filed 8/11/93, effective 9/11/93.]
PDF182-538-130
Exemptions and ending enrollment in managed care.
The medicaid agency enrolls clients into integrated managed care (IMC) based on the rules in WAC 182-538-060. IMC is mandatory in all regional service areas.
(a) The agency exempts or ends enrollment from mandatory managed care when any of the following apply:
(i) The client or enrollee is eligible for medicare;
(ii) The client or enrollee is not eligible for managed care enrollment, for Washington apple health programs, or both.
(b) The agency grants a request to exempt or to end enrollment in managed care, with the change effective the earliest possible date given the requirements of the agency's enrollment system, when the client or enrollee:
(3) Case-by-case clinical criteria. Clinical criteria for an enrollee or client to be exempted or end enrollment in IMC.
(ii) The medically necessary care at issue is covered under the agency's managed care contracts and is not a benefit under the behavioral health services only (BHSO) program;
(ii) The agency limits the period of time based on the circumstances or how long the conditions described are expected to exist.
(6) Denied request. When the agency denies a request for exemption or to end enrollment:
(7) Administrative hearing request. If a client or enrollee does not agree with the agency's decision regarding a request for exemption or to end enrollment, the client or enrollee may file a request for an agency administrative hearing based on RCW 74.09.741, the rules in this chapter, and the agency hearing rules in chapter 182-526 WAC.
(8) MCO request. The agency will grant a request from an MCO to end enrollment of an enrollee when the request is submitted to the agency in writing and includes sufficient documentation for the agency to determine that the criteria to end enrollment in this subsection is met.
(e) The MCO will continue to provide services to the enrollee until the date the person is no longer enrolled.
(f) The agency may exempt the client for the period of time the circumstances are expected to exist. The agency may periodically review those circumstances to determine if they continue to exist. Any authorized exemption will continue only until the client can be enrolled in IMC.
[Statutory Authority: RCW 41.05.021, 41.05.160, 2019 c 325, 2014 c 225, and 2018 c 201. WSR 19-24-063, § 182-538-130, filed 11/27/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 16-23-021, § 182-538-130, filed 11/4/16, effective 1/1/17; WSR 15-24-098, § 182-538-130, filed 12/1/15, effective 1/1/16. Statutory Authority: RCW 41.05.021, 42 C.F.R. 438. WSR 13-02-010, § 182-538-130, filed 12/19/12, effective 2/1/13. WSR 11-14-075, recodified as § 182-538-130, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.09.522. WSR 08-15-110, § 388-538-130, filed 7/18/08, effective 8/18/08; WSR 06-03-081, § 388-538-130, filed 1/12/06, effective 2/12/06; WSR 03-18-111, § 388-538-130, filed 9/2/03, effective 10/3/03. Statutory Authority: RCW 74.09.080, 74.08.510, [74.08.]522, 74.09.450, 1115 Waiver, 42 U.S.C. 1396. WSR 02-01-075, § 388-538-130, filed 12/14/01, effective 1/14/02. Statutory Authority: RCW 74.08.090, 74.09.510 and [74.09.]522 and 1115 Federal Waiver, 42 U.S.C. 1396 (a), (e), (p), 42 U.S.C. 1396r-6(b), 42 U.S.C. 1396u-2. WSR 00-04-080, § 388-538-130, filed 2/1/00, effective 3/3/00. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057 and 74.08.090. WSR 98-16-044, § 388-538-130, filed 7/31/98, effective 9/1/98. Statutory Authority: RCW 74.08.090 and 1995 2nd sp.s. c 18. WSR 95-18-046 (Order 3886), § 388-538-130, filed 8/29/95, effective 9/1/95. Statutory Authority: RCW 74.08.090. WSR 93-17-039 (Order 3621), § 388-538-130, filed 8/11/93, effective 9/11/93.]
PDF182-538-140
PDF182-538-150
PDF182-538-170
[Statutory Authority: RCW 41.05.021, 41.05.160, 2019 c 325, 2014 c 225, and 2018 c 201. WSR 19-24-063, § 182-538-170, filed 11/27/19, effective 1/1/20.]
PDF182-538-180
(y) Receiving a second opinion from a qualified health care professional within an MCO provider network at no cost or having one arranged outside the network at no cost, as provided in 42 C.F.R. Sec. 438.206(b)(3);
[Statutory Authority: RCW 41.05.021, 41.05.160, 2019 c 325, 2014 c 225, and 2018 c 201. WSR 19-24-063, § 182-538-180, filed 11/27/19, effective 1/1/20.]
PDF182-538-190
(5) A BHSO enrollee may change MCOs at any time for any reason with the change becoming effective the earliest possible date given the requirements of the agency's enrollment system.
[Statutory Authority: RCW 41.05.021, 41.05.160, 2019 c 325, 2014 c 225, and 2018 c 201. WSR 19-24-063, § 182-538-190, filed 11/27/19, effective 1/1/20.]