Document:

exv10w1

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Exhibit 10.1

Contract Number: 4000-002089

This Agreement has been entered into between

MOLINA HEALTHCARE OF WASHINGTON, INC.

(Hereinafter referred to as “CONTRACTOR”)

and the

WASHINGTON STATE HEALTH CARE AUTHORITY

(Hereinafter referred to as “HCA”) For the

Washington Basic Health Plan

In consideration of the payment of monthly fees to be made by HCA and the conditions specified in
this Agreement, CONTRACTOR agrees to provide services and benefits, as herein specified, for
enrollees in the Washington Basic Health Plan (BH), consistent with Chapter 70.47 Revised Code of
Washington (RCW) and Chapter 182-25 Washington Administrative Code (WAC) as amended. This Agreement
is subject to all of the terms and conditions set forth herein, including the Exhibits attached
hereto and included in this Agreement by this reference.

This Agreement is effective January 1, 2008, at 12:01 A.M., Pacific Standard Time, at Olympia,
Washington, and will remain in effect through December 31, 2008, unless terminated earlier or
renewed. HCA reserves the right to negotiate annual renewals of this Agreement.

In Witness Whereof, CONTRACTOR and HCA have caused this Agreement to be signed by their respective
officers who are duly authorized as of the effective date.

	 	 	 	 	 	 	 	 	 	 	 
	MOLINA HEALTHCARE	 	 	 	WASHINGTON STATE	 	 
	OF WASHINGTON, INC.	 	 	 	HEALTH CARE AUTHORITY	 	 
	 
	 	 	 	 	 	 	 	 	 	 
	By:

	 	 	 	 	 	By:	 	 	 	 
	 

	 	 

	 	 
	 	 	 	 

	 	 
	 
	Title: President	 	 	 	Title: Deputy Administrator	 	 
	 
	Date:

	 	 	 	 	 	Date:	 	 	 	 
	 

	 	 

	 	 
	 	 	 	 

	 	 
	Address for Notice Purposes:	 	 	 	Address for Notice Purposes:	 	 
	Claudia St. Clair	 	 	 	Bevin Hansell	 	 
	Contract Manager	 	 	 	Director of Basic Health Purchasing	 	 
	P O Box 4004	 	 	 	P O Box 42685	 	 
	Bothell, Washington 98041-4004	 	 	 	Olympia, Washington 98504-2685	 	 

This Contract is approved as to form by the Office of the Attorney General.

 

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Contract Number: 4000-002089

This Agreement has been entered into between

Molina Healthcare of Washington, Inc.

(hereinafter referred to as “CONTRACTOR”)

and the

WASHINGTON STATE HEALTH CARE AUTHORITY

(hereinafter referred to as “HCA”)

for the Washington Basic Health Plan

SUBSTITUTE FINAL SIGNATURE PAGE

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TABLE OF CONTENTS

	 	 	 	 	 	 	 
	1.
	 	DEFINITIONS	 	 	1	 
	1.1.
	 	Administrator	 	 	1	 
	1.2.
	 	Anniversary Date	 	 	1	 
	1.3.
	 	Basic Health Plus	 	 	1	 
	1.4.
	 	Certificate of Coverage (COC) or Member Handbook	 	 	1	 
	1.5.
	 	CONTRACTOR	 	 	1	 
	1.6.
	 	Coordination of Benefits (COB)	 	 	1	 
	1.7.
	 	Covered Services	 	 	2	 
	1.8.
	 	Dependent	 	 	2	 
	1.9.
	 	Enrollee	 	 	2	 
	1.10.
	 	HIPAA	 	 	2	 
	1.11.
	 	Material Provider	 	 	2	 
	1.12.
	 	Maternity Benefits Program	 	 	2	 
	1.13.
	 	Medical Assistance	 	 	2	 
	1.14.
	 	Medicare	 	 	2	 
	1.15.
	 	Participating Provider	 	 	2	 
	1.16.
	 	Personal Information	 	 	3	 
	1.17.
	 	Primary Care Physician (PCP)	 	 	3	 
	1.18.
	 	Privacy Rule	 	 	3	 
	1.19.
	 	Provider	 	 	3	 
	1.20.
	 	Referral Provider	 	 	3	 
	1.21.
	 	Service Area	 	 	3	 
	1.22.
	 	Subcontract	 	 	4	 
	1.23.
	 	Subscriber	 	 	 	 
	1.24.
	 	Consumer Assessment of Health Plans Survey (CAHPS)	 	 	4	 
	1.25.
	 	External Quality Review (EQR)	 	 	4	 

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	1.26.
	 	External Quality Review Organization (EQRO)	 	 	4	 
	1.27.
	 	Partial HEDIS® Compliance Audit Standards, Policies, Procedures	 	 	4	 
	1.28.
	 	Health Employer Data and Information Set (HEDIS®)	 	 	4	 
	1.29.
	 	Managed Care Organization	 	 	5	 
	2.
	 	ELIGIBILITY AND ENROLLMENT	 	 	5	 
	2.1.
	 	Eligibility	 	 	5	 
	2.2.
	 	Enrollment	 	 	5	 
	2.3.
	 	Limited Enrollment	 	 	5	 
	2.4.
	 	Identification Cards and CONTRACTOR Information	 	 	5	 
	2.5.
	 	Medical Assistance Recipients	 	 	7	 
	2.6.
	 	Service Area	 	 	8	 
	3.
	 	TERMINATION AND RELATED PROVISIONS	 	 	8	 
	3.1.
	 	Reservation of Rights and Remedies	 	 	8	 
	3.2.
	 	Termination By HCA	 	 	9	 
	3.3.
	 	Termination By CONTRACTOR	 	 	9	 
	3.4.
	 	Termination Procedure	 	 	10	 
	3.5.
	 	Termination for Withdrawal or Reduction of Funding	 	 	10	 
	3.6.
	 	Termination of Enrollee Coverage	 	 	10	 
	4.
	 	MONTHLY FEES	 	 	11	 
	4.1.
	 	Remittance	 	 	11	 
	4.2.
	 	Retroactive Payment or Refund	 	 	12	 
	4.3.
	 	Responsibility for Enrollment Data	 	 	12	 
	4.4.
	 	Renegotiation of Rates	 	 	12	 
	5.
	 	SERVICES, BENEFITS, EXCLUSIONS, AND LIMITATIONS	 	 	12	 
	5.1.
	 	Plan Description	 	 	12	 
	5.2.
	 	Self-Referral for Women’s Health Care	 	 	12	 
	5.3.
	 	Preventive Care	 	 	13	 

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	6.
	 	COORDINATION OF BENEFITS	 	 	14	 
	6.1.
	 	Benefits Subject To This Provision	 	 	14	 
	6.2.
	 	“Plan” Defined	 	 	14	 
	6.3.
	 	“Allowable Expense” Defined	 	 	14	 
	6.4.
	 	“Claim Determination Period” Defined	 	 	15	 
	6.5.
	 	Facility of Payment	 	 	15	 
	6.6.
	 	Right of Recovery	 	 	15	 
	6.7.
	 	Effect on Benefits	 	 	15	 
	7.
	 	DATA REPORTING	 	 	16	 
	7.1.
	 	Integrated Provider Network Database (IPND)	 	 	16	 
	7.2.
	 	Health Plan Employer Data and Information Set (HEDIS®)	 	 	16	 
	7.3.
	 	Consumer Assessment of Health Plans (CAHPSTM) Survey	 	 	17	 
	7.4.
	 	Experience Data Reports	 	 	17	 
	7.5.
	 	Data Reporting — Paid Claims Data	 	 	18	 
	7.6.
	 	Denials, Appeals, Grievances, and Independent Reviews	 	 	18	 
	8.
	 	QUALITY OF CARE	 	 	19	 
	8.1.
	 	Quality Improvement Program	 	 	19	 
	8.2.
	 	Clinical Outcomes Assessment Programs (COAP)	 	 	20	 
	8.3.
	 	Patient Safety	 	 	20	 
	8.4.
	 	Claims Payment	 	 	20	 
	9.
	 	DATA RECORDS	 	 	20	 
	9.1.
	 	Confidential Personal Information	 	 	20	 
	9.2.
	 	Health Insurance Portability and Accountability Act of 1996 (HIPAA)	 	 	21	 
	9.3
	 	Proprietary Data or Trade Secrets	 	 	21	 
	9.4.
	 	Data Ownership	 	 	22	 
	10.
	 	PERFORMANCE EXPECTATIONS	 	 	23	 

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	10.1.
	 	General Expectations	 	 	23	 
	10.2.
	 	Demonstrated Superior Quality in Health Care Delivery	 	 	23	 
	10.3.
	 	Access to Health Care Services	 	 	24	 
	10.4.
	 	Accountability for Delivery of Affordable Health Care	 	 	25	 
	10.5.
	 	Performance Measures	 	 	26	 
	11.
	 	APPEALS AND COMPLAINTS	 	 	26	 
	11.1.
	 	Enrollee Complaints and Appeals Procedure	 	 	26	 
	11.2.
	 	Disputes and Dispute Resolution Hearings	 	 	26	 
	11.3.
	 	Grievance Timelines	 	 	27	 
	12.
	 	GENERAL PROVISIONS	 	 	27	 
	12.1.
	 	Accessibility of Covered Services	 	 	27	 
	12.2.
	 	Administrative Simplification	 	 	29	 
	12.3.
	 	Assignment	 	 	29	 
	12.4.
	 	Audits and Performance Reviews	 	 	29	 
	12.5.
	 	Clerical Error	 	 	30	 
	12.6.
	 	Compliance With All Applicable Laws and Regulations	 	 	30	 
	12.7.
	 	Covenant Against Contingent Fees	 	 	30	 
	12.8.
	 	Customer Service	 	 	31	 
	12.9.
	 	Defense of Legal Actions	 	 	31	 
	12.10.
	 	Financial Solvency	 	 	31	 
	12.11.
	 	Force Majeure	 	 	32	 
	12.12.
	 	Governing Law and Venue	 	 	33	 
	12.13.
	 	HCA and Enrollee Protection	 	 	33	 
	12.14.
	 	Indemnification	 	 	33	 
	12.15.
	 	Independent Parties	 	 	34	 
	12.16.
	 	Industrial Insurance Coverage	 	 	34	 
	12.17.
	 	Integration and Modification of Agreement	 	 	34	 

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	12.18.
	 	Intermediate Sanctions	 	 	34	 
	12.19.
	 	Licensing, Registration, Certification, and Authorization	 	 	35	 
	12.20.
	 	Marketing and Written Communication Materials	 	 	35	 
	12.21.
	 	Mergers and Acquisitions	 	 	36	 
	12.22.
	 	Noncompliance with Nondiscrimination Laws	 	 	36	 
	12.23.
	 	Nondiscrimination	 	 	36	 
	12.24.
	 	Notification of Organizational Changes	 	 	36	 
	12.25.
	 	Subcontracts	 	 	36	 
	12.26.
	 	Provider Network Changes	 	 	38	 
	12.27.
	 	Records Maintenance and Retention	 	 	39	 
	12.28.
	 	Post Termination Responsibilities	 	 	40	 
	12.29.
	 	Required Notices	 	 	40	 
	12.30.
	 	Services Non-Transferable	 	 	40	 
	12.31.
	 	Severability	 	 	40	 
	12.32.
	 	Waiver	 	 	41	 

Exhibits

	 	 	 
	Exhibit 1:

	 	Monthly Fees
	Exhibit 2:

	 	Certificate of Coverage
	Exhibit 3:

	 	Performance Measures
	Exhibit 4:

	 	Quality Improvement Standards
	Exhibit 5:

	 	Consumer Assessment of Health Plans (CAHPSTM) Reporting Requirements Survey
	Exhibit 6:

	 	Service Area Table
	Exhibit 7:

	 	Network Accessibility Guidelines
	Exhibit 8:

	 	Experience Data Reports
	Exhibit 9:

	 	HEDIS® Measures
	Exhibit 10:

	 	Paid Claims Data Reporting
	Exhibit 11:

	 	Grievances, Appeals and Denials Data Reporting Instructions
	Exhibit 12:

	 	Report Due Dates

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	1.	 	DEFINITIONS
	 
	 	 	For purposes of this Agreement, including all exhibits and amendments, the following terms
shall have the meanings indicated:

	 	1.1.	 	Administrator
	 
	 	 	 	“Administrator” means the Administrator of Health Care Authority (HCA). The
Administrator may designate a representative to act on his behalf. Any
designation may include the representative’s authority to hear and determine any
matter.
	 
	 	1.2.	 	Anniversary Date
	 
	 	 	 	“Anniversary Date” means the first day of January.
	 
	 	1.3.	 	Basic Health Plus
	 
	 	 	 	“Basic Health Plus” means the federal aid medical care program jointly
administered by HCA and Washington State Department of Social and Health
Services (DSHS) for children under age 19 who qualify for Medical Assistance as
defined under Title XIX of the federal social security act.
	 
	 	1.4.	 	Certificate of Coverage (COC) or Member Handbook
	 
	 	 	 	“Certificate of Coverage” or “COC” means the Member Handbook, Exhibit 2 of this
Agreement, published by HCA, which describes requirements for eligibility and
enrollment, Covered Services, and other terms and conditions that apply to
Enrollee participation.
	 
	 	1.5.	 	CONTRACTOR
	 
	 	 	 	“CONTRACTOR” means the entity contracting with HCA to provide a prepaid,
comprehensive system of medical and health care delivery, including preventive,
primary, specialty, and ancillary health services set forth in the COC (Exhibit
2).
	 
	 	1.6.	 	Coordination of Benefits (COB)
	 
	 	 	 	“Coordination of Benefits” or “COB” means the rules for administering HCA health
contracts, whose hospital, medical, or surgical benefits may be reduced because
of other existing coverages.
	 
	 	1.7.	 	Covered Services
	 
	 	 	 	“Covered Services” means services set forth in the COC (Exhibit 2).

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	 	1.8.	 	Dependent
	 
	 	 	 	“Dependent” means family members defined as eligible for Basic Health Covered
Services in the COC (Exhibit 2).
	 
	 	1.9.	 	Enrollee
	 
	 	 	 	“Enrollee” means an individual eligible for Covered Services according to the
eligibility and enrollment criteria set forth in the COC (Exhibit 2).
	 
	 	1.10.	 	HIPAA
	 
	 	 	 	“HIPAA” means the Health Insurance Portability and Accountability Act of 1996 (as
codified at 42 USC 1320(d) et seq.
	 
	 	1.11.	 	Material Provider
	 
	 	 	 	“Material Provider” means a Participating Provider whose loss would degrade access to
care in the Service Area. In evaluating whether a degradation of access has occurred,
HCA will consider the effect on appointment wait times, accessibility of services,
continuity of care, and the accessibility of Providers in relation to the Quality
Improvement Standards set forth in Exhibit 4 and the Network Accessibility Guidelines
set forth in Exhibit 7.
	 
	 	1.12.	 	Maternity Benefits Program
	 
	 	 	 	“Maternity Benefits Program” means the federal aid medical care program (also known as
BH S-Medical Program) jointly administered by the HCA and Department of Social and
Health Services for pregnant women who qualify for
Medical Assistance as defined under Title XIX of the federal social security act.
	 
	 	1.13.	 	Medical Assistance
	 
	 	 	 	“Medical Assistance” means the federal aid medical care program provided to
categorically needy persons as defined under Title XIX of the federal social security
act.
	 
	 	1.14.	 	Medicare
	 
	 	 	 	“Medicare” means the programs of medical care coverage set forth in Title XVIII of
the social security act as amended by Public Law 89-97 or as hereafter amended.
	 
	 	1.15.	 	Participating Provider
	 
	 	 	 	“Participating Provider” means a person, practitioner (as defined in the Quality
Improvement Standards, Exhibit 4), or entity having a written agreement with

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	 	 	 	CONTRACTOR or employed by the CONTRACTOR to provide health care services to
Enrollees during the term of this Agreement.

	 	1.16.	 	Personal Information
	 
	 	 	 	“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 that may be exempt from disclosure to the public
or other unauthorized persons under chapter 42.17 RCW or other applicable state and
federal statutes.
	 
	 	1.17.	 	Primary Care Physician (PCP)
	 
	 	 	 	“Primary Care Physician” or “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 may 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 CONTRACTOR.
	 
	 	1.18.	 	Privacy Rule
	 
	 	 	 	“Privacy Rule” shall mean the Standards for Privacy of Individually Identifiable Health
Information at 45 CFR Parts 160 and 164, Subparts A and E.
	 
	 	1.19.	 	Provider
	 
	 	 	 	“Provider” means an individual medical professional, hospital, skilled nursing
facility, other facility or organization, pharmacy, program, equipment and supply
vendor, or other entity that provides care or bills for health care
services or products.
	 
	 	1.20.	 	Referral Provider
	 
	 	 	 	“Referral Provider” means a provider, who is not the Enrollee’s PCP, to whom an
Enrollee is referred for Covered Services.
	 
	 	1.21.	 	Service Area
	 
	 	 	 	“Service Area” means the geographic area covered by this Agreement set forth at
Exhibit 6.

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	 	1.22.	 	Subcontract
	 
	 	 	 	“Subcontract” means a written agreement between CONTRACTOR and a Subcontractor, or
between a Subcontractor and another Subcontractor, to perform all or a portion of
the duties and obligations CONTRACTOR is obligated to perform under the terms of
this Agreement.
	 
	 	1.23.	 	Subscriber
	 
	 	 	 	“Subscriber” means that person or those persons defined in the COC (Exhibit 2) as the
person on a BH account who is responsible for payment of premiums and copayments and to
whom BH sends all notices and communications.
	 
	 	1.24.	 	Consumer Assessment of Health Plans Survey (CAHPS)
	 
	 	 	 	“Consumer Assessment of Health Plans Survey (CAHPS) means a commercial and Medicaid
standardized survey instrument used to measure client experience of health care.
	 
	 	1.25.	 	External Quality Review (EQR)
	 
	 	 	 	“External Quality Review (EQR) means the analysis and evaluation by an EQRO, of
aggregated information on quality, timeliness, and access to health care services that
a managed care organization or their contractors furnish to Medicaid recipients.
	 
	 	1.26.	 	External Quality Review Organization (EQRO)
	 
	 	 	 	“External Quality Review Organization (EQR0)” 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.
	 
	 	1.27.	 	Partial HEDIS® Compliance Audit TM Standards, Policies, and Procedures
	 
	 	 	 	“Partial HEDIS® Compliance Audit TM Standards, Policies and Procedures”
means the methods used to validate the accuracy and reliability of HEDIS® data by
conducting a thorough assessment of MCO information systems, coupled with an assessment
of compliance with production of HEDIS® performance measures. The compliance audit
includes an audit of the survey
sample for the CAHPS survey.
	 
	 	1.28.	 	Health Employer Data and Information Set (HEDIS®)
	 
	 	 	 	“Health Employer Data and Information Set (HEDIS®) is a set of performance measures
used in the managed care industry. HEDIS® is developed and

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	 	 	 	maintained by the National Committee for Quality Assurance, a not-for-profit
organization committed to assessing, reporting on and improving the quality of
care provided by organized delivery systems.

	 	1.29.	 	Managed Care Organization (MCO)
	 
	 	 	 	“Managed Care Organization” means a health carrier that contracts with the state
of Washington to provide managed health care services.

	2.	 	ELIGIBILITY AND ENROLLMENT

	 	2.1.	 	Eligibility
	 
	 	 	 	Eligibility of Subscribers and their Dependents and the terms of their coverage
shall be as set forth in the COC (Exhibit 2), subject to amendment in accordance
with current and future provisions of chapter 70.47 RCW and Title 182 WAC.
	 
	 	2.2.	 	Enrollment
	 
	 	 	 	Each applicant for enrollment must file an application form and must fulfill all
conditions of enrollment described in the COC (Exhibit 2). Coverage begins for
Enrollees as described in the COC (Exhibit 2).
	 
	 	 	 	At the direction of HCA, CONTRACTOR shall enroll any person for whom HCA pays
monthly fees on a retroactive basis for Covered Services, even though the person
may not have complied with the prescribed time limits for obtaining coverage.
When a person has been retroactively enrolled, services covered during that
retroactive period may be limited to those provided by Participating Providers,
or emergency care services. In addition, with regard to services that require
preauthorization, retroactive coverage may be limited to services that would
have been preauthorized had the Enrollee been actively enrolled at the time
services were provided.
	 
	 	2.3.	 	Limited Enrollment
	 
	 	 	 	Upon at least 90 days’ prior written notice, and with prior agreement in writing
by HCA, CONTRACTOR may limit enrollment or set priorities for acceptance of new
applications for enrollment. Said limitations shall be based on a determination
by CONTRACTOR that its capacity, in relation to its total enrollment, is not
adequate to provide services to additional persons. The consent of HCA will not
be unreasonably withheld.
	 
	 	2.4.	 	Identification Cards and CONTRACTOR Information
	 
	 	 	 	HCA shall:

	 	2.4.1.	 	Publish and distribute the COC to all persons enrolled in BH as of
January 31 of each calendar year.

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	 	2.4.2.	 	Issue a notice to all new Enrollees and Enrollees requesting a change of BH
CONTRACTORS, providing the following information: (1) the name(s) or other
identification of the Enrollee(s) eligible for coverage; (2) the effective date of
coverage for each Enrollee; and (3) the BH
CONTRACTOR selected by the Enrollee(s). This notice will serve as temporary
membership identification pending issuance of identification cards by
CONTRACTOR. An Enrollee’s out-of-pocket maximum liability begins on the
effective date of coverage with CONTRACTOR.

	 	 	 	CONTRACTOR shall:

	 	2.4.3.	 	Respond promptly and courteously to inquiries from Enrollees and candidates
for enrollment in BH coverage. CONTRACTOR shall provide sufficient, accurate oral
and written information to assist Enrollee to make informed decisions about
enrollment. CONTRACTOR shall provide Enrollees with a summary of benefits, including an
Enrollee’s rights and obligations related to the administration of
deductibles, coinsurance, and out-of-pocket maximums. CONTRACTOR shall ensure
Enrollees have written information about how to obtain care in CONTRACTOR’S
health care system and network and the role of the PCP in providing and
authorizing care. Upon request from Enrollee, CONTRACTOR shall provide
adequate and timely information to Enrollees or potential Enrollees so that
they are informed as to how they can access care and choose an appropriate PCP
for coverage prior to their effective date of enrollment with the CONTRACTOR.
	 
	 	2.4.4.	 	Submit any materials intended primarily for use by BH Enrollees or candidates for
enrollment in BH coverage for approval by HCA prior to distribution. In addition,
CONTRACTOR must submit to BH a courtesy copy of all other materials sent to BH Enrollees
or candidates for enrollment in BH coverage.
	 
	 	2.4.5.	 	Distribute the COC to Enrollees enrolled for coverage effective on or after
February 1 within 15 business days of receipt of confirmation of enrollment from HCA.
	 
	 	2.4.6.	 	Distribute to Enrollees, upon request, a copy of CONTRACTOR’S drug formulary or
list used for Enrollees covered under the terms of this Agreement. CONTRACTOR shall
ensure Enrollees know how to request a copy of the formulary and that they have timely
access to the formulary upon request.
	 
	 	2.4.7.	 	Distribute to Enrollees in writing, at the time of enrollment, or at any time
upon request, information about the CONTRACTOR’S complaint and appeal
procedures.

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	 	2.4.8.	 	Assist HCA in the distribution of any disclosure forms, benefits descriptions or
other material that may be required by HCA, or by any provision of Washington or
federal law or by regulation.
	 
	 	2.4.9.	 	Send identification cards to Enrollees. This information must be sent to the
Enrollees within 15 business days of receipt of enrollment verification from HCA.
	 
	 	2.4.10.	 	Ensure that Participating Providers accept the HCA-issued notice detailed at
Section 2.4.2. of this Agreement as verification of enrollment until an official
identification card is issued to the Enrollee by CONTRACTOR.
	 
	 	2.4.11.	 	Provide all Participating Providers with timely information so that adequate
care for Enrollees can be reasonably assured. Timely information includes, but is not
limited to, enrollment information and, where appropriate, preauthorizations for Covered
Services or referrals to non-Participating Providers. Enrollment data must be available
to Participating Providers within 5 business days after receipt from HCA.
	 
	 	2.4.12.	 	Issue Explanation of Benefits (EOB) reflecting patient’s responsibility for
claims and accumulated amount toward deductibles and out-of-pocket maximums.
CONTRACTOR’S appropriate staff must have electronic access to an Enrollee’s benefit
history in order to provide timely response to Enrollee queries related to benefit
usage.

	 	2.5.	 	Medical Assistance Recipients
	 
	 	 	 	Pursuant to RCW 70.47.110, DSHS will determine if a BH Plus or Maternity Benefits
Program applicant is eligible for Medical Assistance under chapter 74.09 RCW. DSHS will
make payments to HCA on behalf of any BH Plus or Maternity Benefits Program Enrollee.
Any Enrollee on whose behalf HCA makes such payments to CONTRACTOR, will be entitled to
the BH Plus or the Maternity Benefits Program services set forth in the BH Plus and
Maternity Benefits Program Agreement signed by CONTRACTOR and HCA, effective January 1,
2008. CONTRACTOR agrees to cooperate with HCA in effecting the smooth transfer of
Enrollees from BH to BH Plus or the Maternity Benefits Program. CONTRACTOR is required
to cooperate with DSHS to ensure compliance with the BH Plus and Maternity Benefits
Program contract terms.

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	 	2.6.	 	Service Area

	 	2.6.1.	 	CONTRACTOR’S Service Area includes those counties and partial counties
set forth at Exhibit 6. Enrollees are eligible to enroll with
CONTRACTOR if they reside in CONTRACTOR’S Service Area. If the U.S.
Postal Service alters the ZIP codes within CONTRACTOR’S Service Area,
HCA shall redetermine the boundaries of the Service Area.
	 
	 	2.6.2.	 	HCA may require CONTRACTOR to cover full ZIP codes that cross county
borders served by CONTRACTOR in order to assure continuity of care or ready
access to health care services. Enrollees may be required by CONTRACTOR to
access care in the county where CONTRACTOR has been awarded a contract even
though the Enrollee’s residence may be in the portion of the ZIP code which
crosses the county line.
	 
	 	2.6.3.	 	CONTRACTOR shall not change its Service Area without prior approval of
the HCA. CONTRACTORS must have a sufficient number of Participating Providers in
a Service Area before requesting a Service Area expansion. HCA shall apply the
Network Accessibility
Guidelines (Exhibit 7) when evaluating the adequacy of the network.
	 
	 	2.6.4.	 	HCA reserves the right to request full reimbursement for any costs
incurred by HCA as a result of a CONTRACTOR’S withdrawal from a Service Area.
HCA may reduce CONTRACTOR’S final December premium or final mid-year premium,
whichever occurs earliest, to recover those costs. This reimbursable expense
will be in addition to any other provision of this Agreement.
	 
	 	2.6.4.1.	 	The Network Accessibility Guidelines for rural access (Exhibit 7) for
Asotin County are waived based on the demonstrated lack of provider access. If
provider access should improve, either through the
CONTRACTOR’S reporting methods, or through the HCA’s reporting
methods, the Network Accessibility Guidelines for rural access will be
required within 30 days from date once agreed to and confirmed by both
parties.

	3.	 	TERMINATION AND RELATED PROVISIONS

	 	3.1.	 	Reservation of
Rights and Remedies
	 
	 	 	 	A material default or breach in this Agreement will cause irreparable injury to
HCA. In the event of any claim for default or breach of this Agreement, no
provision in this Agreement shall be construed, expressly or by implication, as
a waiver by the state of Washington to any existing or future right or remedy
available by law. Failure of the state of Washington to insist upon the strict
performance of any term or condition of this Agreement or to exercise or delay 

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	 	 	 	the exercise of any right or remedy provided in this Agreement or by law, or the
acceptance of (or payment for) materials, equipment or services, shall not
release CONTRACTOR from any responsibilities or obligations imposed by this
Agreement or by law, and shall not be deemed a waiver of any right of the state
of Washington to insist upon the strict performance of this Agreement. In
addition to any other remedies that may be available for default or breach of
this Agreement, in equity or otherwise, HCA may seek injunctive relief against
any threatened or actual breach of this Agreement without the necessity of
proving actual damages. HCA reserves the right to recover any or all
administrative
costs incurred in the performance of this Agreement during or as a result of any
threatened or actual breach.

	 	3.2.	 	Termination By HCA
	 
	 	 	 	HCA may terminate this Agreement upon occurrence of any of the following:

	 	3.2.1.	 	Any threatened or actual material breach by CONTRACTOR. Upon
HCA’s knowledge of a material breach by CONTRACTOR, HCA shall provide an
opportunity for CONTRACTOR to cure the breach or end the violation. HCA
reserves the right to terminate this Agreement if CONTRACTOR does not cure the
breach or end the violation within the time specified by HCA, or immediately
terminate this Agreement if CONTRACTOR has breached a material term of this
Agreement and cure is not possible.
	 
	 	3.2.2.	 	HCA has reasonably determined that management practices adopted by CONTRACTOR or
the current financial condition of CONTRACTOR present a substantial material risk of
interrupting or interfering with the delivery of Covered Services or the quality of
such services.
	 
	 	3.2.3.	 	Receipt of notice of change in ownership or other material change in
organization pursuant to Section 12.24. of this Agreement, “Notification of
Organizational Changes,” if HCA reasonably determines that such change presents a risk
of interrupting or interfering with the delivery or quality of Covered Services.
	 
	 	3.2.4.	 	HCA has informed CONTRACTOR in writing of its continuing failure to arrange for
the provision of Covered Services or of other continuing unsatisfactory performance by
CONTRACTOR and CONTRACTOR has not taken reasonable, effective, and prompt steps to
correct the alleged failures or unsatisfactory performance or to demonstrate that the
concerns of HCA are not justified.
	 
	 	3.2.5.	 	Any anniversary date of this Agreement.
	 
	 	3.2.6.	 	Any violation of the State Ethics Law, chapter 42.52 RCW.

	 	3.3.	 	Termination By CONTRACTOR

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	 	 	 	If HCA fails to pay the monthly fees in the amounts and manner specified at Section 4
(Monthly Fees) of this Agreement, CONTRACTOR may terminate this Agreement by giving
advance written notice received by HCA of not less than 60 days prior to termination.

	 	3.4.	 	Termination Procedure

	 	3.4.1.	 	A party seeking to terminate this Agreement pursuant to Sections 3.2. or 3.3. of
this Agreement shall give not less than 60 days’ advance written notice to the other
party of the intent to terminate. The notice shall explain the reason for termination
and shall include an explanation of any alleged breach.
Notwithstanding anything herein provided to the contrary, the breaching party shall have
the right to cure the breach during the 60 day notice period. The party seeking to
terminate this Agreement shall review any efforts to cure the alleged breach and
determine whether such efforts are sufficient to cure the breach. Failure of a party to
cure the breach within the 60 day time period shall allow the other party to terminate
this Agreement upon the delivery of a written notice declaring a termination.
	 
	 	3.4.2.	 	Termination shall be in addition to any other remedies that may be available
by law or under this Agreement. Termination of this
Agreement will not terminate the rights or liabilities of either party
arising out of performance for any period prior to such termination.

	 	3.5.	 	Termination for Withdrawal or Reduction of Funding
	 
	 	 	 	In the event funding from any state, federal, or other sources is withdrawn,
substantially reduced, or limited in any way after the effective date of this Agreement
and prior to the termination date, HCA may terminate this Agreement upon 60 days’ prior
written notice to CONTRACTOR or upon the effective date of withdrawn or reduced funding,
whichever occurs earlier. If this Agreement is so terminated, HCA shall be liable only
for payment in accordance with the terms of this Agreement for services rendered prior
to the effective date of termination.

	 	3.6.	 	Termination of Enrollee Coverage

	 	3.6.1.	 	Enrollee coverage may be terminated by HCA in accordance with the eligibility
provisions set forth in WAC 182-25-030 and as described in the COC (Exhibit 2).
	 
	 	3.6.2.	 	In the event that an Enrollee appeals a disenrollment decision through the HCA
appeals process, HCA may require CONTRACTOR to continue to provide services to the
Enrollee under the terms of this Agreement pending the final decision. CONTRACTOR agrees
to continue to provide services, provided HCA continues to pay the monthly fee to
CONTRACTOR for such Enrollee according to the

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	 	 	 	terms of this Agreement. With prior
approval of HCA, CONTRACTOR may discontinue providing services to an Enrollee during the
appeals process if the Enrollee has demonstrated a danger or threat to the safety or
property of the CONTRACTOR, its staff, Providers, patients, or visitors.

	 	3.6.3.	 	CONTRACTOR may request that HCA immediately terminate an
Enrollee’s coverage for repeated failure to pay copayments, coinsurance or
other cost-sharing in full on a timely basis; abuse, intentional misconduct,
danger or threat to the safety of the CONTRACTOR, its staff, Providers,
patients, or visitors; or refusal to accept or follow procedures or treatment
determined by CONTRACTOR to be essential to the health of the Enrollee, when
CONTRACTOR has advised the Enrollee and demonstrated to the satisfaction of BH
that no professionally acceptable alternative form of treatment is available
from CONTRACTOR.
	 
	 	 	 	Prior to requesting disenrollment for abuse, intentional misconduct, or posing
an imminent danger or threat, CONTRACTOR shall ensure CONTRACTOR’S Medical
Director has reviewed the circumstances to ensure the Enrollee has been
appropriately evaluated and offered all appropriate Covered Services.
	 
	 	 	 	Prior to requesting disenrollment under the terms of this Section, CONTRACTOR
must: (a) afford the Enrollee with notice of the action CONTRACTOR intends to
take; (b) ensure the Enrollee is afforded an opportunity to be heard; and (c)
in the case of non-payment, the Enrollee is given an opportunity to make
payments prior to the disenrollment request. Involuntary termination of an
Enrollee under this Section will be considered a “Special Circumstance” and
HCA shall approve or disapprove CONTRACTOR’S request for termination as soon
as reasonably possible but no later than 30 business days after receipt of
such request and CONTRACTOR’S supporting documentation.
	 
	 	3.6.4.	 	If an Enrollee is confined in a hospital or skilled nursing facility for which
benefits are provided when Basic Health coverage ends and the Enrollee is not
immediately covered by other health care coverage, benefits will be extended until the
earliest of the following events: (1) the Enrollee is discharged from the hospital or
from a hospital to which the Enrollee is directly transferred; (2) the Enrollee is
discharged from a skilled nursing facility when directly transferred from a hospital
when the skilled nursing facility confinement is in lieu of hospitalization; (3) the
Enrollee is discharged from the skilled nursing facility or from a skilled nursing
facility to which the Enrollee is directly transferred; (4) the Enrollee is covered by
another health plan which will provide benefits for the services; or (5) benefits are
exhausted.

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	4.	 	MONTHLY FEES

	 	4.1.	 	Remittance
	 
	 	 	 	Subject to the provisions of Section 12.18. of this Agreement (Intermediate
Sanctions), HCA shall remit a monthly fee to CONTRACTOR on behalf of each
Enrollee in full consideration of the work to be performed by CONTRACTOR under
this Agreement. The “Monthly Fee” specified in Exhibit 1, shall be based on
HCA’s then current enrollment information. Payment shall be remitted to
CONTRACTOR on or before the 15th day of the month during which Covered Services
are to be provided to eligible Enrollees. Monthly fees for BH Plus and the
Maternity Benefits Program are set forth in the separate Agreement between HCA
and CONTRACTOR.
	 
	 	4.2.	 	Retroactive Payment or Refund
	 
	 	 	 	Retroactive payment or refund of monthly fees to reflect additions or deletions
of Enrollees added or omitted based on HCA’s enrollment records will be made by
HCA.
	 
	 	4.3.	 	Responsibility for Enrollment Data

	 	4.3.1.	 	HCA will furnish current enrollment information to CONTRACTOR upon which
CONTRACTOR may rely without further verification. HCA may provide enrollment
verification by telephone, which will be followed by written or electronic
confirmation.
	 
	 	4.3.2.	 	CONTRACTOR shall perform a full file enrollment match not less frequently
than twice a year, shall report resulting mismatches to HCA within 30 days of
the receipt of HCA enrollment file, and shall resolve reconciliation
discrepancies within 90 days of receipt of the HCA enrollment file. It is the
responsibility of CONTRACTOR to contact the
HCA Information Services Quality Assurance Manager to coordinate
transmittal of the full file match and mismatch report.

	 	4.4.	 	Renegotiation of Rates
	 
	 	 	 	The Monthly Fees set forth in Exhibit 1 shall be subject to negotiation during
the Agreement period if HCA determines that changes in federal or state law or
regulations materially affect the risk to CONTRACTOR or its costs of doing
business.

	5.	 	SERVICES, BENEFITS, EXCLUSIONS, AND LIMITATIONS  

	 	5.1.	 	Plan Description
	 
	 	 	 	The services, benefits, exclusions, and limitations applicable to Enrollees are
set forth in the COC (Exhibit 2).

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	 	5.2.	 	Self-Referral for Women’s Health Care

	 	5.2.1.	 	Pursuant to WAC 284-43-250, access to women’s health care
Providers may not be restricted based solely on a woman’s choice of PCP. If
CONTRACTOR restricts access for other services to a subnetwork of fewer than
the entire panel of Participating Providers available to all Enrollees,
access to women’s health care services may not be restricted to the same
subnetwork, but Enrollees may be required to use a Participating Provider.
	 
	 	5.2.2.	 	If an Enrollee is required to use facilities (such as hospitals) affiliated
with her PCP or the PCP’s subnetwork for services generally, this limitation may not
be imposed for women’s health care services.
Enrollees may be required to use a Participating Provider facility
within CONTRACTOR’S network.

	 	5.3.	 	Preventive Care

	 	5.3.1.	 	Primary and secondary preventive care services shall be provided in accordance
with the edition of the “Guide to Clinical Preventive Services” of the U.S. Preventive
Services Task Force as of the effective date of this contract and as follows:

	 	5.3.1.1.	 	Those services rated “A” shall be covered and
CONTRACTOR shall take active steps to assure their
provision.
	 
	 	5.3.1.2.	 	Those services rated “B” shall be covered.
	 
	 	5.3.1.3.	 	Those services rated “D” shall not be covered.
	 
	 	5.3.1.4.	 	Those services rated “I” shall not be covered, and
CONTRACTOR shall take steps to determine that if those services
are provided, there is informed consent.
	 
	 	5.3.1.5.	 	Those services rated “C” and those services not rated shall be
provided at the discretion of CONTRACTOR to determine the appropriate level of
care for the Enrollee consistent with the terms of the COC (Exhibit 2) and this
Agreement.

	 	5.3.2.	 	CONTRACTOR may substitute generally recognized accepted guidelines, such as
those developed by the American Academy of Pediatrics or the Canadian Task Force on
the Periodic Health Examination, as a basis to define the content and periodicity
of coverage of preventive services, as long as such substitution is approved in
advance, in writing, by HCA.

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	 	5.3.3.	 	CONTRACTOR shall provide the Enrollee with a description of preventive
care benefits to be used by CONTRACTOR in the materials required by Section 2.4.
(Identification Cards and CONTRACTOR Information).

	6.	 	COORDINATION OF BENEFITS

	 	6.1.	 	Benefits Subject To This Provision
	 
	 	 	 	Benefits under this Agreement shall be coordinated as prescribed in this
Section.
	 
	 	6.2.	 	“Plan” Defined

	 	6.2.1.	 	“Plan,” as used in this Section 6. only, means any of the following
sources of benefits or services:

	 	6.2.1.1.	 	Group or blanket disability insurance policies and health
care service contractor and health maintenance organization group
agreements, issued by insurers, health care service contractors, and
health maintenance organizations, respectively;
	 
	 	6.2.1.2.	 	Labor-management trustee Plans, labor organization
Plans, employer organization Plans or employee benefit
organization Plans;
	 
	 	6.2.1.3.	 	Governmental programs; and
	 
	 	6.2.1.4.	 	Coverage required or provided by any statute.

	 	6.2.2.	 	“Plan” shall be construed separately with respect to each health contract
or other arrangement for benefits or services, and separately with respect to
the respective portions of any such health contract or other arrangement which
do and which do not reserve the right to take the benefits or services of other
health contracts or other arrangements into consideration in determining its
benefits.

	 	6.3.	 	“Allowable Expense” Defined

	 	6.3.1.	 	“Allowable Expense,” as used in this Section 6., means the customary and
reasonable charge for any necessary health care service or supply when the
service or supply is covered at least in part under any of the Plans involved.
When a Plan provides benefits in the form of services or supplies rather than
cash payments, the reasonable cash value of each service rendered or supply
provided shall be considered an allowable expense. The difference between the
cost of a private hospital room and the cost of a semi-private hospital room is
not considered an allowable expense unless the Enrollee’s stay in a 

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	 	 	 	private
hospital room is considered medically necessary under at least one of the Plans
involved.

	 	6.3.2.	 	In the case where coverage is provided through internal maximums in the contract,
CONTRACTOR shall coordinate benefits in such a manner as to allow coverage for the
internal maximums provided for in both the primary contract and this Agreement. If
internal maximums are provided for by a specified maximum dollar amount, then CONTRACTOR
must coordinate benefits as secondary Plan until benefits under the primary contract are
exhausted, then pay BH benefits (up to BH internal maximum dollar amount) until BH
benefits are exhausted. If internal maximums are provided for by a specified maximum
number of visits, then CONTRACTOR must coordinate benefits as secondary Plan until
benefits under the primary contract are exhausted, then pay BH benefits (up to BH
maximum) until BH benefits are exhausted.

	 	6.4.	 	“Claim Determination Period” Defined
	 
	 	 	 	“Claim Determination Period,” as used in this Section 6., means a calendar year.
	 
	 	6.5.	 	Facility of Payment
	 
	 	 	 	Whenever payments which should have been made under this Agreement in accordance with
this provision have been made under any other Plan, CONTRACTOR shall have the right,
exercisable alone and in its sole discretion, to pay over to any Plan making such other
payments any amounts it shall determine to be warranted in order to satisfy the intent
of this provision. Amounts so paid shall be considered benefits paid under this Plan
and, to the extent of such payments, CONTRACTOR shall be fully discharged from
liability under this Plan. This provision shall not apply to the extent it conflicts
with the requirements of RCW 48.44.026.
	 
	 	6.6.	 	Right of Recovery
	 
	 	 	 	Whenever payments have been made by CONTRACTOR with respect to allowable expenses in
excess of the maximum amount of payment necessary to satisfy the intent of this
Agreement, CONTRACTOR shall have the right to recover such payments, to the extent of
such excess, from one or more of the following, as CONTRACTOR shall determine: (1) any
persons to or for or with respect to whom such payments were made, (2) any other
insurers, (3) any service Plans, or (4) any other organizations or other Plans.
	 
	 	6.7.	 	Effect on Benefits

	 	6.7.1.	 	This Section shall apply in determining the benefits for a person covered under
this Agreement for a particular claim determination period if, for the allowable
expenses incurred as to such person during such period, the sum of: (1) the benefits
that would be payable under 

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	 	 	 	this Agreement in the absence of this provision, and (2)
the benefits that would be payable under all other health Plans in the absence therein
of provisions of similar purpose to this provision would exceed such allowable expenses.
	 
	 	6.7.2.	 	As to any claim determination period with respect to which this
Section is applicable, the benefits that would be payable under this
Agreement in the absence of this provision for the allowable expenses
incurred as to such person during the applicable claim determination
period shall be reduced to the extent necessary so that the sum of
reduced benefits and all the benefits payable for allowable expenses
under all other health Plans, except as provided elsewhere in this
Section, shall not exceed the total of allowable expenses. Benefits
payable under another health Plan include the benefits that would have
been payable had claim been duly made therefore.
	 
	 	6.7.3.	 	Except where in conflict with federal or state law, or regulations
promulgated thereunder, the benefits of any other health Plan which covers the
Enrollee shall be determined before the benefits of BH.
	 
	 	6.7.4.	 	When this provision operates to reduce the total amount of benefits
otherwise payable as to a person covered under this Plan during any claim
determination period, each benefit that would be payable in the absence of this
provision shall be reduced proportionately, and such reduced amount shall be
charged against any applicable benefit limit of this Plan.

	7.	 	DATA REPORTING

	 	 	CONTRACTOR shall submit the following data to HCA:

	 	7.1.	 	Integrated Provider Network Database (IPND)
	 
	 	 	 	Contractor shall submit a report of Providers currently under contract. This
report shall be submitted to DSHS through the designated data management
contractor in accord with the Provider Network Reporting Requirements published
by DSHS at http://maa.dshs.wa.gov/healthyoptions/IPND
	 
	 	7.2.	 	Health Plan Employer Data and Information Set (HEDIS®)
	 
	 	 	 	CONTRACTOR is required to submit audited HEDIS® information on the BH
non-Medicaid population. CONTRACTOR and HCA agree that the HEDIS® audit will be
performed by a third party vendor under contract with the Department of Social
and Health Services. CONTRACTOR agrees that HCA shall reduce CONTRACTOR’S
monthly premium in accordance with the terms set forth in this
agreement, to pay the cost of such audit, as described in Exhibit 9.

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	 	 	 	All BH CONTRACTORS must comply with the HEDIS® requirements set forth in the BH Plus
and Maternity Benefits Program contract.

	 	7.2.1	 	CONTRACTOR shall provide raw HEDIS® data for the following three measures:
Childhood Immunizations, Use of Appropriate Medication for People with Asthma, and
Children and Adolescents’ Access to Primary Care Practitioners. This data shall be
submitted to the HCA electronically no later than June 30th of each year
according to the specifications communicated by the HCA to the CONTRACTOR no later than
May of each year.

	 	7.3.	 	Consumer Assessment of Health Plans (CAHPSTM) Survey
	 
	 	 	 	CONTRACTOR shall submit a set of data from its commercial CAHPSTM 4.0 survey by June 30
each year. (See Exhibit 5 for instructions.)

	 	7.4.	 	Experience Data Reports

	 	7.4.1.	 	CONTRACTOR shall provide health experience data (utilization and costs) for
services rendered during the term of this Agreement.
CONTRACTOR shall provide this data for the current year, as well as all
outstanding data from any previous Agreement year, whether or not this
Agreement is renewed for any subsequent term. Experience data shall be
submitted on a yearly basis consistent with the instructions in Exhibit 8.
	 
	 	7.4.2.	 	Should CONTRACTOR merge, be acquired by, or otherwise become affiliated with
another health plan, whether or not that health plan is under contract with HCA at the
time of the merger, acquisition, or other affiliation, CONTRACTOR shall provide the
required health experience data for the entire calendar year as well as data from any
previous calendar year for which data is outstanding as of the date of the merger,
acquisition, or other affiliation. HCA reserves the right to modify or clarify the data
request at that time.
	 
	 	7.4.3.	 	CONTRACTOR shall reimburse HCA for the reasonable cost of obtaining CONTRACTOR’S
experience data in the event CONTRACTOR does not provide data in accordance with the
terms of this Agreement.

	 	•	 	CONTRACTOR shall also provide the same health
experience data (utilization and costs), consistent with
instructions as described in Exhibit 8, for enrolled Health
Coverage Tax Credit enrollees.

	 	 	 	The data set for Health Coverage Tax Credit enrollees is to be collected
and submitted separate and distinct from Basic Health enrollment data.

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	 	7.5	 	Data Reporting — Paid Claims Data

	 	7.5.1.	 	CONTRACTOR shall submit Basic Health and Health Coverage Tax
Credit paid claims electronically as per the following requirements:
	 
	 	 	 	Encounter and Eligibility Data Submission Obligations: The CONTRACTOR will
provide the Health Care Authority with detailed encounter and eligibility for
the Basic Health and Health Care Tax Credit populations on a monthly basis
with the data elements listed in Exhibit 10. The data will include:

	 	i)	 	A one time historical load of data that includes encounters and eligibility
from January 1, 2006 to December 31, 2007, paid through December 31, 2007.
	 
	 	ii)	 	The most granular service lines for each claim or encounter should be
provided. Data should not be rolled up into aggregate stays or visits.
	 
	 	iii)	 	Beginning with January 1, 2008 data, data will be submitted monthly, not
more than 30 days after the end of the next month (i.e. for enrollment in and
claims paid in January 1, 2008 to January 31, 2008, data will be received by
February 28, 2008).
	 
	 	iv)	 	Data will be submitted in a file format agreed upon by the HCA and the
CONTRACTOR, including but not limited to DVD, USB Drive, FTP site, or other
electronic media that is mutually agreeable.
	 
	 	v)	 	Data, to be transferred, will be encrypted in a mutually agreed upon
method.
	 
	 	vi)	 	The CONTRACTOR will provide all identifiers necessary to link providers and
members to HCA identifiers.
	 
	 	vii)	 	The data files will be comma separated or tab delimited.
	 
	 	viii)	 	The CONTRACTOR will supply control totals with the files that include
the total number of records, the total number of enrollees for each month, and
the total amount billed for each month. These totals should balance to
CONTRACTOR financial reports.

	 	7.6.	 	Denials, Appeals, Grievances, and Independent Reviews
	 
	 	 	 	CONTRACTOR shall maintain a record of all grievances, denials, appeals, and
decisions from independent review organizations (IRO) of any adverse decisions by
the health plan. CONTRACTOR shall provide a report of

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	 	 	 	complete denials, appeals, grievances, and IRO decisions to HCA four times a
year. The fourth quarter of 2007 shall be due to the HCA on February 1, 2008.
The first quarter of 2008 shall be due to the HCA on May 1, 2008. The second
quarter of 2008 shall be due to the HCA on September 1, 2008; and third quarter
of 2008 shall be reported to the HCA on November 1, 2008. CONTRACTOR is responsible for maintenance of records for and reporting of any
grievances, denials, appeals, and IRO decisions handled by delegated entities.
Delegated denials, appeals, grievances, and IRO decisions are to be integrated
into CONTRACTOR’S report. The report shall contain all of the data elements
formatted as specified in the Grievance System Reporting Requirements, Exhibit
11.

	8.	 	QUALITY OF CARE

	 	8.1.	 	Quality Improvement Program

	 	8.1.1.	 	CONTRACTOR shall maintain a quality improvement program that meets or
exceeds the requirements of the HCA’s Quality Improvement Standards, a subset of
the National Committee for Quality Assurance (NCQA) Standards (Exhibit 4). If
NCQA updates the standards for a July 1, 2008 effective date, the HCA will permit any CONTRACTOR
seeking accreditation to administer the updated standards, to the
extent they do not conflict with federal or state regulations. HCA
will not require a mid-year contract amendment requiring CONTRACTOR to
comply with mid-year updated NCQA standards. If HCA determines that a
standard adopted by NCQA mid-year should be included in the future,
that new standard may be added in a subsequent contract.
	 
	 	8.1.2.	 	CONTRACTOR shall use data provided by HCA and its own data
(including external quality review findings, agency audits, contract
monitoring activities, and Enrollee complaint and satisfaction survey
findings), to identify and correct problems and to improve care and
service to Enrollees.
	 
	 	8.1.3.	 	If CONTRACTOR has had an accreditation review or visit by NCQA or another
accrediting body, CONTRACTOR shall provide the complete report from that
organization to HCA. If permitted by the accrediting body, CONTRACTOR shall
allow a Washington State representative to accompany any accreditation review
team during the site visit in an official observer status. CONTRACTOR must
provide the HCA with adequate prior notice of any scheduled accreditation review
in order that HCA might observe the review. The state representative is allowed
to share information with HCA, Department of Health (DOH), and DSHS as needed,
to reduce duplicated work for both CONTRACTOR and the State.
	 
	 	8.1.4.	 	CONTRACTOR shall encourage its participating hospitals to self-report on
the Leapfrog web site.

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	 	8.2.	 	Clinical Outcomes Assessment Program (COAP)
	 
	 	 	 	CONTRACTOR shall require Participating Providers of selected cardiac services
(CPTs: 33400 -33401, 33403, 33405-33406, 33410-33411, 33413, 33425-33427, 33430,
33460, 33464-33465, 33472, 33474, 33475, 33510-33536, 92980-92984, and 92974) to
provide demographic and clinical registry information to the ongoing Clinical
Outcomes Assessment Program (COAP), a Certified Quality Improvement Program
protected at RCW 43.60.510.
	 
	 	 	 	Additionally, when the Foundation establishes its abdominal surgical procedures
(SCOAP) program, carriers are encouraged to participate. The selected abdominal
surgical CPT codes are: Appendectomy 44950, 44960, 44970; Bariatric Surgery
43644, 43645, 43842-43848, Colon or rectal resection 44140-44147, 44150-44156,
44160, 44204-44208, 44210-44212, 44116, 45123, 45110, 45111, 45112, 45113,
45114, 45116, 45119-45121, 45123, 45126, 45130, 45135, 45136.
	 
	 	8.3.	 	Patient Safety
	 
	 	 	 	CONTRACTOR shall require participating hospitals, ambulatory care surgery
centers, and office-based surgery sites to endorse and adopt procedures for
verifying the correct patient, the correct procedure, and the correct surgical
site that meets or exceeds those set forth in the Universal Protocol
TM developed by JCAHO.
	 
	 	8.4	 	Claims Payment
	 
	 	 	 	CONTRACTOR shall comply with the claims payment provisions set forth in WAC
284-43-321, and WAC 284-43-200(7), as amended.

	9.	 	DATA RECORDS

	 	9.1.	 	Confidential Personal Information

	 	9.1.1.	 	CONTRACTOR shall undertake all reasonable efforts to protect and preserve
the confidentiality of HCA’s data or information which is defined as
confidential under state or federal law or regulation or data that HCA has
identified as confidential.
	 
	 	9.1.2.	 	HCA and CONTRACTOR shall comply with all applicable federal and state
laws and regulations concerning collection, use, and disclosure of Personal
Information set forth in Governor Locke’s Executive Order 00-03 and Protected
Health Information (PHI), defined at 45 CFR Sec.
160.103, as may be amended from time to time. Personal Information or
PHI collected, used, or acquired in connection with this Agreement
shall be used solely for the purposes of this Agreement.

CONTRACTOR shall not release, divulge, publish, transfer, sell, or
otherwise make known to unauthorized third parties Personal
Information or PHI without the advance express written consent of

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	 	 	 	the individual who is the subject matter of the Personal Information or PHI or
as otherwise required in this Agreement or as permitted or required by state
or federal law or regulation. CONTRACTOR shall implement appropriate physical,
electronic, and managerial safeguards to prevent unauthorized access to
Personal Information and PHI. CONTRACTOR shall require the same standards or
confidentiality of all its Subcontractors.
	 
	 	9.1.3.	 	The HCA reserves the right to monitor, audit, or investigate the use of
Personal Information and PHI of Enrollees collected, used, or acquired by
CONTRACTOR during the term of this Agreement. All HCA representatives
conducting onsite audits of CONTRACTOR, including TEAMonitor, agree to keep
confidential any patient-identifiable information which may be reviewed
during the course of any site visit or audit.
	 
	 	9.1.4.	 	Any material breach of this confidentiality provision may result in termination
of this Agreement. CONTRACTOR shall indemnify and hold HCA harmless from any damages
related to CONTRACTOR’S or Subcontractor’s unauthorized use or release of Personal
Information or PHI of Enrollees. In the event of termination of this Agreement,
HCA and CONTRACTOR agree that it may not be feasible for CONTRACTOR to return
or destroy all Personal Information or PHI concerning HCA Enrollees. Thus, if
CONTRACTOR is not able to return or destroy all Personal Information or PHI of
Enrollees, CONTRACTOR agrees to continue to apply privacy protections contained
in this Section, or as are then in effect, to all Personal Information or PHI
retained by CONTRACTOR after termination and for as long as such Personal
Information or PHI is in its possession. If CONTRACTOR is able to return or
destroy Personal Information or PHI of Enrollees or if CONTRACTOR ceases to do
business with HCA, HCA will provide advice on how to transfer information to
HCA or to destroy it.

	 	9.2.	 	Health Insurance Portability and Accountability Act of 1996 (HIPAA)
	 
	 	 	 	CONTRACTOR and its Subcontractors shall comply with the applicable provisions of
the HIPAA Privacy Rule and shall fully cooperate with HCA efforts to implement
all applicable HIPAA requirements.

	 	9.3.	 	Proprietary Data or Trade Secrets

	 	9.3.1.	 	Except as required by law, regulation, or court order, data identified by
CONTRACTOR as proprietary trade secret information shall be kept strictly
confidential, unless CONTRACTOR provides prior written consent of disclosure
to specific parties. Any release or disclosure of data shall include
CONTRACTOR’S interpretation.
	 
	 	9.3.2.	 	CONTRACTOR shall identify data which it asserts is proprietary or is trade
secret information as permitted by RCW 41.05.026. HCA will

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	 	 	 	notify CONTRACTOR upon receipt of any request under the Public Disclosure Law
(chapter 42.17 RCW) or otherwise for data or Claims Data identified by
CONTRACTOR as proprietary trade secret information and will not release any
such information until 5 business days after it has notified CONTRACTOR of the
receipt of such request.
	 
	 	9.3.3.	 	If CONTRACTOR files legal proceedings within the aforementioned 5 day period in
order to prevent disclosure of the data, HCA agrees not to disclose the information
unless it is ordered to do so by a court, CONTRACTOR dismisses its lawsuit, or
CONTRACTOR agrees that the data may be released.
	 
	 	9.3.4.	 	Nothing in this Section shall prevent HCA from filing its own lawsuit or joining
any lawsuit filed by CONTRACTOR to prevent disclosure of the data, or to obtain a
declaration as to the disclosure of the data, provided that HCA will immediately notify
CONTRACTOR of the filing of any such lawsuit.

	 	9.4.	 	Data Ownership

	 	9.4.1.	 	All original material and data, either written or readable by machine,
prepared for or with HCA solely for the purposes of this Agreement, except for Claims
Data, shall belong to and be the property of CONTRACTOR.
	 
	 	9.4.2.	 	All Claims Data is the property of HCA. For the purpose of this
Section, “Claims Data” means event level cost and utilization data, including,
but not limited to, hospital, facility, professional, dental, and prescription
drug services. “Event Level Data” includes, but is not limited to, the cost of
Covered Services provided to the Enrollee in accordance with the terms of this
Agreement, including, but not limited to, vendor discounts, rebates, capitation
payments, or other similar payments made or revenues received for the purpose
of administering the health care services under this Agreement. HCA will
withhold from public inspection all such data as “cost and utilization data” as
provided for at RCW 41.05.026.
	 
	 	9.4.3.	 	CONTRACTOR shall retain custody, possession, and control of all data and will
provide it to HCA upon reasonable request in a mutually acceptable form. CONTRACTOR in
its sole discretion may attach its interpretation to any data provided to HCA, and any
such interpretation shall become a permanent part of such data.

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	10.	 	PERFORMANCE EXPECTATIONS

	 	10.1.	 	General Expectations

	 	10.1.1.	 	Throughout the period of this Agreement and any subsequent renewals
thereof, CONTRACTOR shall maintain a Certificate of Registration as either a
Health Maintenance Organization or a Health Care Service Contractor from the
Insurance Commissioner.
CONTRACTOR shall be in good standing with the Insurance Commissioner
and comply with the applicable solvency provisions of Title 48 RCW, as
amended and regulations promulgated thereunder.
	 
	 	10.1.2.	 	CONTRACTOR shall provide access to consistently high-quality,
cost-effective care which is designed to improve the health of Enrollees,
through efficient, stable networks or delivery systems. Throughout the period of
this Agreement, HCA will review and assist CONTRACTOR, where appropriate, to
develop or refine its risk management plan to address the performance
expectations. CONTRACTOR’S ability to address the performance expectations of
this Agreement will be considered when evaluating any renewal offer of this
Agreement.

	 	10.2.	 	Demonstrated Superior Quality in Health Care Delivery
	 
	 	 	 	CONTRACTOR shall provide evidence that it has and uses the following:

	 	10.2.1.	 	Programs to reach out to Enrollees to ensure appropriate detection of
disease, illness, or injury and preventive care services are available and
effectively delivered.
	 
	 	10.2.2.	 	A plan that considers community health issues, including, but not
limited to, collaboration with other local health plans or health departments.
	 
	 	10.2.3.	 	A plan which provides for all aspects of Enrollee health, including
minimizing Enrollee disability and absenteeism. CONTRACTOR shall be able to
demonstrate how its plan incorporates disease management standards which
reinforce quality of care.
	 
	 	10.2.4.	 	A plan to support the efforts of Providers to improve quality, service,
safety, and effectiveness of care. CONTRACTOR shall be able to demonstrate how
its efforts incorporate information sharing, Provider development programs, and
regular feedback on performance.
	 
	 	10.2.5.	 	A plan to hold all components of the delivery system accountable for the
appropriateness of care delivered to Enrollees, for patient outcomes, and for
Enrollee satisfaction.

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	 	10.2.6.	 	Programs that focus on Enrollee safety. CONTRACTOR shall be able to describe its
use of up-to-date standards for patient safety and Provider feedback, including a
description for evaluating safety concerns.
	 
	 	10.2.7.	 	A plan to improve its quality, care delivery and satisfaction scores, and
other standard measures; for example, HEDIS® and CAHPSTM.
	 
	 	10.2.8.	 	A plan (including timelines) to meet or exceed the transaction, security and
privacy requirements of state and federal law (including chapter 70.02
RCW, the Washington State Patient Bill of Rights, HIPAA, and to protect the Personal
Information and PHI of Enrollees.
	 
	 	10.2.9.	 	CONTRACTOR’s formulary must reflect an evidence-based formulary that includes
all therapeutic classes of drugs and meets or exceeds the recommendations set forth by
the Academy of Managed Care Pharmacists. Additionally, CONTRACTOR is encouraged to
expand its Pharmacy & Therapeutics Committee to include at least one voting professional
provider who is not employed by CONTRACTOR.

	 	10.3.	 	Access to Health Care Services
	 
	 	 	 	CONTRACTOR shall ensure that an adequate network of Providers that deliver high
quality health care services is available to Enrollees. HCA will apply the Quality
Improvement Standards (Exhibit 4) and the Network Accessibility Guidelines (Exhibit
7) when evaluating a CONTRACTOR’S network adequacy. Upon request, CONTRACTOR shall
demonstrate that it ensures the following, for the benefit of HCA Enrollees:

	 	10.3.1.	 	A comprehensive, organized system of care that is accountable for delivery,
development, and performance throughout the period of the Agreement.
	 
	 	10.3.2.	 	Accessible, high quality PCPs, specialists, hospitals, and pharmacies.
CONTRACTOR shall be able to demonstrate how its network is of sufficient
size and distribution to meet Enrollee needs, and meets or exceeds the
network accessibility guidelines of HCA.
	 
	 	10.3.3.	 	Long-term relationships with Providers. CONTRACTOR shall be able to demonstrate
that its Provider relationships are designed to ensure that continuity and coordinated
care are available to Enrollees.
	 
	 	10.3.4.	 	Adequate and timely access to medically appropriate Providers outside the
contracted network if there is an insufficient number of Participating Providers.

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	 	10.4.	 	Accountability for Delivery of Affordable Health Care
	 
	 	 	 	In its demonstration of fiscal accountability to HCA, Enrollees, and Providers,
CONTRACTOR shall provide for and ensure that CONTRACTOR has and uses the following:

	 	10.4.1.	 	Financial contracts and agreements with Providers which focus on efficiency
and effectiveness of health care.
	 
	 	10.4.2.	 	A plan to improve administrative systems that promote
CONTRACTOR’S performance and efficiencies, including information management
systems to support HCA’s expectations and objectives and, in particular, the
ability of CONTRACTOR to monitor and promote continuous quality improvements.
Upon request, CONTRACTOR shall demonstrate how such programs reinforce quality of care
and do not impede access to or the delivery of care.
	 
	 	10.4.3.	 	Financial arrangements with Providers that are designed to ensure
Enrollees receive appropriate and cost-effective care.
	 
	 	10.4.4.	 	A risk management plan that is designed to anticipate and reduce threats to
continued Enrollee access to care.
	 
	 	10.4.5.	 	A system to incorporate disease management, use of clinical
guidelines, and evidence-based medicine.
	 
	 	10.4.6.	 	Policies and procedures to prevent and detect fraud and abuse activities
related to the BH program. These may include, but not be limited to: claims prior
authorization, utilization management and quality review, Enrollee complaint and
grievance resolution, Provider credentialing and contracting, Provider and staff
education to prevent fraud and abuse, and corrective action plans to remedy situations
where fraud and abuse have been detected.

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	 	10.5.	 	Performance Measures

	 	10.5.1.	 	CONTRACTOR agrees to comply with the performance measures as outlined in
Exhibit 3. CONTRACTOR agrees to maintain adequate records, satisfactory to HCA,
documenting compliance with these measures.
	 
	 	10.5.2.	 	CONTRACTOR shall self-report compliance with the performance measures as
described in Exhibit 3 on July 31 for the contract period January 1 through June
30 and on January 31 of the following year for the period July 1 through
December 31 of the contract period. If HCA determines that it is not feasible
for CONTRACTOR to report compliance with a measure on a BH-specific basis, then
CONTRACTOR may report compliance with that measure for their total book of
business.

	11.	 	APPEALS AND COMPLAINTS

	 	11.1.	 	Enrollee Complaints and Appeals Procedure
	 
	 	 	 	CONTRACTOR shall establish and maintain a procedure for the timely resolution of
complaints and appeals from Enrollees that meets the requirements in the Quality
Improvement Standards (Exhibit 4), any other applicable provision of this
Agreement, or as required by federal or state law or regulation.
	 
	 	11.2.	 	Grievance Timelines
	 
	 	 	 	CONTRACTOR will provide written notice of its resolution of a grievance (as
defined in 48.43.005 (14) RCW) to an Enrollee within 30
days of the receipt of the grievance, unless CONTRACTOR notifies the Enrollee
that an extension is necessary to complete the grievance review process and the
Enrollee gives informed, written consent to an extension.
	 
	 	11.3.	 	Dispute and Dispute Resolution Hearings

	 	11.3.1.	 	Except as otherwise provided in this Agreement, when a bona fide dispute
arises between HCA and CONTRACTOR and it cannot be resolved, CONTRACTOR may
request a dispute resolution hearing with the Administrator. The request for a
dispute resolution hearing must be in writing and shall clearly state all of the
following:

	 	(1)	 	The disputed issue(s),
	 
	 	(2)	 	An explanation of the positions of the parties, and
	 
	 	(3)	 	Any additional facts necessary to explain completely and accurately the
nature of the dispute.

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	 	11.3.2.	 	Requests for a dispute resolution hearing shall be mailed to the
Administrator, Washington State Health Care Authority (HCA), P.O. Box
42700, Olympia, WA 98504-2700 within 15 days after CONTRACTOR receives
notice of the disputed issue(s). The Administrator will determine a
time that is mutually agreeable to the parties during which they may
present their views on the disputed issue(s). The format and time
allowed for the presentations are solely within the Administrator’s
reasonable discretion, but it is understood that such presentations
will be informal in nature. The Administrator will provide written
notice of the time, format, and location of the presentations. At the
conclusion of the presentations, the Administrator will consider all of the evidence available to him and
shall render a written recommendation as soon as practicable, but in
no event more than 30 days after the conclusion of the presentations.
The Administrator may designate an employee of HCA or an
Administrative Law Judge to hear and determine the matter.
	 
	 	11.3.3.	 	The parties hereby agree that this dispute process shall precede any
judicial or quasi-judicial proceeding.

	12.	 	GENERAL PROVISIONS

	 	12.1.	 	Accessibility of Covered Services
	 
	 	 	 	CONTRACTOR shall ensure Enrollees have access to Covered Services defined in the COC (Exhibit
2) by the medically appropriate Provider.

	 	12.1.1.	 	Network Adequacy. CONTRACTOR shall maintain the support services and a
Provider network sufficient to serve Enrollees, consistent with the requirements
of this Agreement. CONTRACTOR will provide the Covered Services required by this Agreement through
non-Participating Providers if its network of Participating Providers is
insufficient to meet the medical needs of Enrollees in a manner consistent with
this Agreement. CONTRACTOR shall make services accessible consistent with the
provisions of this Agreement, including, but not limited to, the Quality
Improvement Standards (Exhibit 4) and the Network Accessibility Guidelines
(Exhibit 7). CONTRACTOR shall make Covered Services as accessible to Enrollees
under this Agreement as under its other state, federal, or private contracts.
	 
	 	12.1.2.	 	24/7 Availability of Services. CONTRACTOR shall have the following
services available to Enrollees on a 24 hour-a-day, 7 days a week basis. These
services may be provided directly by the CONTRACTOR or may be delegated to Subcontractors, provided that all
Subcontractors perform subject to the applicable terms and conditions
of this Agreement:

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	 	12.1.2.1.	 	Medical advice for Enrollees from licensed health care
professionals concerning the emergent, urgent, or routine nature of a medical
condition.
	 
	 	12.1.2.2.	 	Authorization of emergency services, out-of-area urgent care, or
authorizing care at other facilities when the use of participating facilities
is not practical.

	 	12.1.3.	 	Office Appointment Standards. CONTRACTOR shall comply with appointment
standards that are no longer than the following:

	 	12.1.3.1.	 	Non-symptomatic (e.g., preventive care) office visits shall be
available from the Enrollee’s PCP or an alternative provider within 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 children and adult immunizations.
	 
	 	12.1.3.2.	 	Non-urgent, symptomatic (e.g., routine care) office visits shall be
available from the Enrollee’s PCP or an alternative practitioner within 7
calendar days. A non-urgent, symptomatic office visit is associated with the
presentation of medical signs not requiring immediate attention.
	 
	 	12.1.3.3.	 	Urgent, symptomatic office visits shall be available within
24 hours. An urgent, symptomatic visit is associated with the
presentation of medical signs that require immediate attention,
but are not life threatening.
	 
	 	12.1.3.4.	 	Emergency medical care shall be available 24 hours per day, 7
days per week.

	 	12.1.4.	 	Access to Specialty Care. CONTRACTOR shall provide for availability of
necessary covered specialty care for Enrollees in a Service Area. If an Enrollee needs
specialty care from a specialist who is not available within
CONTRACTOR’S Participating Provider network, CONTRACTOR shall provide the necessary
services with a qualified specialist outside CONTRACTOR’S Participating Provider
network without additional expense (except applicable coinsurance or copayment amounts)
to the Enrollee and to HCA.
	 
	 	12.1.5.	 	Equal Access for Enrollees with Communications Barriers.
CONTRACTOR shall assure equal access of Covered Services, as described in the
COC (Exhibit 2), for all Enrollees when oral or written language creates a
barrier to such access.
	 
	 	12.1.6.	 	Americans with Disabilities Act. CONTRACTOR shall make reasonable
accommodation for Enrollees with disabilities, in accord with the Americans with
Disabilities Act, for all Covered Services and

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	 	 	 	shall assure physical and communication barriers shall not inhibit Enrollees with disabilities from obtaining
Covered Services.

	 	12.2.	 	Administrative Simplification

	 	12.3.1.	 	To maximize understanding, communication, and administrative economy among
all BH CONTRACTORS, their Subcontractors, governmental entities, and Enrollees,
CONTRACTOR shall use and follow the most recent updated versions of:

	 	•	 	Current Procedural Terminology (CPT)
	 
	 	•	 	International Classification of Diseases (ICD-9 CM)
	 
	 	•	 	Healthcare Common Procedure Coding System (HCPCS)
	 
	 	•	 	CMS Relative Value Units (RVUs)
	 
	 	•	 	CMS billing instructions and rules, including HCFA 1500 & UB-92
instructions

	 	12.3.2.	 	In lieu of the most recent versions, CONTRACTOR may request an exception.
HCA’s consent thereto will not be unreasonably withheld.
	 
	 	12.3.3.	 	CONTRACTOR may set its own conversion factor(s), including special code-specific
or group-specific conversion factors, as it deems appropriate.

	 	12.3.	 	Assignment
	 
	 	 	 	Responsibilities and rights under this Agreement may not be assigned by either
CONTRACTOR or HCA without the prior written consent of the other party, which
consent will not be unreasonably withheld.
	 
	 	12.4.	 	Audits and Performance Reviews

	 	12.4.1.	 	HCA may undertake periodic audits or performance reviews at its expense
regarding any aspect of the provision of Covered Services or CONTRACTOR’S administration
of this Agreement. Such audits or reviews will be designed not to interfere with the
delivery of health care services by Participating Providers of CONTRACTOR. Audits or
reviews may be undertaken directly by HCA, by third parties engaged by HCA, the
Interagency Contract Review Team (currently referred to as TEAMonitor), or the State of
Washington Auditor’s Office. With reasonable advance written notice, CONTRACTOR and its
Subcontractors shall provide access to its facilities and the financial and medical
records pertinent to this Agreement to monitor and evaluate performance under this
Agreement, including, but not limited to, the quality, cost, use, and timeliness of
services, and assessment of the CONTRACTOR’S capacity to bear the potential financial
losses.

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	 	12.4.2.	 	CONTRACTOR agrees to provide HCA the results of final financial, market
conduct, or special examinations performed by OIC and any final audit report produced
by the U. S. Department of Health and Human Services.
	 
	 	12.4.3.	 	CONTRACTOR shall submit a business or corrective action plan, including
timelines for remediation, in response to any final audit or performance review
recommendations identified by HCA or its agent.
Such action plan is due to the HCA within 60 calendar days after the date on
the final report.

	 	12.5.	 	Clerical Error
	 
	 	 	 	No clerical error on the part of HCA or CONTRACTOR, which is discovered within 12
months of its occurrence, shall operate to defeat any of the rights, privileges, or
benefits of any Enrollee.
	 
	 	12.6.	 	Compliance With All Applicable Laws and Regulations

	 	12.6.1.	 	In the provision of services under this Agreement, the HCA,
CONTRACTOR, and its Subcontractors shall comply with all applicable federal
and state statutes and regulations, and all amendments thereto, that are in
effect when the Agreement is signed or that come into effect during the term
of the Agreement or any renewals thereof. The provisions of this Agreement
which are in conflict with applicable state or federal laws or regulations are
hereby amended to conform to the minimum requirements of such laws or
regulations.
	 
	 	12.6.2.	 	CONTRACTOR and HCA shall comply with all the applicable provisions of
the HIPAA
	 
	 	12.6.3.	 	CONTRACTOR shall comply with all the applicable provisions of chapter 70.02
RCW and the Washington State Patient Bill of Rights, including, but not limited to,
the administrative and financial responsibility for independent reviews.

	 	12.7.	 	Covenant Against Contingent Fees
	 
	 	 	 	CONTRACTOR certifies that no person or selling agent has been employed or retained to
solicit or secure this Agreement for a commission, percentage, brokerage or contingent
fee, excepting bona fide employees or bona fide established agents maintained by
CONTRACTOR for the purpose of securing business. HCA shall have the right, in the event
of breach of this clause by CONTRACTOR, to terminate this Agreement or, in its
discretion, to deduct from amounts due CONTRACTOR under the Agreement or recover by other means the full
amount of any such commission, percentage, brokerage or contingent fee.

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	 	12.8.	 	Customer Service

	 	12.8.1.	 	CONTRACTOR shall provide adequate staff to provide customer service
representation at a minimum from 8 a.m. to 5 p.m., Pacific Standard Time or Daylight
Savings Time (depending on the season), Monday through Friday, year round and shall
provide customer service on all dates that are recognized as work days for state
employees. HCA will authorize exceptions to this requirement if
CONTRACTOR provides HCA with written assurance that its
Participating Providers will accept enrollment information from the BH
Provider Line or HCA’s system-generated notice to the Enrollee that
acknowledges his or her enrollment with CONTRACTOR.
	 
	 	12.8.2.	 	Toll free numbers shall be provided at the expense of CONTRACTOR for
out-of-state and in-state lines.
	 
	 	12.8.3.	 	CONTRACTOR shall provide a list of known dates that are not considered
business days for CONTRACTOR, but are considered work days for state employees no
later than March 1, 2008. Throughout the period of this Agreement, CONTRACTOR shall give HCA not less
than 30 days’ prior notice of any additional dates that subsequently are
identified where customer service representation will be unavailable to BH
Enrollees.

	 	12.9.	 	Defense of Legal Actions
	 
	 	 	 	Each party to this Agreement shall advise the other as to matters that come to its
attention with respect to potential substantial legal actions involving allegations
that may give rise to a claim for indemnification from the other. Each party shall
fully cooperate with the other in the defense of any action arising out of matters
related to this Agreement by providing without additional fee all reasonably available
information relating to such actions and by providing necessary testimony.
	 
	 	12.10.	 	Financial Solvency

	 	 12.10.1.	 	CONTRACTOR shall deliver to HCA copies of any financial reports prepared at the
request of the Office of the Insurance Commissioner (OIC). CONTRACTOR’S routine
quarterly and annual statements submitted to the OIC are exempt from this requirement.
CONTRACTOR shall also deliver copies of related documents and correspondence
(including, but not limited to, Risk-Based Capital [RBC] calculations and
Management’s Discussion and Analysis), at the same time CONTRACTOR submits
them to the OIC.
	 
	 	 12.10.2.	 	CONTRACTOR shall notify HCA within 10 business days after the end of any month
in which CONTRACTOR’S net worth (capital and/or surplus) reaches a level representing
two or fewer months of expected claims and other operating expenses, or other change

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	 	 	 	which may jeopardize its ability to perform under this Agreement or which may otherwise materially affect the relationship
of the parties under this Agreement.
	 
	 	12.10.3.	 	CONTRACTOR shall notify HCA within 24 hours after any action by the Insurance
Commissioner which may affect the relationship of the parties under this Agreement.
	 
	 	12.10.4.	 	CONTRACTOR shall notify HCA if the OIC requires enhanced reporting
requirements within 14 calendar days after CONTRACTOR’S notification by the OIC.
CONTRACTOR agrees that HCA may, at any time, access any financial reports submitted to
the Insurance Commissioner in accordance with any enhanced reporting requirements and
consult with OIC staff concerning information contained therein.
	 
	 	12.10.5.	 	If CONTRACTOR, any Subcontractor, or any Participating Provider becomes
insolvent during the term of this Agreement:

	 	12.10.5.1.	 	The state of Washington, HCA, and its Enrollees shall not be
liable in any manner for the debts and obligations of the CONTRACTOR.
	 
	 	12.10.5.2.	 	Under no circumstances shall CONTRACTOR, or any
Provider who delivers Covered Services under the terms of this
Agreement, charge Enrollees more than the Enrollee cost share
set forth in the COC (Exhibit 2).
	 
	 	12.10.5.3.	 	CONTRACTOR shall provide for the continuity of care for
Enrollees in accordance with RCW 48.44.055.

	 	12.11.	 	Force Majeure
	 
	 	 	 	If CONTRACTOR is prevented from performing any of its obligations hereunder, in whole or
in part, as a result of major epidemic, act of God, act of war (declared or undeclared),
civil disturbance, court order, labor dispute, or any other cause beyond its control,
CONTRACTOR shall make a good faith effort to perform such obligations through its
then-existing Participating Providers and personnel. Upon the occurrence of any such
event, if CONTRACTOR is unable to fulfill its obligations either directly or through
Participating Providers, CONTRACTOR shall make a good faith effort to arrange for
the provision of alternate and comparable performance.

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	 	12.12.	 	Governing Law and Venue
	 
	 	 	 	This Agreement shall be governed by the laws of the state of Washington. In the event
of a lawsuit involving this Agreement, venue shall be proper only in the Superior
Court of Thurston County.
	 
	 	12.13.	 	HCA and Enrollee Protection

	 	12.13.1.	 	Any written referral by a Participating Provider or contracted
Referral Provider is considered a CONTRACTOR-authorized
referral unless the Enrollee (or Enrollee’s legal representative) is given a
copy of a statement acknowledging that the referral services will not or may
not be covered by CONTRACTOR, or that the referral must have prior
authorization by CONTRACTOR to ensure that the services are a covered
benefit. CONTRACTOR may not deny charges for referral services unless
CONTRACTOR, or a Participating Provider or contracted Referral Provider on
behalf of CONTRACTOR, has first provided the above-referenced statement to
the Enrollee or Enrollee’s legal representative.
	 
	 	12.13.2.	 	Under no circumstances shall CONTRACTOR, or any Provider used to deliver
Covered Services under the terms of this Agreement, charge an Enrollee more than the
Enrollee cost share set forth in the COC (Exhibit 2) including, but not limited to,
emergent care or Covered Services administered by a Provider referred by CONTRACTOR or
referred by CONTRACTOR’S Participating Providers.

	 	12.14.	 	Indemnification
	 
	 	 	 	HCA and CONTRACTOR shall each be responsible for its own acts and omissions, and the
acts and omissions of its agents and employees. Each party to this Agreement shall
defend, protect and hold harmless the other party, or any of the other party’s agents,
from and against any loss and all claims, settlements, judgments, costs, penalties,
and expenses (including attorney fees) arising from any willful misconduct, or
dishonest, fraudulent, reckless, unlawful, or negligent act or omission of the first
party, or agents of the first party, while performing under the terms of this
Agreement except to the extent that such losses result from the willful misconduct, or
dishonest, fraudulent, reckless, unlawful or negligent act or omission on the part of
the second party. CONTRACTOR shall indemnify and hold harmless HCA from any claims by
Participating or non-Participating Providers related to the provision of Covered
Services to Enrollees according to the terms of this Agreement. Each party agrees to
promptly notify the other party in writing of any claim and provide the other party
the opportunity to defend and settle the claim.

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	 	12.15.	 	Independent Parties
	 
	 	 	 	CONTRACTOR acknowledges and certifies that its directors, officers, partners, employees,
and agents are not officers, employees, or agents of HCA or the state of Washington.
CONTRACTOR shall not hold itself out as or claim to be an officer, employee, or agent of
HCA or the state of Washington by reason of this Agreement. CONTRACTOR shall not claim
any rights, privileges, or benefits that would accrue to a civil service employee under
chapter 41.06 RCW.
	 
	 	12.16.	 	Industrial Insurance Coverage
	 
	 	 	 	CONTRACTOR shall provide or purchase industrial insurance coverage prior to performing
work under this Agreement. HCA will not be responsible for payment of industrial insurance premiums or for any other claim or benefit for
CONTRACTOR, or any Subcontractor or employee of CONTRACTOR, which might arise under the
industrial insurance laws during performance of duties and services under this
Agreement.
	 
	 	12.17.	 	Integration and Modification of Agreement
	 
	 	 	 	Any amendment to this Agreement shall require the approval of both HCA and CONTRACTOR.
Any amendment shall be in writing and shall be signed by a CONTRACTOR’S authorized
officer and an authorized representative of HCA. No other understandings, oral or
otherwise, regarding the subject matter of this Agreement shall be deemed to exist or to
bind any of the parties hereto.
	 
	 	12.18.	 	Intermediate Sanctions

	 	12.18.1.	 	If CONTRACTOR fails to meet a material obligation under the terms of this
Agreement, HCA may impose intermediate sanctions by withholding up to 5 percent of
payments to the CONTRACTOR rather than terminate this Agreement. CONTRACTOR agrees that
any intermediate sanction assessed by HCA shall not be regarded as a waiver of any
requirements contained in this Agreement or any provision therein, nor as a waiver by
HCA of any other remedy available in law or in equity.
	 
	 	12.18.2.	 	HCA will notify CONTRACTOR in writing of any default and provide a reasonable
deadline for curing the default before imposing intermediate sanctions. CONTRACTOR may
request a dispute resolution hearing, as described at Section 11.2. of this Agreement
(Disputes and Dispute Resolution Hearings). CONTRACTOR agrees that any intermediate
sanction assessed under this Section shall be in addition to any other legal or
equitable remedies allowed by this Agreement or awarded by a court of law, including
injunctive relief.

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	 	12.18.3.	 	If the dispute is resolved in favor of CONTRACTOR, HCA shall immediately pay
to CONTRACTOR any and all withheld payments.
Interest shall not accrue on any amount withheld as an intermediate
sanction. If the dispute is resolved in favor of HCA, HCA may withhold said
amounts until such breach is cured.

	 	12.19.	 	Licensing, Registration, Certification, and Authorization
	 
	 	 	 	CONTRACTOR shall comply with all applicable local, state, and federal licensing,
certification, accreditation, and registration standards and requirements necessary for
the performance of this Agreement, including, but not limited to, licensing,
registration, certification, or authorization as a health maintenance organization,
health care service contractor, or disability insurer under Title 48 RCW.
	 
	 	12.20.	 	Marketing and Written Communication Materials

	 	12.20.1.	 	CONTRACTOR shall not engage in any marketing activity related to this Agreement
without the prior written approval of HCA.
	 
	 	12.20.2.	 	CONTRACTOR will not use identifying marks of BH, HCA, or the state of
Washington on any materials produced or issued by CONTRACTOR without the prior written
consent of HCA. This contract term includes, but is not limited to marketing,
advertising or other direct communications to members, terminated members or potential
members.
	 
	 	12.20.3.	 	CONTRACTOR agrees not to represent itself as endorsed, supported by,
or affiliated with the state of Washington.
	 
	 	12.20.4.	 	CONTRACTOR agrees to submit all written communications and marketing
materials, developed and used by CONTRACTOR to communicate specifically with BH
Enrollees at any time during the contract period, to HCA for review and approval. This
subsection does not refer to such items as Provider directories and plan-wide
newsletters as long as they do not contain information on eligibility, enrollment,
benefits, rates, etc., which HCA must review.
	 
	 	12.20.5.	 	CONTRACTOR agrees that it will not advertise or distribute any information to
BH Enrollees, terminated BH Enrollees, and candidates for BH enrollment or Providers
that contains false or misleading information. Violation of this subsection is subject
to the Rights and Remedies defined in Sections 3.1. and 12.18. of this Agreement.
CONTRACTOR further agrees that if erroneous or misleading information is
sent to an Enrollee or Subcontractors (including contracted Providers)
regarding any matter related to this Agreement, HCA may require CONTRACTOR
to mail a correction or clarification to correctly inform the recipients of
such written materials.

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	 	12.20.6.	 	Nothing in this Section shall be construed to prohibit
CONTRACTOR from acknowledging that it has entered into this Agreement
with HCA.

	 	12.21.	 	Mergers and Acquisitions
	 
	 	 	 	If a CONTRACTOR is involved in an acquisition of assets or merger with another HCA
CONTRACTOR after the effective date of this Agreement, HCA reserves the right, to the
extent permitted by law, to require that each CONTRACTOR maintain its separate
business lines for the remainder of the Agreement period.

	 	12.22.	 	Nondiscrimination
	 
	 	 	 	During the performance of this Agreement, CONTRACTOR, and any of its Subcontractors
performing any of the obligations of CONTRACTOR set forth in this Agreement, shall
comply with all federal and state laws, regulations, and Executive Orders regulating
discrimination. These include, but are not limited to, the following and any amendments
thereto: Titles VI and VII of the Civil Rights Act of 1964, Executive Order 11246 as
amended by Executive Order 11375, Sections 503 and 504 of the Rehabilitation Act of
1973, the Age Discrimination in Employment Act of 1967, the Age Discrimination Act of
1975, the 1974 Vietnam Era Veterans Readjustment Assistance Act, the Americans with
Disabilities Act of 1990, as amended, including the provisions of Title II as if they
were a public entity, the Civil Rights Act of 1991, and the Washington State Law Against
Discrimination (chapter 49.60 RCW).

	 	12.23.	 	Noncompliance with Nondiscrimination Laws
	 
	 	 	 	In the event of noncompliance with any nondiscrimination law, regulation, or policy by
CONTRACTOR, HCA may rescind, cancel, or terminate this Agreement in whole or in part,
and CONTRACTOR may be declared ineligible for further contracts or agreements with HCA
for a period of up to 2 years. CONTRACTOR shall be given a reasonable time, not to
exceed 60 days, in which to cure this noncompliance. Any dispute may be addressed in
accordance with Section 11.2. (Disputes and Dispute Resolution Hearings).

	 	12.24.	 	Notification of Organizational Changes
	 
	 	 	 	CONTRACTOR shall provide HCA with 90 days’ prior written notice of any change in
CONTRACTOR’S ownership or legal status. CONTRACTOR shall provide HCA notice of any
changes to CONTRACTOR’S key personnel including, but not limited to, CONTRACTOR’S Chief
Executive Officer, HCA government relations contact, and Medical Director as soon as
reasonably possible.

	 	12.25.	 	Subcontracts

	 	12.25.1.	 	Subcontracts, as defined at Section 1.22., may be used by
CONTRACTOR for the provision of any service under this

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	 	 	 	Agreement; however, no Subcontract shall act to terminate CONTRACTOR’S legal
responsibility to HCA for any work required to be performed under this
Agreement. If the terms or conditions of an agreement between CONTRACTOR and
its Subcontractors conflict with this Agreement, the terms and conditions of
this Agreement shall prevail for purposes of administration of this
Agreement.

	 	12.25.2.	 	CONTRACTOR is responsible for ensuring that all terms, conditions, assurances,
and certifications set forth in this Agreement are carried forward to any
Subcontractors, including, but not limited to, those contract terms set forth in
Section 9. (Data Records), Section 12.1. (Accessibility of Covered Services), Section
12.13. (HCA and Enrollee Protection), and Section 12.27. (Records Maintenance and
Retention). CONTRACTOR shall be responsible for educating its
Subcontractors on the nature and purpose of CONTRACTOR’S relationship with
HCA, including Covered Services for Enrollees under this Agreement,
coordination of care requirements, and HCA policies as they relate to this
Agreement.
	 
	 	12.25.3.	 	If a Subcontractor is at financial risk and CONTRACTOR imposes solvency
requirements on the Subcontractor, the terms of the solvency requirement and how
frequently and by what means CONTRACTOR will monitor compliance with solvency
requirements must be in writing and enforced throughout the term of the Subcontract
agreement.
	 
	 	12.25.4.	 	Contracts or Subcontracts with Providers, including those for facilities,
must ensure the terms and conditions of this Agreement apply to the Subcontractor. The
Subcontract must also contain the following provisions:

	 	12.25.4.1.	 	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 Covered
Services in accordance with the terms and conditions set forth in this
Agreement, and which provides a free exchange of information with CONTRACTOR
to assist CONTRACTOR in complying with Sections 8. and 10. of this
Agreement.

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	 	12.25.4.2.	 	A 90 day termination notice provision for Participating
Providers and a specific “short term” notice of
termination when a Provider is excluded from
participation due to quality of care concerns.
	 
	 	12.25.4.3.	 	Whether referrals for Enrollees will be restricted to
Providers affiliated with a specific network group and, if so,
a description of those restrictions.
	 
	 	12.25.4.4.	 	The Subcontractor accepts payment from
CONTRACTOR as payment in full and shall not request
payment from HCA or any Enrollee for any
services performed under the Subcontract.

	12.26.	 	Provider Network Changes

	 	12.26.1.	 	CONTRACTOR shall furnish health care services at its health care facilities or
through its Participating Providers throughout the term of this Agreement.
	 
	 	12.26.2.	 	CONTRACTOR shall provide HCA not less than 90 calendar days’ advance written
notice of termination of a Material Provider.

	 	12.26.2.1.	 	In the event CONTRACTOR receives fewer than 90 days’ notice of
termination from a Material Provider, CONTRACTOR shall provide written notice
of the termination to HCA within 5 business days after CONTRACTOR’S receipt
of the termination notice from the Provider.
	 
	 	12.26.2.2.	 	If CONTRACTOR gives HCA fewer than 90 days’ termination notice
to a Material Provider due to the Provider’s loss of accreditation or
Medicare or Medicaid certification, or because of serious concerns about
service delivery or quality of care, CONTRACTOR shall notify HCA within 5
business days after such termination.
	 
	 	12.26.2.3.	 	If HCA receives fewer than 90 days’ notice of termination of a
Participating Provider determined by HCA to be material to the performance of
this Agreement and the access goals of HCA, HCA may, at its sole discretion,
require CONTRACTOR to continue providing services through the Material
Provider for a period not to exceed 90 days. CONTRACTOR shall cooperate with
HCA to ensure continuity of care and that treatment protocols are not
materially affected by Provider terminations. CONTRACTOR shall cooperate with
HCA to effect the orderly transition of Enrollees to 

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	 	 	 	other Participating
Providers or programs of health care coverage for which such Enrollees may be
eligible.

	 	12.26.3.	 	If CONTRACTOR requires a Participating Provider to accept a revised structure
or method of reimbursement (e.g., moving from a fee schedule reimbursement methodology
to full-risk capitation payment) during the period of this Agreement as a condition of
continued participation with CONTRACTOR and the change is rejected by the Provider,
CONTRACTOR shall extend the terms of the existing Subcontract to continue service for
BH Enrollees until the end of the calendar year in which the change is proposed.
	 
	 	12.26.4.	 	CONTRACTOR shall notify Enrollees affected by any Provider termination which
occurs without cause, 60 calendar days prior to the effective date. Notices to Enrollees
of Provider termination shall have prior approval of HCA. If CONTRACTOR fails to notify
affected Enrollees of a Provider termination 60 calendar days prior to the effective
date, CONTRACTOR shall allow affected Enrollees to continue to receive services from the
terminating Provider, at the Enrollees’ option, and administer benefits to the lesser of
a period of 60 calendar days from the date CONTRACTOR notifies Enrollees of the
termination or the Enrollee’s effective date of enrollment with another Provider or
another BH CONTRACTOR.
	 
	 	12.26.5.	 	If because of changes in the Participating Provider network, the network
becomes so changed that Enrollees are unable to obtain services from Participating
Providers, or if in the sole judgment of HCA the change in network adversely impacts
Enrollees, HCA may transfer the affected Enrollees to another CONTRACTOR.
	 
	 	12.26.6.	 	HCA reserves the right to reduce the December premium to recover any expenses
incurred by HCA as a result of the withdrawal of a material Subcontractor from a Service
Area. This reimbursable expense shall be in addition to any other provisions of this
Agreement.

	12.27.	 	Records Maintenance and Retention

	 	12.27.1.	 	CONTRACTOR and its Subcontractors shall maintain financial, medical, and other
records relevant to this Agreement. Medical records and supporting management systems
shall include all relevant information related to the medical management of each
Enrollee. Other records shall be maintained as necessary to clearly reflect all actions
taken by CONTRACTOR related to this Agreement.
	 
	 	12.27.2.	 	All records and reports relating to this Agreement, and any subsequent
amendments extending the effective date of this Agreement, shall be retained by
CONTRACTOR and its

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	 	 	 	Subcontractors for a minimum of six (6) years after final payment is made
under this Agreement. 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.

	12.28.	 	Post Termination Responsibilities
	 
	 	 	The following requirements survive termination of this Agreement.
CONTRACTOR shall:

	 	12.28.1.	 	Cover Enrollees hospitalized on the date of termination until discharge,
consistent with subsections 3.6.4. and 12.10.5.3. of this Agreement.
	 
	 	12.28.2.	 	Submit all data and reports required in Section 7. of this Agreement.
	 
	 	12.28.3.	 	Provide access to records, as required in Section 12.4. of this
Agreement.
	 
	 	12.28.4.	 	Provide administrative services associated with Covered Services
(e.g., claims processing and Enrollee appeals) provided to Enrollees under
the terms of this Agreement.

	12.29.	 	Required Notices
	 
	 	 	Any notice required hereunder shall be deemed to be sufficient if mailed to the
addresses appearing on the signature page of this Agreement.

	12.30.	 	Services Non-Transferable
	 
	 	 	No person other than the Enrollee is entitled to receive services and benefits
furnished under this Agreement. Rights to services and benefits are not transferable.

	12.31.	 	Severability
	 
	 	 	If any provision of this Agreement or any provision of any document, law, or regulation
incorporated by reference shall be held invalid, such invalidity shall not affect the
other provisions of this Agreement which can be given effect without the invalid
provision, and to this end the provisions of this Agreement are declared to be
severable.

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	12.32.	 	Waiver
	 
	 	 	Waiver of any default shall not be deemed to be a waiver of any subsequent default.
Waiver of breach of any provision of this Agreement shall not be deemed to be a waiver
of any other or subsequent breach and shall not be construed to be a modification of
the terms of this Agreement unless stated to be such in writing, signed by the parties,
and attached to the original Agreement.

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Molina Healthcare of Washington, Inc — Exhibit 1 Monthly Fees

Basic Health CY 08 Final Rate Summary

Changes to monthly fees because of the addition of a newborn or adoptive child will be effective
the first of the month following the date of birth, or date of placement of a child for purposes of
adoption.

Monthly fees are determined by an enrollee’s age as of January 1 of each calendar year regardless
of the date when Basic Health coverage began. Monthly fees will not increase for an enrollee at
any date

other than January 1. Student dependents and disabled dependents who are less than 23 years old
will be assigned the “child” monthly fee. Enrollees who are less than age 19 and are not
dependents will be assigned the 0—39 year old monthly fee. “Monthly fee” means the amount paid on a
monthly basis to an MHCS by the HCA.

Monthly fees paid for enrollees in Basic Health Plus and Maternity Benefits Program will be the
Medicaid fees set forth by the Department of Social and Health Services and described in the Basic
Health Plus and Maternity Benefits Program contract.

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	2008 Tiered Bid Rates for Subsidized BH	 	2008 Tiered Bid Rates for HCTC BH
	County	 	One child	 	2 children	 	3+ children	 	Adult 0-39	 	Adult 40-54	 	Adult 55-64	 	Adult 65+	 	One child	 	2 children	 	3+ children	 	Adult 0-39	 	Adult 40-54	 	Adult 55-64	 	Adult 65+
	Adams
	 	$	87.28	 	 	$	174.56	 	 	$	261.84	 	 	$	189.10	 	 	$	242.44	 	 	$	414.57	 	 	$	523.67	 	 	$	94.35	 	 	$	188.70	 	 	$	283.05	 	 	$	204.42	 	 	$	262.07	 	 	$	448.14	 	 	$	566.07	 
	Asotin
	 	$	99.54	 	 	$	199.08	 	 	$	298.62	 	 	$	215.66	 	 	$	276.49	 	 	$	472.80	 	 	$	597.22	 	 	$	106.85	 	 	$	213.70	 	 	$	320.55	 	 	$	231.52	 	 	$	296.82	 	 	$	507.56	 	 	$	641.12	 
	 
	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 
	Chelan
	 	$	87.28	 	 	$	174.56	 	 	$	261.84	 	 	$	189.10	 	 	$	242.44	 	 	$	414.57	 	 	$	523.67	 	 	$	94.35	 	 	$	188.70	 	 	$	283.05	 	 	$	204.42	 	 	$	262.07	 	 	$	448.14	 	 	$	566.07	 
	Clallam
	 		 	 	 		 	 	 		 	 	 		 	 	 		 	 	 		 	 	 		 	 	 		 	 	 		 	 	 		 	 	 		 	 	 		 	 	 		 	 	 		 	 
	 
	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 
	Columbia
	 	$	99.54	 	 	$	199.08	 	 	$	298.62	 	 	$	215.66	 	 	$	276.49	 	 	$	472.80	 	 	$	597.22	 	 	$	106.85	 	 	$	213.70	 	 	$	320.55	 	 	$	231.52	 	 	$	296.82	 	 	$	507.56	 	 	$	641.12	 
	 
	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 
	Douglas
	 	$	87.28	 	 	$	174.56	 	 	$	261.84	 	 	$	189.10	 	 	$	242.44	 	 	$	414.57	 	 	$	523.67	 	 	$	94.35	 	 	$	188.70	 	 	$	283.05	 	 	$	204.42	 	 	$	262.07	 	 	$	448.14	 	 	$	566.07	 
	Ferry
	 	$	87.28	 	 	$	174.56	 	 	$	261.84	 	 	$	189.10	 	 	$	242.44	 	 	$	414.57	 	 	$	523.67	 	 	$	94.35	 	 	$	188.70	 	 	$	283.05	 	 	$	204.42	 	 	$	262.07	 	 	$	448.14	 	 	$	566.07	 
	 
	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 
	Garfield
	 	$	99.54	 	 	$	199.08	 	 	$	298.62	 	 	$	215.66	 	 	$	276.49	 	 	$	472.80	 	 	$	597.22	 	 	$	106.85	 	 	$	213.70	 	 	$	320.55	 	 	$	231.52	 	 	$	296.82	 	 	$	507.56	 	 	$	641.12	 
	Grant
	 	$	87.28	 	 	$	174.56	 	 	$	261.84	 	 	$	189.10	 	 	$	242.44	 	 	$	414.57	 	 	$	523.67	 	 	$	94.35	 	 	$	188.70	 	 	$	283.05	 	 	$	204.42	 	 	$	262.07	 	 	$	448.14	 	 	$	566.07	 
	Grays Harbor
	 	$	95.27	 	 	$	190.54	 	 	$	285.81	 	 	$	206.42	 	 	$	264.64	 	 	$	452.53	 	 	$	571.62	 	 	$	102.50	 	 	$	205.00	 	 	$	307.50	 	 	$	222.09	 	 	$	284.72	 	 	$	486.88	 	 	$	615.00	 
	 
	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 
	 
	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 
	King
	 	$	82.95	 	 	$	165.90	 	 	$	248.85	 	 	$	179.73	 	 	$	230.42	 	 	$	394.02	 	 	$	497.71	 	 	$	89.93	 	 	$	179.86	 	 	$	269.79	 	 	$	194.85	 	 	$	249.81	 	 	$	427.17	 	 	$	539.58	 
	 
	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 
	Kittitas
	 	$	82.95	 	 	$	165.90	 	 	$	248.85	 	 	$	179.73	 	 	$	230.42	 	 	$	394.02	 	 	$	497.71	 	 	$	89.93	 	 	$	179.86	 	 	$	269.79	 	 	$	194.85	 	 	$	249.81	 	 	$	427.17	 	 	$	539.58	 
	 
	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 
	Lewis
	 	$	95.27	 	 	$	190.54	 	 	$	285.81	 	 	$	206.42	 	 	$	264.64	 	 	$	452.53	 	 	$	571.62	 	 	$	102.50	 	 	$	205.00	 	 	$	307.50	 	 	$	222.09	 	 	$	284.72	 	 	$	486.88	 	 	$	615.00	 
	Lincoln
	 	$	87.28	 	 	$	174.56	 	 	$	261.84	 	 	$	189.10	 	 	$	242.44	 	 	$	414.57	 	 	$	523.67	 	 	$	94.35	 	 	$	188.70	 	 	$	283.05	 	 	$	204.42	 	 	$	262.07	 	 	$	448.14	 	 	$	566.07	 
	 
	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 
	Okanogan
	 	$	87.28	 	 	$	174.56	 	 	$	261.84	 	 	$	189.10	 	 	$	242.44	 	 	$	414.57	 	 	$	523.67	 	 	$	94.35	 	 	$	188.70	 	 	$	283.05	 	 	$	204.42	 	 	$	262.07	 	 	$	448.14	 	 	$	566.07	 
	Pacific
	 	$	99.54	 	 	$	199.08	 	 	$	298.62	 	 	$	215.66	 	 	$	276.49	 	 	$	472.80	 	 	$	597.22	 	 	$	106.85	 	 	$	213.70	 	 	$	320.55	 	 	$	231.52	 	 	$	296.82	 	 	$	507.56	 	 	$	641.12	 
	Pend Oreille
	 	$	87.28	 	 	$	174.56	 	 	$	261.84	 	 	$	189.10	 	 	$	242.44	 	 	$	414.57	 	 	$	523.67	 	 	$	94.35	 	 	$	188.70	 	 	$	283.05	 	 	$	204.42	 	 	$	262.07	 	 	$	448.14	 	 	$	566.07	 
	Pierce
	 	$	95.27	 	 	$	190.54	 	 	$	285.81	 	 	$	206.42	 	 	$	264.64	 	 	$	452.53	 	 	$	571.62	 	 	$	102.50	 	 	$	205.00	 	 	$	307.50	 	 	$	222.09	 	 	$	284.72	 	 	$	486.88	 	 	$	615.00	 
	 
	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 
	 
	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 
	 
	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 
	 
	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 
	Spokane
	 	$	82.95	 	 	$	165.90	 	 	$	248.85	 	 	$	179.73	 	 	$	230.42	 	 	$	394.02	 	 	$	497.71	 	 	$	89.93	 	 	$	179.86	 	 	$	269.79	 	 	$	194.85	 	 	$	249.81	 	 	$	427.17	 	 	$	539.58	 
	Stevens
	 	$	87.28	 	 	$	174.56	 	 	$	261.84	 	 	$	189.10	 	 	$	242.44	 	 	$	414.57	 	 	$	523.67	 	 	$	94.35	 	 	$	188.70	 	 	$	283.05	 	 	$	204.42	 	 	$	262.07	 	 	$	448.14	 	 	$	566.07	 
	Thurston
	 	$	95.27	 	 	$	190.54	 	 	$	285.81	 	 	$	206.42	 	 	$	264.64	 	 	$	452.53	 	 	$	571.62	 	 	$	102.50	 	 	$	205.00	 	 	$	307.50	 	 	$	222.09	 	 	$	284.72	 	 	$	486.88	 	 	$	615.00	 
	 
	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 
	Walla Walla
	 	$	82.95	 	 	$	165.90	 	 	$	248.85	 	 	$	179.73	 	 	$	230.42	 	 	$	394.02	 	 	$	497.71	 	 	$	89.93	 	 	$	179.86	 	 	$	269.79	 	 	$	194.85	 	 	$	249.81	 	 	$	427.17	 	 	$	539.58	 
	Whatcom
	 	$	87.28	 	 	$	174.56	 	 	$	261.84	 	 	$	189.10	 	 	$	242.44	 	 	$	414.57	 	 	$	523.67	 	 	$	94.35	 	 	$	188.70	 	 	$	283.05	 	 	$	204.42	 	 	$	262.07	 	 	$	448.14	 	 	$	566.07	 
	Whitman
	 	$	87.28	 	 	$	174.56	 	 	$	261.84	 	 	$	189.10	 	 	$	242.44	 	 	$	414.57	 	 	$	523.67	 	 	$	94.35	 	 	$	188.70	 	 	$	283.05	 	 	$	204.42	 	 	$	262.07	 	 	$	448.14	 	 	$	566.07	 
	Yakima
	 	$	82.95	 	 	$	165.90	 	 	$	248.85	 	 	$	179.73	 	 	$	230.42	 	 	$	394.02	 	 	$	497.71	 	 	$	89.93	 	 	$	179.86	 	 	$	269.79	 	 	$	194.85	 	 	$	249.81	 	 	$	427.17	 	 	$	539.58	 

Table of Contents

 

Table of Contents

Contact Information

	 	 	 	 	 	 	 
	 	 	Customer	 	Customer Service	 	 
	 	 	Service Hours	 	Phone Numbers	 	Web Site Address
	Basic Health

	 	24-hour self-service
	 	1-800-842-7712
	 	www.basichealth.hca.wa.gov
	 

	 	Mon. – Fri.
	 	1-800-660-9840	 	 
	 

	 	8 a.m. – 5 p.m.
	 	TTY: 1-888-923-5622	 	 
	Spanish

	 	8 a.m. – 5 p.m.
	 	1-800-321-0291	 	 
	Korean

	 	8 a.m. – 5 p.m.
	 	1-800-324-1658	 	 
	Vietnamese

	 	8 a.m. – 5 p.m.
	 	1-800-423-2231	 	 
	Russian

	 	8 a.m. – 5 p.m.
	 	1-800-387-8224	 	 
	 
	 	 	 	 	 	 
	Internal Revenue Service

(to request federal 

income tax information)

	 	Mon. – Fri.
	 	1-800-829-1040
	 	www.irs.gov
	 
	 	 	 	 	 	 
	Health Coverage Tax

	 	Mon. – Fri.
	 	1-866-628-4282
	 	www.irs.gov
	Credit (HCTC) Program

	 	5 a.m. – 5 p.m.
	 	TTY: 1-866-626-4282
	 	(Keyword: HCTC)
	 
	Columbia United

	 	Mon. – Fri.
	 	1-800-315-7862 or
	 	www.cuphealth.com
	Providers, Inc.

	 	8 a.m. – 5 p.m.
	 	360-891-1520	 	 
	 

	 	 	 	TDD:	 	 
	 

	 	 	 	1-866-287-9962	 	 
	 
	 	 	 	 	 	 
	Community Health

	 	Mon. – Fri.
	 	1-800-440-1561
	 	www.chpw.org
	Plan of Washington

	 	8 a.m. – 6 p.m.
	 	TTY: 1-800-833-6388	 	 
	 
	 	 	 	 	 	 
	Group Health

	 	Mon. – Fri.
	 	1-888-901-4636
	 	www.ghc.org
	Cooperative

	 	8 a.m. – 5 p.m.
	 	TTY: 1-800-833-6388	 	 
	 
	 	 	 	 	 	 
	Kaiser Foundation

	 	Mon. – Fri.
	 	1-800-813-2000
	 	www.kaiserpermanente.org
	Health Plan
of the Northwest

	 	8 a.m. – 6 p.m.
	 	TTY: 1-800-324-8010	 	 
	 
	 	 	 	 	 	 
	Molina Healthcare

	 	Mon. – Fri.
	 	1-800-869-7165
	 	www.molinahealthcare.com
	of Washington, Inc.

	 	7:30 a.m. – 5:30 p.m.
	 	TTY: 1-877-665-4629	 	 

Premium payments are due by the 5th day
of the month before the actual month of
coverage; the amount and due date are
shown on each month’s bill. Your bill is
sent about six weeks before the month to be
covered by that payment. For example, the
bill for August coverage is sent mid-June and
payment is due July 5.

	 	 	 
	Basic Health	 	Mailing Addresses
	Premium payments
	 	P.O. Box 34270, Seattle, WA

98124-1270
	 
	General correspondence
	 	

P.O. Box 42683, Olympia, WA

98504-2683
	 
	Basic Health appeals 
(see page 20)

	 	

P.O. Box 42690, Olympia, WA

98504-2690

 i

 

Table of Contents

	 	 	 	 	 
	If you have any questions about...	 	Contact...
	•

	 	Adding and/or dropping coverage
	 	Basic Health at
1-800-842-7712 to get forms or hear recorded information, go to
www.basichealth.hca.wa.gov or call 1-800-660-9840 to talk to a
Basic Health representative.
	•

	 	Address changes
	 
	•

	 	Income changes
	 
	 
	 	 	 	 
	•

	 	A bill for medical care
	 	Your health plan. (See the phone
number on the previous page.)
	•

	 	Choosing a provider
	 	 
	•

	 	Covered services	 	 
	•

	 	Services received from providers	 	 
	•

	 	Waiting period	 	 
	 
	 	 	 	 
	•

	 	Your medical care
	 	Your primary care provider.
	•

	 	Referrals to specialists	 	 
	 
	 	 	 	 
	•

	 	Your monthly premium
	 	Basic Health at
1-800-842-7712 for 24-hour, self-service payment information; or
1-800-660-9840, then follow the instructions to talk to an accounting representative.
	•

	 	Your bill from Basic Health
	 
	•

	 	Refunds
	 
	 
	 	 	 	 
	•

	 	Your family’s enrollment
	 	Visit
www.hca.wa.gov/ecoverage.shtml or call 1-800-660-0840.
	•

	 	Your health plan
	 
	•

	 	Your premium	 	 

When you call or write to us...

Include your name, Basic Health ID number, address, and a daytime phone number. Be sure to
note the date of the call, the name of the person you talked to, and the organization you
contacted. If you have Basic Health through your employer, a home care agency, or a financial
sponsor, first contact your representative
(usually your payroll officer or financial sponsor representative). Your representative may have the
information you need, or may need to know about the change you’re making.

To obtain this document in another format (such as Braille or audio), call our Americans with
Disabilities Act (ADA) Coordinator at 360-923-2805. TTY users (deaf, hard of hearing, or speech
impaired), call 360-923-2701 or toll-free 1-888-923-5622.

ii

 

 

Table of Contents

	 	 	 	 	 
	Introduction
	 	 	1	 
	 
	Chapter One:
	 	 	 	 
	Eligibility for Basic Health Programs
	 	 	2	 
	Family enrollment
	 	 	2	 
	Premiums
	 	 	2	 
	Basic Health Plus
	 	 	3	 
	Maternity Benefits Program
	 	 	3	 
	Basic Health for foster parents and personal
care workers
	 	 	3	 
	Basic Health through your employer, financial sponsor, or
home care agency
	 	 	3	 
	Health Coverage Tax Credit
	 	 	3	 
	 
	Chapter Two:
	 	 	 	 
	Income Guidelines
	 	 	4	 
	How your income is calculated
	 	 	4	 
	Income table
	 	 	5	 
	 
	Chapter Three:
	 	 	 	 
	Making Changes and Maintaining Eligibility
	 	 	6	 
	Changing health plans
	 	 	6	 
	Address changes
	 	 	6	 
	Dependent living away from home
	 	 	7	 
	Out of county
	 	 	7	 
	Out of state
	 	 	7	 
	Family changes
	 	 	7	 
	When coverage begins for added family
members
	 	 	8	 
	Income changes
	 	 	8	 
	Reporting income changes
	 	 	9	 
	Recertification
	 	 	9	 
	What if I don’t report a change in income?
	 	 	10	 
	What if I don’t repay the amount I owe?
	 	 	10	 
	Legal penalties
	 	 	10	 
	 
	Chapter Four:
	 	 	 	 
	Suspension, Disenrollment, and Reenrollment
	 	 	11	 
	Suspension
	 	 	11	 
	Disenrollment
	 	 	11	 
	Disenrollment from employer, financial
sponsor, or home care agency coverage
	 	 	12	 
	Reenrollment
	 	 	12	 
	 
	Chapter Five:
	 	 	 	 
	Rights, Responsibilities, and Privacy
	 	 	13	 
	Basic Health member rights
	 	 	13	 
	Basic Health member responsibilities
	 	 	14	 
	Informed consent
	 	 	14	 
	Advance directives
	 	 	14	 
	Privacy
	 	 	15	 
	Personal health information
	 	 	15	 
	Account information
	 	 	15	 
	 
	Chapter Six:
	 	 	 	 
	Grievances, Complaints, and Appeals
	 	 	16	 
	Grievances against your health plan
	 	 	16	 
	Appeals to your health plan
	 	 	16	 
	Complaints against Basic Health
	 	 	17	 
	Appeals to Basic Health
	 	 	17	 
	 
	Chapter Seven:
	 	 	 	 
	Health Plans and Providers
	 	 	18	 
	How the health plans work
	 	 	18	 
	When does my coverage begin?
	 	 	18	 
	ID cards
	 	 	18	 
	The right to object to certain services
	 	 	19	 
	Primary care provider (PCP)
	 	 	19	 
	Women’s health care services
	 	 	19	 
	 
	Chapter Eight:
	 	 	 	 
	Covered Services and Member Costs
	 	 	20	 
	Emergency care
	 	 	20	 
	Preexisting condition waiting period
	 	 	20	 
	Organ transplants
	 	 	20	 
	Maternity care
	 	 	20	 
	When your pregnancy ends
	 	 	21	 
	Member costs
	 	 	22	 
	If you receive a bill for covered services
	 	 	22	 
	If a third party is responsible for your injury or illness
	 	 	23	 
	 
	Appendix A:
	 	 	 	 
	Schedule of Benefits
	 	 	24	 
	 
	Appendix B:
	 	 	 	 
	Health Coverage Tax Credit (HCTC) — Basic Health
	 	 	38	 
	 
	Appendix C:
	 	 	 	 
	Definitions of Terms
	 	 	42	 
	 
	Index
	 	 	46	 

 

Table of Contents

Introduction

Basic Health offers quality, low-cost health coverage to eligible people who live in Washington
State. It is a state program managed by the Washington State Health Care Authority (HCA). The HCA
contracts with health plans to offer Basic Health and Basic Health Plus coverage. Each health plan
works with hospitals, clinics, pharmacies, physicians, and other providers to serve Basic Health
and Basic Health Plus members.

If any of your family members are enrolled in Basic Health Plus or the Maternity Benefits Program,
you should have received A Guide to Basic Health Plus and the Maternity Benefits Program, with
specific information about these programs.

You must give Basic Health the information needed to determine your continued eligibility for the
program. You must also give your health plan all information they need to process claims, including
medical records.

You must follow your health plan’s rules to get the benefits described in this handbook. Rules may
be different between health plans. Be sure to read your health plan’s materials for details, and
call them if you have questions about your benefits.

This handbook is your “certificate of coverage.” It describes what Basic Health covers, and the
rules you must follow when using your coverage. This handbook is subject to state laws governing
Basic Health (Chapter 70.47 RCW) and the administrative rules of Basic Health (Chapter 182-25 of
the Washington Administrative Code). If there are any conflicts between this handbook and the law,
the law governs.

Keep this Member Handbook handy, and look at it when you have a question about your benefits. Basic
Health may send other important documents, such as Hot Policy Pages and open enrollment materials.
These may include updates to this handbook. Always keep them with your Member
Handbook.

If you are enrolled
in Basic Health as
a Health Coverage
Tax Credit (HCTC)
enrollee, read
Appendix B of this
handbook, starting on
page 41, first.

Throughout this handbook, “you” generally refers to the main subscriber on the Basic Health account or

to an adult who will be reading and referring to coverage information on behalf of an enrolled child.

			
	 	 	 
	Basic Health 2008 Member Handbook
	 	1  

 

Table of Contents

Chapter One:

Eligibility for Basic Health Programs

Basic Health is available to anyone who lives in Washington and:

	•	 	Meets income guidelines (see pages 5–6).
	 
	•	 	Is not eligible for free or purchased Medicare.
	 
	•	 	At the time of enrollment, is not confined in or living in a
government-funded institution that has historically provided health
care.
	 
	•	 	Is not attending school full-time in the United States on a student
visa.

Specific programs may have additional eligibility requirements. Basic Health is also available to
people eligible for the Health Coverage Tax Credit through the Internal Revenue Service (IRS),
whether or not they meet the above criteria.

Family members who should be listed as dependents on your account (even if they are not enrolling
for coverage) include:

	•	 	Your spouse living in the same house and
not legally separated from you.
	 
	•	 	Your unmarried child, including
stepchild, legally adopted child, and a
child placed in your home for purposes of
adoption or under your legal
guardianship, who is:

	 	•	 	Under age 19; or
	 
	 	•	 	Under age 23 and a full-time student at an accredited school. You are required to send
proof from the school each year when your dependent is age 19 through 22, to show that he or
she is a full-time student. If your dependent over age 18 is no longer a full-time student,
you must notify Basic Health within 30 days of this change.

	•	 	Your unmarried child under age 19, enrolling
for Basic Health coverage, and in your custody
under an informal guardianship agreement that
is signed by the child’s parent(s) and allows
you to get medical care for the child. To request
coverage for a child living with you under such
an agreement, you must provide a copy of the
guardianship agreement and proof that you are providing at least 50 percent of the child’s
support. You cannot list a child who is in your home under a foster care agreement.
	 
	•	 	Your unmarried child, stepchild, legally adopted child, or legal dependent of any age who
cannot take care of him-or herself due to disability. You must provide
proof of disability. If
the dependent with a disability is not your birth or adopted child, you must also provide
proof of legal guardianship.

Family members who are not eligible for coverage on your account may be able to enroll
separately—for example, a child who reaches age 19 and is not disabled or attending school full
time. This family member must complete a separate Basic Health application.

Family enrollment

Individuals may apply for Basic Health, Basic Health Plus, the Maternity Benefits Program, or other
programs for themselves and qualified family members. You and your family members may be enrolled
in different programs. For example, you may enroll in Basic Health, your spouse in the Maternity
Benefits Program, and your child in Basic Health Plus.

Premiums

Premium payments are due by the 5th day of each month before the actual month of coverage; the
amount and due date are shown on each month’s bill. Your bill is sent about six weeks before the
month to be covered by that payment. For example, the bill for August’s coverage is sent mid-June
and payment is due July 5.

If the entire premium is not paid on time, Basic Health will send you a late notice. This notice
will include the bill for both the past due amount (called the delinquent balance) and the premium
for the

			
	 	 	 
	  2
	 	Basic Health 2008 Member Handbook

 

Table of Contents

following month’s coverage. Basic Health must receive payment for each amount due by the due date
given, or your coverage will be suspended for one month. Partial payment or checks that cannot be
processed (for example, insufficient funds or missing a signature) will be considered nonpayment
and may cause you to lose coverage. For more information, refer to page 13.

Basic Health Plus

This Basic Health and Department of Social and Health Services (DSHS) program is for children under
age 19. With Basic Health Plus, children receive additional health care coverage such as dental
care, vision care, and physical therapy. Children enrolled in Basic Health Plus receive services
through the same health plan that provides your Basic Health coverage.

Your family will have to meet DSHS’s income guidelines, available at
http://fortress.wa.gov/dshs/maa/eligibility/OVERVIEW/MedicalOverview.htm. The children
must be your legal dependents, live in your home, and be:

	•	 	Under age 19.
	 
	•	 	U.S. citizens, or immigrants who have legally lived in the U.S. for five years.
	 
	•	 	Not enrolled in any other managed care plan, including TRICARE.
	 
	•	 	Not receiving Temporary Assistance for Needy Families (TANF) grants from DSHS.

For some Basic Health Plus services, such as dental and vision care, the state pays the provider
directly.

If you would like to transfer your child’s coverage from Basic Health to Basic Health Plus, call
1-800-842-7712 or visit our Web site (www.basichealth.hca.wa.gov) to request a Basic Health
Plus application.

Maternity Benefits Program

This Basic Health and DSHS program provides pregnant women with full maternity coverage, usually
through the same providers and health plan chosen for Basic Health coverage. See pages 23–24 for
more information on maternity coverage.

Basic Health for personal care workers

If you are working for DSHS as a personal care worker, and meet Basic Health income guidelines, you
may be able to pay even less for Basic Health coverage.

For more information or to request a personal care worker application, call 1-800-660-9840 or check
Basic Health’s Web site.

Basic Health for foster parents

If you have a current foster parent license issued by DSHS, you may be eligible for lower premium
rates through our foster parent program. For information or to request a foster parent application
call 1-800-660-9840 or visit our Web site.

The licensed foster parents in your family may qualify for coverage even if they exceed income
limits for Basic Health. See chart on page 6 for income guidelines.

Basic Health through your employer, financial sponsor, or home care agency

Employers, home care agencies, and financial sponsors may enroll their employees or sponsored
members in Basic Health. Your employer or sponsor pays your premium, but may collect part of it
from you. Your main contact with Basic Health will be through your employer or sponsor.

If your employer, home care agency, or financial sponsor doesn’t pay the premium on time, or if you
no longer qualify for coverage through them, you may be disenrolled. If your entire organization is
disenrolled, Basic Health will offer you individual coverage; however, you may have a break in
coverage.

Health Coverage Tax Credit

If you are enrolled in Basic Health through the federal Health Coverage Tax Credit (HCTC) program,
please read Appendix B of this handbook. If you are not enrolled in HCTC-Basic Health, but think
you may qualify, call 1-866-628-4282, or visit www.irs.gov (keyword: HCTC).

			
	 	 	 
	Basic Health 2008 Member Handbook
	 	3  

 

Table of Contents

Chapter Two:

Income Guidelines

How your income is calculated

Basic Health requires current pay stubs and a copy of your IRS Form 1040 for the most recent tax
year, with all schedules fled. We will look at your income from both sources and use the one that
gives the best picture of your income.

If you cannot provide IRS documentation (you were not
required to file a tax return), we will use your most recent income
documentation, unless your income is seasonal. If Basic Health
determines that your income is seasonal, we will use an average of
your income over several months. We may require you to provide
additional documents.

If you are reporting self-employment or rental income, Basic Health
will use a
12-month average
of that income, unless you have had the business or rental property for less than 12 months. When
figuring your self-employment income, Basic Health will not deduct depreciation or amortization, and
may not deduct business use of your home. A net loss from this calculation will not be used to
offset other income sources (a loss equals zero).

If you paid for child care or for the care of a disabled dependent so either you or your spouse
could work or go to school, you may be allowed to deduct expenses, up to a maximum of $1,025
per month per child or disabled

dependent. We require proof showing the amount you paid and to whom. (Tis will not count if paid to
the child’s parent or stepparent, or to another dependent of the main subscriber.) If the expenses
were for the care of a disabled dependent, we will require you to provide documents of the
disability and proof that the dependent cannot care for himself/herself and, if the care is during
school hours, that
(s)he cannot attend public schools.

Eligibility and premiums for most Basic Health programs are based on
your family’s gross income, which is adjusted according to the number
of people in the family (the “income band” for the family). The
following table shows the income bands used for determining
eligibility and premiums through June 2008. After June 30, 2008,
please check
our Web site(www.basichealth.hca.wa.gov) or call 1-800-660-9840 for information. To find your income
band, find your family size and your family’s gross monthly income (before taxes and other
deductions).

The information in chapters 2-4 does not apply to HCTC-Basic Health members.

			
	 	 	 
	  4
	 	Basic Health 2008 Member Handbook

 

Table of Contents

Income Table

Number of People in Your Family

Gross Monthly Income

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Income
	1	 	2	 	3	 	4	 	5	 	6	 	7	 	Band
	$0 –

$553.04
	 	$0 –

$741.54
	 	$0 –

$930.04
	 	$0 –

$1,118.54
	 	$0 –

$1,307.04
	 	$0 –

$1,495.54
	 	$0 –

$1,684.04
	 	A
	553.05 –

850.83
	 	741.55 –

1,140.83
	 	930.05 –

1,430.83
	 	1,118.55 –

1,720.83
	 	1,307.05 –

2,010.83
	 	1,495.55 –

2,300.83
	 	1,684.05 –

2,590.83
	 	B
	850.84 –

1,063.54
	 	1,140.84 –

1,426.04
	 	1,430.84 –

1,788.54
	 	1,720.84 –

2,151.04
	 	2,010.84 –

2,513.54
	 	2,300.84 –

2,876.04
	 	2,590.84 –

3,238.54
	 	C
	1,063.55 –

1,191.16
	 	1,426.05 –

1,597.16
	 	1,788.55 –

2,003.16
	 	2,151.05 –

2,409.16
	 	2,513.55 –

2,815.16
	 	2,876.05 –

3,221.16
	 	3,238.55 –

3,627.16
	 	D
	1,191.17 –

1,318.79
	 	1,597.17 –

1,768.29
	 	2,003.17 –

2,217.79
	 	2,409.17 –

2,667.29
	 	2,815.17 –

3,116.79
	 	3,221.17 –

3,566.29
	 	3,627.17 –

4,015.79
	 	E
	1,318.80 –

1,446.41
	 	1,768.30 –

1,939.41
	 	2,217.80 –

2,432.41
	 	2,667.30 –

2,925.41
	 	3,116.80 –

3,418.41
	 	3,566.30 –

3,911.41
	 	4,015.80 –

4,404.41
	 	F
	1,446.42 –

1,574.04
	 	1,939.42 –

2,110.54
	 	2,432.42 –

2,647.04
	 	2,925.42 –

3,183.54
	 	3,418.42 –

3,720.04
	 	3,911.42 –

4,256.54
	 	4,404.42 –

4,793.04
	 	G
	1,574.05 –

1,701.75
	 	2,110.55 –

2,281.78
	 	2,647.05 –

2,861.80
	 	3,183.55 –

3,441.83
	 	3,720.05 –

4,021.86
	 	4,256.55 –

4,601.89
	 	4,793.05 –

5,181.92
	 	H
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Foster Parent Income Lim its* 

	1,701.76 –

2,127.16
	 	2,281.79 –

2,852.19
	 	2,861.81 –

3,577.22
	 	3,441.84 –

4,302.25
	 	4,021.87 –

5,027.28
	 	4,601.90 –

5,752.31
	 	5,181.93 –

6,477.34
	 	I
	2,127.17 –

2,552.58
	 	2,852.20 –

3,422.61
	 	3,577.23 –

4,292.64
	 	4,302.26 –

5,162.67
	 	5,027.29 –

6,032.70
	 	5,752.32 –

6,902.73
	 	6,477.35 –

7,772.75
	 	J

			
	 	 	 
	* I & J apply only to licensed Foster Parent
	 	Valid through June 30, 2008

The information in chapters 2-4 does not apply to HCTC-Basic Health members.

			
	 	 	 
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	 	5  

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Chapter Three:

Making Changes

and Maintaining Eligibility

Changes to your account could affect your Basic Health coverage. Report changes to Basic
Health within the timelines noted in this chapter. You may use the Change Form included with your
monthly bill to make some account changes. To get other forms, call our 24-hour, automated,
self-service phone line at 1-800-842-7712 or visit our Web site. You may also write to Basic Health
at PO Box 42683, Olympia, WA 98504-2683.

If you are enrolled through your employer or a financial sponsor, make sure the sponsor knows about
changes in your income or family, too, because it may affect the amount you pay for your coverage.
Contact your financial sponsor, employer, or payroll office if you have questions.

Changing health plans

Open enrollment is the time each year when you can change your health plan (if you have more than
one plan available in your area), except as noted elsewhere in this section. During open
enrollment, Basic Health will send you information about any changes to your coverage, and will
tell you about health plans in your area and their monthly premiums. You’ll be notified before each
open enrollment and given instructions for making changes.

Other than during open enrollment, you may only change health plans under certain conditions. These
are explained later in this chapter. You cannot change health plans because your provider is no
longer with your health plan. (An exception may be made in some cases if you can prove that you
need to continue a current course of treatment with a specific provider.) When you change health
plans,
remember each health plan contracts with different providers and has its own list of prescription
drugs. Call the health plan or your provider to find out if your provider contracts with the health
plan you are considering. If you take any prescription drugs, contact the health plan to see if
they will be covered.

If you change health plans, any services you had approved under your previous health plan will need
to be reviewed and approved again by your new health plan. Also, your deductible and out-of-pocket
maximum will start over. Check with your health plan for further information.

Basic Health will do its best to make sure your health plan is available throughout the year.
However, if your health plan becomes unavailable, you will be asked to choose one of the plans in
your county. If only one health plan remains, you will be assigned to that plan.

Address changes

You must give Basic Health your new address within 30 days of a change. You may call Basic Health
at 1-800-660-9840, complete and return the Change Form included with your bill, or write to Basic
Health at PO Box 42683, Olympia, WA 98504-2683. Include your Basic Health ID number, your name, new
address and county, your old address, and your new phone number. Be sure to say if your new address
is permanent or temporary (less than three months), and if your mailing address is different from
your street address.

If you move out of Washington State, you will be disenrolled from Basic Health. If you move out of
your health plan’s service area, you will have to

The information in chapters 2-4 dose not apply to HCTC-Basic Health members.

 
			
	 	 	 
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select a new health plan. If your current health plan is still available to you, but would cost
more, or you have plan choices that weren’t available before you moved, you may request a plan
change. While you are waiting to be transferred to your new health plan, you will need to keep
using your old health plan for anything except emergency services. When you change health plans,
your deductible and out-of-pocket maximum will start over.

Please note: Basic Health double-checks addresses with the U.S. Postal Service, so be sure to file
any change of address with your post office.

Dependent living away from home

If your dependent is living away from home, as described below, Basic Health will cover only
emergency care while the dependent is out-of-state or staying in a county that is not served by
your health plan. Routine services should be scheduled when the dependent is home.

Out-of-county

If your child lives in a different county, you may be able to choose a health plan that provides
service to both your home county and the county the dependent lives in. When necessary, Basic
Health allows your dependent to enroll in a different health plan under a separate account so the
dependent may receive services in the county where the dependent lives. You will be sent a separate
bill for their account.

Out of state

If your child is a Washington State resident, but lives away from home part of the time (to attend
college, for example), (s) he may be eligible to receive Basic Health
coverage as long as (s) he
remains a Washington State resident and returns to Washington State during scheduled breaks. You
may be required to provide proof of out-of-state tuition or that the child’s residence is in
Washington State.

Family changes

Eligible
family members may enroll in Basic Health during open enrollment. You will get
information telling you how to enroll a family member at that time.

Family members may be added, removed, or enrolled at other times during the year, based on the
guidelines below, by completing and submitting a Family Changes Form. Adding, enrolling, or
removing a family member may change your monthly premium. You will get written verification of any
changes to your account. Also, if the number of family members living in your home goes down, you
may no longer be eligible for Basic Health. If you do not report changes to your account in the
required timeframe, you may be disenrolled. To make any family changes to your account, call
1-800-842-7712 or visit Basic Health’s Web site to request the Family Changes Form. When you notify
Basic Health of a change in family size (such as birth, marriage, divorce, or death), you will be
required to submit proof of your current income and Washington State residence.

	•	 	Loss of or transfer from other continuous coverage: If you or a family member either left

The information in chapters 2-4 dose not apply to HCTC-Basic Health members.

 
			
	 	 	 
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or chose not to enroll in Basic Health coverage because you or they had other health care
coverage, and then that person loses or wants to transfer from that coverage, the request must be
received by Basic Health within 30 days of the loss of coverage. You must show proof of the other
continuous coverage.

	•	 	Enrolling a new family member: To enroll a new spouse, child, or dependent, Basic Health must
receive the appropriate application within the timeframes below. Otherwise, the family member
will be counted for family size when figuring your monthly premium, but will not have
coverage.

	 	•	 	Marriage: Within 30 days of the date of your marriage.
	 
	 	•	 	Newborn or newly adopted child: Within 60 days of the birth or placement for adoption.
	 
	 	•	 	Other dependents (students age 19 through 22, adult with disability): Within 30 days of
the date they become your dependent or move into your home. See page 3 for details.

Removing a family member: Basic Health needs notice of the following changes within the required
timeframes.

	•	 	Divorce or separation: We must receive notice within 30 days of the divorce or separation. If
you get back together and are living in the same home, you must tell Basic Health, in writing,
and we will stop the separation of your account.
	 
	•	 	Transfer of a former student to separate account: You must notify Basic Health within 30 days
of the date the person stops attending school full time. A former student who is taken off the
parents’ account because the child is no longer
a full-time student, may apply for coverage on a separate account.

When coverage begins for added family members

If you get married and follow the procedures explained in “Family changes” (above), coverage for
your new family members will begin on the first day of the month after eligibility has been
determined and full payment is received.

Your newborn or adopted child is covered from the date of birth or placement in your home if you or
a family member is enrolled in Basic Health or Basic Health Plus, and if Basic Health receives the
application for the child within 60 days of the birth or placement. If Basic Health receives your
application more than 60 days after the child’s birth or placement, your child will be included for
family size only when calculating your premium (this usually reduces your premium), but will not
have medical coverage. See page 8 for more information.

Income changes

If your income changes, your monthly premium or eligibility for Basic Health may change, too. You
must report any income change to Basic Health within 30 days of the end of the first month at the
new income. You must continue paying your premium as billed until we tell you the new premium
amount. (See additional information on pages 10-11.)

If you begin receiving Social Security Disability Benefits, you must notify Basic Health
immediately. This may affect your eligibility for Basic Health.

When sending income information to Basic Health, use the list below. If this list changes, we will
send you an update. Keep all updates with this handbook.

Include proof of all income received from the following sources:

	•	 	Salaries, wages, commissions, tips, work-study training stipends, or assistantships,
including overtime and bonuses
	 
	•	 	Self-employment
	 
	•	 	Rental property
	 
	•	 	Unemployment
	 
	•	 	Strike benefits
	 
	•	 	Social Security retirement, survivor, disability, or supplemental security income (including
money received by dependent children)
	 
	•	 	Retirement and pensions
	 
	•	 	Child support or alimony
	 
	•	 	Insurance benefits and compensation for an injury

The information in chapters 2-4 dose not apply to HCTC-Basic Health members.

 
			
	 	 	 
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(other than reimbursement for a loss or medical costs), including workers’ compensation

	•	 	Interest, dividends, periodic receipts from a trust, and royalties
	 
	•	 	Net short-term capital gains
	 
	•	 	Veterans’ benefits and military allotments
	 
	•	 	Public assistance (DSHS cash assistance)
	 
	•	 	Estate income
	 
	•	 	Net gambling or lottery winnings, unless you received them more than one month before you
apply for coverage
	 
	•	 	All other income that’s not specifically in the “Income does not include” list, below

Income does not include:

	•	 	Income, such as wages, earned by dependent children (however, you must include distributions
from a corporation, partnership, or business, even if distributed to a child)
	 
	•	 	Any assets drawn down as withdrawals from a bank, or proceeds from the sale of personal
property, such as a car
	 
	•	 	Tax refunds, gifts, or loans
	 
	•	 	Income from a family member who lives in another household, when that income is not
available to you or eligible dependents
	 
	•	 	University scholarships, grants, VA education grants, or fellowships
	 
	•	 	Non-cash benefits (such as food stamps, school lunches, or housing instead of wages)
	 
	•	 	Payments for adoption support received from the Department of Social and Health Services
(DSHS)
	 
	•	 	Individual Retirement Account (IRA) distributions
	 
	•	 	Crime victims’ compensation
	 
	•	 	L&I (Labor and Industries) one-time payments
	 
	•	 	Long-term capital gains

Reporting income changes

Send a Family Income Reporting Form, along with
proof of current income and IRS documentation for
the most current tax year. You may get this form by
calling 1-800-842-7712, or visiting our Web site.
(See “Recertification” for acceptable IRS and income
documentation.)

	•	 	Include proof of childcare expenses up to $1,025 per child, if the childcare was necessary for
both parents to work or attend school

Basic Health will send you a Personal Eligibility Statement. It will show any changes to your
account that affect your monthly premium or eligibility for the program. It may include a bill for
an additional amount you must pay as a result of the change.

Recertification

State law requires Basic Health to periodically review members’ income and eligibility for this
program. This is called “recertification.” Under this process, Basic Health members must send in
proof of income, benefits, and Washington State residency. Being selected for recertification does
not mean Basic Health believes you have given us the wrong information; it is a legal requirement
for all of our members. If you have to wait for Basic Health coverage because the program is full,
you may be recertified soon after your coverage begins.

If you get a recertification notice, Basic Health must receive all documentation requested by the
due date given. Otherwise, you and your covered family members will lose your coverage for at least
12 months. If you reapply for Basic Health at the end of the 12 months, you will have to provide
proof of income and eligibility at that time. Even if you are found eligible, if Basic Health is
full, you will have to wait until space is available.

To complete your recertification, you must send all of the following:

	•	 	Proof that you live in Washington State.
	 
	•	 	The Recertification Form sent to you, signed by any enrolled family members age 18 and over.
	 
	•	 	A copy of one of the following for the most current tax year:

	 	•	 	Your IRS Form 1040 (federal income tax form) and all schedules
	 
	 	•	 	IRS transcript of your return, if you do not have a copy of your IRS Form 1040

The information in chapters 2-4 dose not apply to HCTC-Basic Health members.

			
	 	 	 
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	•	 	Verification of non-filing from the IRS if you were not required to file a tax return
(non-filing status)

	•	 	Copies of pay stubs for the last 30 days for you and your spouse.
	 
	•	 	Written proof of all other income and benefits
received by your family for the last 30 days.
	 
	•	 	If you are self-employed or have rental income,
a copy of all business forms and schedules filed with the IRS, a complete copy of your Schedules
K-l (if applicable), and a Self-Employment/Rental Income Reporting Form if you:

	 	•	 	Were not required to file a tax return; or
	 
	 	•	 	Have been in business for less than 12 months.

We will send you more details when we select you for recertification.

What if I don’t report a change in income?

We base your monthly premium in part on your income; you must report all changes in your income to
Basic Health. We check with other sources to make sure your this information is accurate. If we
find you have not reported an income change, you must pay the difference between the premium you
paid and the premium you should have paid.

If this happens, Basic Health will send you a notice showing the amount we believe you owe the
state. If you believe you do not owe the amount shown on that notice, you must follow the
instructions in the notice. If you do not respond, or if you are unable to prove that the amount of
income you reported to us was correct, Basic Health will bill you for the amount you owe.

What if I don’t repay the amount I owe?

If you are billed, you must pay based on the billing schedule we provide. If you do not pay your
full bill on time, you will lose your Basic Health coverage. (See page 13 for more information.) If
you do not repay the total amount, your account will be sent to a collection agency and you will
also have to pay any
fees charged by the collection agency.

Legal penalties

Basic Health may bill you for twice the amount due if you:

	•	 	Intentionally provide misleading or false income information.
	 
	•	 	Withhold information about income.

If you intentionally provide false or misleading information or withhold information, Basic Health
may take additional legal action, such as:

	•	 	Prosecution for perjury.
	 
	•	 	Immediate disenrollment back to the date your coverage would have been affected. This means
we will bill you for the total cost of your health coverage since that date.

In addition, if your health plan has paid for services during a time you were enrolled through
fraud, they may demand you repay them.

The information in chapters 2-4 dose not apply to HCTC-Basic Health members.

			
	 	 	 
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Chapter Four:

Suspension, Disenrollment,

and Reenrollment

Suspension

If you (or your financial sponsor or employer, if enrolled through them) do not pay your premium on
time, you will lose coverage for one month (suspension). If your premium is paid in full by the due
date on your notice of suspension, you will be reenrolled the next month. If you lose coverage for
one month, any payments you have made toward your deductible and out-of-pocket maximums will still
count.

Disenrollment

To stop Basic Health or Basic Health Plus coverage for yourself, a family member, or your entire
family, call 1-800-660-9840, or write to Basic Health, PO Box 42683, Olympia, WA 98504-2683. You
must include:

	•	 	Your name and Basic Health ID number.
	 
	•	 	The name of each person you want to disenroll.
	 
	•	 	The reason you want to disenroll (especially if due to other insurance, Medicare, or
Medicaid).
	 
	•	 	The date you want coverage to end. We need to receive your request to disenroll at least 10
days before the first of the month you want coverage to end.

You are no longer eligible for Basic Health and will be disenrolled if you:

	•	 	Leave Washington State with no plan to return, or if you are gone for more than three months
in a row.
	 
	•	 	Become eligible for free or purchased Medicare coverage, regardless of whether you actually
have Medicare coverage.
	 
	•	 	Have income above Basic Health’s income guidelines.

If you are disenrolled because you became ineligible (as previously described) and your
circumstances change, you may reapply for Basic Health coverage, but may have to wait until space
is available.

You will be disenrolled from Basic Health and will not be allowed back in for at least 12 months if
you:

	•	 	Are suspended for nonpayment three times in a 12-month period, or do not reenroll the month
following a one-month suspension.
	 
	•	 	Are billed for the amount Basic Health overpaid for your coverage, and you do not pay the
amount based on the billing schedule we provide. (See “What if I don’t report a change in
income?” on page 11.)
	 
	•	 	Do not provide documents Basic Health asks for to check your eligibility or income.
	 
	•	 	Take part in any abuse, intentional misconduct, or fraud against Basic Health or your health
plan or its providers, or knowingly give information to Basic Health that is false or
misleading.
	 
	•	 	Intentionally withhold required information, such as a change in income or family size.

You may also be disenrolled from Basic Health if you:

	•	 	Purposely put the safety or property of Basic Health or your health plan, or their
staff, providers, patients, or visitors, at risk.
	 
	•	 	Refuse to follow procedures or treatment recommended by your provider and determined by your
health plan’s medical director to be essential to your health or the health of your child, and
you have been told by your health plan that no other treatment is available.

The information in chapters 2-4 dose not apply to HCTC-Basic Health members.

			
	 	 	 
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	 	11   

 

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	•	 	Repeatedly fail to pay copayments, coinsurance, or other cost-sharing requirements on time.
	 
	•	 	Intentional misconduct. This includes withholding from your health plan information you have
about a legally responsible third party, or refusing to help your health plan collect from
that legally responsible third party

These conditions for loss of coverage also apply to family members enrolled on your Basic Health
account.

Family members enrolled in Basic Health Plus or the Maternity Benefits Program through DSHS may
stay with these programs as long as they are eligible, even if your coverage is suspended for one
month or you are disenrolled from Basic Health for failing to pay your required premium.

If your coverage ends, you will receive written notice of the reason and the date your coverage
ends.

Disenrollment
from employer, financial sponsor, or home care agency coverage

If you have Basic Health coverage through your employer, you may be able to continue your coverage
through the federal Consolidated Omnibus Budget Reconciliation Act (COBRA). Under COBRA, you can
continue coverage for up to 18 months; however, you will have to pay the full cost of that
coverage, including any premium share that had been paid by your employer. Contact your employer to
find out if you qualify for COBRA coverage.

If you are no longer eligible for employer, home care agency, or financial sponsor coverage, but
still qualify for individual Basic Health, Basic Health will offer you coverage on your own
account. If you get an offer from us, you must tell us right away if you want to transfer to your
own account. If you do, you must pay the premium for your continued coverage.

Reenrollment

The reenrollment process depends on the reason your Basic Health coverage ended and the amount of
time since you last had coverage. When you reapply for Basic Health, you may be required to send in
a new application, proof of income and residency, and proof of other continuous coverage.

Generally, when you disenroll from Basic Health, you have to wait at least 12 months before
you can reenroll, and may have to wait until space is available. However, the 12-month wait
for reenrollment may be waived if either:

	•	 	You left for other coverage, and you reapply for Basic Health within 30 days of losing other
continuous coverage (you will be required to provide proof of other continuous coverage).
	 
	•	 	You move out of the state, then move back to stay.
	 
	•	 	You were disenrolled because you were no longer eligible for Basic Health coverage, but you
are now eligible again.

Even if the 12-month wait for reenrollment is waived, if Basic Health is full, you will have to
wait until space is available.

Reenrollment after disenrollment to Medicaid coverage

If you leave Basic Health for Medicaid coverage (for example Healthy Options, SSI, or GA-U), and
then lose the Medicaid coverage, you may reenroll in BH without waiting for space to be available.
You must request enrollment in Basic Health within 30 days of losing Medicaid. When you re-apply to
Basic Health you may be required to send a new application, proof of income, a copy of your IRS
1040 and all your schedules for the most current tax year, and proof of Washington State residency.

The information in chapters 2-4 dose not apply to HCTC-Basic Health members.

			
	 	 	 
	  12

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Chapter Five:

Rights, Responsibilities, and Privacy

Basic Health member rights

As a Basic Health member, you have the right to:

	•	 	Get understandable notices or have the materials explained or interpreted.
	 
	•	 	Receive timely information about your health plan.
	 
	•	 	Get courteous, prompt answers from your health plan and Basic Health.
	 
	•	 	Be treated with respect.
	 
	•	 	Have your privacy protected by Basic Health, your health plan, and its providers.
	 
	•	 	Get information about all medical services covered by Basic Health.
	 
	•	 	Choose your health plan and primary care provider from among available health plans and their
contracted networks.
	 
	•	 	Receive proper medical care, consistent with Appendix A of this handbook, without discrimination
no matter what your health status or condition, sex, ethnicity, race, marital status, or religion.
	 
	•	 	Get all medically necessary covered services and supplies listed in the Basic Health Schedule
of Benefits, subject to the limits, exclusions, and cost-sharing described in Appendix A.
	 
	•	 	Take part in decisions about your and your child’s health care, including having a candid
discussion of appropriate or medically necessary treatment options, regardless of cost or coverage.
	 
	•	 	Get medical care without a long delay.
	 
	•	 	Refuse treatment and be told of the possible results of refusing, including if your refusal may
result in disenrollment from Basic Health.
	 
	•	 	Expect your and your child’s records and conversations with providers to be kept confidential.

	•	 	Get a second opinion by another provider in your health plan when you disagree with the initial
provider’s recommended treatment plan.
	 
	•	 	Make a complaint about the health plan or providers and receive a timely answer.
	 
	•	 	File an appeal with your health plan or Basic Health if you are not satisfied with their
decision (see pages 19-20).
	 
	•	 	Receive a review of a Basic Health appeal decision, if you disagree with it.
	 
	•	 	Change your primary care provider for a good reason (call your health plan for assistance).

			
	 	 	 
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Basic Health member responsibilities

As a Basic Health member, you and/or your enrolled dependents have the responsibility to:

	•	 	Understand Basic Health.
	 
	•	 	Accurately and promptly report changes that may affect your premium or eligibility, such as an
address change, or a change in family status or income, and send in the required forms and
documents. (Read Chapters Two and Three for timelines and instructions.)
	 
	•	 	Choose a health plan in your area.
	 
	•	 	Choose a primary care provider from your health plan before receiving services.
	 
	•	 	Work with your health plan to help get any third-party payments for medical care.
	 
	•	 	Tell your health plan about any outside sources of health care coverage or payment, such as
insurance coverage for an accident.
	 
	•	 	Tell your or your child’s primary care provider about medical problems, and ask questions about
things you do not understand.
	 
	•	 	Decide whether to receive a treatment, procedure, or service.
	 
	•	 	Get medical services from (or coordinated by) your or your child’s primary care provider,
except in an emergency or in the case of a referral.
	 
	•	 	Get a referral from the primary care provider before you or your child goes to a specialist.
	 
	•	 	Pay copayments in full at the time of service.
	 
	•	 	Pay your Basic Health premiums in full by the due date.
	 
	•	 	Pay your deductible and coinsurance in full when they are due.
	 
	•	 	Not engage in fraud or abuse in dealing with Basic Health, Basic Health Plus, the Maternity
Benefits Program, your health plan, your primary care provider, or other providers.
	 
	•	 	Keep appointments and be on time, or call the provider’s office when you or your child will be
late or can’t keep the appointment.
	 
	•	 	Keep your family members’ medical I.D. cards with the family member at all times, or with you if
your children are young.
	 
	•	 	Notify the health plan or primary care provider within 24 hours, or as soon as is reasonably
possible, of any emergency services provided outside the health plan.
	 
	•	 	Use only your selected health plan and primary care provider to coordinate services for your
family’s medical needs.
	 
	•	 	Comply with requests for information, including requests for medical records or information
about other coverage, by the date requested.
	 
	•	 	Cooperate with your primary care provider and referred providers by following recommended
procedures or treatment.
	 
	•	 	Work with your health plan and providers to learn how to stay
healthy.

Informed consent

You have the right to give your consent to treatment or care. Be sure to ask your provider about
the side effects of your or your child’s care. You have the right to know about them, and give your
consent before getting care.

Advance directives

“Advance directives” put your health care choices into writing. They may also name
someone to speak for you if you are not able to speak. Before signing such a document, talk to a
lawyer or legal counselor. Washington State law has two kinds of advance directives:

	1.	 	Durable Power of Attorney for Health Care- Names someone to make medical decisions for you if you are not able to make them for yourself.
	 
	2.	 	A Directive to Physicians (Living Will) - A document that lets you tell your doctor what you do or do not want done if you have a terminal
condition or are permanently unconscious.

			
	 	 	 
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Privacy

Personal health information

The Health Care Authority (HCA) will not release any personal health
information that is provided verbally, electronically, or in writing to anyone but you or your
health plan without your prior written authorization. Exception: Basic Health and DSHS may exchange
information about your pregnancy.

Account information

Without your written permission, the HCA cannot release personal account details such as
eligibility, enrollment, monthly premium, or payment to anyone but you or your health plan.

Exceptions:

	•	 	If your employer, a home care agency, or a financial sponsor is paying your premium, limited
information may be released to your representative. Ask your representative for details.
	 
	•	 	Information about a dependent minor child will be released to either parent.
	 
	•	 	Your information may be shared with DSHS if DSHS is paying any part of your premium (for
example, if you are applying for or enrolling in Basic Health Plus or the Maternity Benefits
Program, or as a foster parent, personal care worker, or home care worker).
	 
	•	 	Providing information to law enforcement.

If you want to let someone else (such as a friend or a relative) access or make changes to your
account, you need to send written permission to Basic Health. Be sure to sign and date your letter
and include the person’s name, their relationship to you, and what information you want released to
them or changes they can make. Only the information you specify will be released. You will also
need to tell us if this permission is for a specific time period or for as long as you are enrolled
in Basic Health. When this person calls, they’ll need your Basic Health ID number, and will be
asked for other identifying information.

The HCA privacy notice is available on request by calling 360-923-2822 or online at www.hca.wa.gov.

			
	 	 	 
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Chapter Six:

Grievances, Complaints, and Appeals

If you have a grievance or appeal about services from your health plan, its providers, or benefits,
contact your health plan directly. You can find the toll-free numbers on the inside front cover of
this book. If you disagree with the determination of your ineligibility for the Health Coverage Tax
Credit, contact the HCTC Customer Contact Center for information. (See Appendix B for HCTC contact
information.) If you have a complaint about an action taken by Basic Health, call 1-800-660-9840.
If you call Basic Health or your health plan, be sure to note the date of the call, the name of the
person you talked to, and whether that person was with Basic Health or your health plan.

Your health plan is required to give you information on its grievance and appeals process:

	•	 	When you enroll.
	 
	•	 	Annually and/or whenever there is a change to their grievance and appeal process.
	 
	•	 	When the health plan sends you a notice of a denial of a benefit or service, or notice of an
appeal decision.

Grievances against your health plan

If you disagree with a decision made by your health plan (such as a denial of a claim or benefits
interpretation) or have a grievance regarding your health plan’s services, providers, or
facilities, you must follow your health plan’s procedures for resolving the problem. Basic Health
staff are available to help you resolve the issue informally, but the matter cannot be appealed to
Basic Health. You may file a grievance in writing, in person at the health plan’s office, or over
the phone. The health plan will help you with this process.

If you file a grievance with your health plan, the health plan must respond within 30 days after
receiving it. If you file a grievance against a health plan’s service, provider, or facility,
Washington
State law limits the information the health plan may provide you regarding the resolution of your
grievance.

Appeals to your health plan

If you are denied a service, or the health plan changed a service that
was already approved, you may file an appeal. An appeal is a request for the health plan to review
its decision. You may file an appeal or a grievance in writing, in person at the health plan’s
office, or over the phone. The health plan will help you with this
process.

When you file an appeal with your health plan:

	•	 	Within five working days, the health plan will send you a letter saying they’ve received your
appeal.
	 
	•	 	Within 14 calendar days, your health plan must respond to you in writing with either a
decision or notification of a reason for a delay. However, unless you agree to an additional delay,
the decision must be made within 30 calendar days after the health plan receives your appeal.

If waiting for a decision could put your health at risk, you can ask, or have your provider ask,
for an expedited (quick) review. The health plan will make a decision within 72 hours after
receiving an expedited appeal.

If you have gone through your health plan’s appeal process and disagree with their decision, or if
your health plan has not responded to you within the timelines referenced above, you have the right
to request a review of the decision by an Independent Review Organization (IRO). This is done
through your health plan and at no cost to you. Your health plan is required by law to give the IRO
all information used in making its decision within three business days of receiving the request.
You may also be required to provide additional information or documentation needed for the IRO’s
decision. If waiting for a decision could put your health at risk,

			
	 	 	 
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you can ask for an expedited (quick) review. The IRO will make a decision within 72 hours. The
health plan will let you know the outcome.

You may choose someone, including an attorney or provider, to serve as your personal representative
to act on your behalf for the appeal. The health plan must receive written consent from you
allowing this person to represent you before the person can act on your behalf. Contact your health
plan for additional information.

Complaints against Basic Health

If you have a complaint or want an explanation of an action Basic Health has taken on your account,
write to Basic Health at PO Box 42683, Olympia, WA 98504-2683, or call 1-800-660-9840. A
representative will try to resolve your issue.

Appeals to Basic Health

If you disagree with a Basic Health decision, such as premium calculation, premium adjustment or
penalty, change of health plan, denial of Basic Health eligibility, or loss of Basic Health
coverage, you may file a written appeal with Basic Health within 30 days of the notice of the
decision. Write to Basic Health Appeals, PO Box 42690, Olympia, WA 98504-2690, stating you want to
file an appeal. Your letter must include your name, address, Basic Health ID number, a daytime
phone number, a summary of the decision you are appealing, and a statement explaining why you
believe the decision was incorrect. You must also include copies of any evidence that will help
explain or prove that the decision should be changed. If your appeal is not received within 30 days
of the notice of the decision, you will lose your right to appeal that decision.

In your appeal, you may ask to explain in person or by phone why you believe the decision was
incorrect and should be changed. Be sure to let us know if you will need an interpreter and, if so,
what language and dialect you speak. Also let us know if you will need any assistance due to
disability.

Basic Health will confirm that your appeal was received. If you have asked to explain your appeal
over the phone or in person, our Appeals Department will contact you to schedule a conference. The
conference will be recorded to ensure an accurate record, and you will be questioned as well as
given an opportunity to explain your point of view. You should be prepared to give detailed
information to support your opinion that the decision was in error.

Your appeal will be reviewed carefully, and Basic Health will mail a written notice of the decision
to you within 60 days of receiving your appeal. If additional time is required for investigation of
your appeal, you’ll be notified in writing and a decision date will be set.

If you disagree with Basic Health’s decision on your appeal, you may request a further review of
that decision verbally or by writing to: Basic Health Appeals, PO Box 42690, Olympia, WA
98504-2690. Basic Health must receive your request for review within 30 days of the date on the
notice of Basic Health’s appeal decision. You should explain that you are asking for a review of
Basic Health’s appeal decision. You must provide additional written evidence to show why you
believe the appeal decision was incorrect. Also provide a summary of the decision you are
contesting, why you believe the decision was incorrect, and a daytime phone number where we can
reach you. In addition, the request must include all evidence that has not yet been provided and on
which you will rely to explain why you believe Basic Health acted incorrectly. If your request for
a review is not received within 30 days of the notice of the appeal decision, you will lose your
right for a review.

The Office of Administrative Hearings will review Basic Health’s appeal decisions regarding
disenrollment due to nonpayment. A presiding officer appointed by the Administrator of the Health
Care Authority will review Basic Health’s appeal decisions on all other issues, based on the record
of the appeal and any evidence you send. Be sure to include all information you want considered.
The presiding officer may contact you for further information, but you generally will not be
offered an opportunity to explain in person or by phone at this point in the process. The HCA will
notify you in writing of the final decision.

You may choose someone, including an attorney or provider, to serve as your personal representative
to act on your behalf for the appeal. Basic Health must receive written consent from you allowing
this person to represent you before the person can act on your behalf. Contact Basic Health for
additional information.

			
	 	 	 
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Chapter Seven:

Health Plans and Providers

How the health plans work

All health plans offer the same basic benefits and require you to choose
a primary care provider (PGP) to coordinate or provide your care. Costs, providers and facilities,
covered prescription drugs, referral practices, and other things may differ by health plan.

Each health plan contracts with a number of providers and facilities (called the health plan’s
“provider network”). Your health plan may refer you to a specialist or facility
outside the health plan’s network if you or your child needs a provider or hospital not available
inside your health plan’s network. You must get your health plan’s approval to be treated by a
provider or facility not available through your health plan’s provider network, except in an
emergency (see page 23).

Some health plans may contract with provider groups called subnetworks; this may restrict your
choice of providers. You may be required to see specialists or use facilities, such as hospitals,
in the same subnetwork as your PGP. This means that even if a provider is in your health plan’s
provider network, the provider’s services may not be available to you unless the provider is also
in the same subnetwork as your PCP.

Call the health plan or your PCP to find out if your PCP can refer you to a provider with that
health plan’s provider network, or if your PCP can refer you to only a selected group of providers
within the health plan.

When does my coverage begin?

Basic Health notifies you in writing when your coverage is effective. Take note of the effective
date of coverage shown in that letter. Basic Health will not cover any services received before
your coverage begins.

ID cards

After you enroll in Basic Health, the health plan will send ID cards to you and your enrolled
family members. Some health plans may require you to choose a PCP before they issue your ID card.
The card has important information, including the number to call if you are hospitalized or have
questions. If you need care before you receive the card, contact the health plan at the number
listed on the inside front cover of this handbook. Don’t throw your enrollment confirmation letter
away from Basic Health; it can serve as your temporary identification until you receive your
card(s).

			
	 	 	 
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The right to object to certain services

Religiously sponsored health plans, health care providers,
or employers have the right to not provide benefits or services for termination of pregnancy or
other services to which they object because of religious belief or issues of conscience. If your
health plan or employer objects to providing a specific service that is normally provided, you will
be told how to receive this particular service from another provider, with no added cost to you.
Contact your health plan for more information.

If you object to having coverage for termination of pregnancy or other services, you may notify
Basic Health in writing. Benefits will not be provided to you for those services; however, your
premium will not change.

Primary care provider (PCP)

Each covered family member must enroll in the same health plan, but may choose a different PCP
within your health plan. Except in an emergency, your PCP and staff will provide or coordinate all
your health care, including referrals to specialists. Primary care providers may be family or
general practitioners, internists, pediatricians, or other providers approved by your health plan.
You may change your PCP during the year. Contact your health plan for details on changing providers
or for a current list of providers. You may also contact a provider you’re considering and to find
out if the provider contracts with your health plan for Basic Health coverage. When you call a
provider, be sure to
mention the health plan name and Basic Health, and ask whether the provider is accepting new
patients.

To be covered by your health plan, your PCP must provide all health care services, unless:

	•	 	You are referred to another provider by your PCP (in most cases, the referral must be approved
by your health plan);
	 
	•	 	You need emergency care, as described on page 23; or
	 
	•	 	You self-refer for women’s health care services (see below) or covered chiropractic care to a
provider who contracts with your health plan.

If you have questions, call your health plan at the number listed on the inside, front cover of
this handbook.

Women’s health care services

The following women’s health care services are covered by Basic Health
without a PCP referral or health plan preauthorization:

	•	 	Maternity care, including prenatal, delivery, and postnatal care.
	 
	•	 	Routine gynecological exams.
	 
	•	 	Examination and treatment of disorders of the female reproductive system, except as specifically
excluded.
	 
	•	 	Other health problems discovered and treated during the course of a woman’s health care visit,
as long as the treatment is within the provider’s scope of practice, and the service provided is
not excluded.

You may seek these services from any women’s health care provider who contracts with your health
plan. Services provided by hospitals or outpatient surgical centers may require preauthorization
from your health plan. Also, any follow-up services for conditions not directly related to
maternity care, routine gynecological exams, or disorders of the female reproductive system may
require referral and preauthorization by your health plan.

			
	 	 	 
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	 	19  

 

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Chapter Eight:

Covered
Services and Member Costs 

The list of services covered under Basic Health, called
the “Schedule of Benefits,” is in Appendix A of this
handbook. If you have questions about a particular medical
condition or Basic Health benefit, contact your health
plan directly at the number listed on the inside, front
cover of this handbook.

Emergency care

Emergency care is covered 24-hours a day, seven days a
week. (See page 45 for the definition of “emergency.”) To
receive emergency care benefits, it is important to follow
these steps:

	•	 	Depending on how serious the problem is, go
directly to the nearest emergency room, call 911,
or call your PCP.

	•	 	If you are admitted to a hospital or other health
care facility, call (or have a friend, family
member, or staff member call) your health plan or
PCP within 24 hours or as soon as is reasonably
possible.

	•	 	See (or be referred by) your PCP for follow-up
care.

Important: If you do not follow these instructions, and
the provider bills for a higher amount than your health
plan would pay a contracted provider, you may be required
to pay the balance. If the case is determined not to be
an emergency (whether or not you follow the
instructions), you will be responsible for all costs.

Preexisting condition waiting period

Generally, you must wait nine months from the day your
coverage begins before Basic Health will cover
preexisting conditions, except for maternity care and
prescription drugs. For more information, see
“Limitations and exclusions” on page 37.

A preexisting condition is defined as an illness,
injury, or condition for which, in the six months
immediately preceding a member’s effective date of
enrollment in Basic Health:

	•	 	Treatment, consultation, or a diagnostic test was
recommended for or received by the member;

	•	 	Medication was prescribed or recommended for the
member; or

	•	 	Symptoms existed which would ordinarily cause a
reasonably prudent individual to seek medical
diagnosis, care, or treatment.

If you were enrolled in health care coverage that was
similar to Basic Health at any time during the three
months just before you applied for or were enrolled in
Basic Health, your waiting period for treatment of a
preexisting condition may be waived or shortened as
described in “Limitations and exclusions” beginning on
page 37.

If you had to wait for Basic Health coverage because the
program was full, you may receive up to three months’
credit toward the waiting period. (This does not apply to
the waiting period for organ transplant services.)

Organ transplants

You must be a Basic Health member for 12 months in a row
before an organ transplant for a preexisting condition
will be covered. See pages 30–31 for details.

Maternity care

If you or an enrolled family member becomes pregnant,
call 1-800-660-9840 right away. We will mail a
Maternity Benefits Application for you to complete and
return to us.

Basic Health only covers maternity services for 30 days
after pregnancy is confirmed by a medical

			
	 	 	 
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provider, unless you apply for the Maternity Benefits
Program. This Basic Health and DSHS program provides full
maternity coverage and allows you to receive care through
the same health plan you choose for your Basic Health
coverage. When choosing a provider for your maternity
care, make sure the PCP contracts with your chosen health
plan to provide Maternity Benefits Program services
through Basic Health.

The Maternity Benefits Program includes the following
benefits at no cost during pregnancy and for two months
after your pregnancy ends:

	•	 	Prenatal care

	•	 	Maternity support services

	•	 	Dental care

	•	 	Labor and delivery

	•	 	Family planning

	•	 	Physical therapy

	•	 	Postpartum care

	•	 	Transportation to appointments

	•	 	Hearing

	•	 	Childbirth education

	•	 	Maternity case management

	•	 	Vision (eye exams and glasses)

DSHS determines eligibility for the Maternity Benefits
Program based on their eligibility criteria. Information
about this program is available in a separate booklet
called A Guide to Basic Health Plus and the Maternity
Benefits Program. This document will be sent to you when
you enroll in the Maternity Benefits Program.

Don’t stop paying your Basic Health premiums until your
effective date for your enrollment in the Maternity
Benefits Program. Once you are enrolled in the Maternity
Benefits Program, you will not have monthly premiums or
copayments, and you will continue to receive your care
from the health plan you chose through Basic Health. You
still must pay the monthly premiums for any family members
enrolled in Basic Health.

If you do not meet citizenship requirements for the
Maternity Benefits Program, you may be eligible for
other DSHS programs that cover maternity care.

To receive these benefits, you must report your
pregnancy to Basic Health.

If you do not apply for the Maternity Benefits Program,
Basic Health will not cover the cost of any maternity
services beyond 30 days after pregnancy is confirmed by
a medical provider.

Maternity services will be covered by Basic Health if
DSHS finds you ineligible for maternity coverage. Refer
to Appendix A for information on maternity coverage for
those who are ineligible for the Maternity Benefits
Program.

When your pregnancy ends

You must notify Basic Health at 1-800-660-9840 as soon as
your pregnancy ends. We will mail you an application to
add your newborn child to your Basic Health account. To
avoid a break in coverage, Basic Health must receive your
completed application to add your newborn within 60 days
of the child’s birth.

Your Basic Health medical coverage will resume when your
maternity benefits end only if your family’s Basic Health
premiums (if any) have been paid while you were enrolled
in the Maternity Benefits Program. For example, if you
have a spouse and/or dependent(s) enrolled in Basic Health
and they are disenrolled for nonpayment while you are
covered through the Maternity Benefits Program, your
coverage will continue until two months after your
pregnancy ends. At that point, you will lose your
coverage, and you and your family (except for children
enrolled in Basic Health Plus) will not be able to
reenroll in Basic Health for 12 months. In addition, if
Basic Health is full at that time, you will have to wait
until space is available.

If the pregnant family member is a child enrolled in
Basic Health Plus, she does not need to apply for the
Maternity Benefits Program, although you must notify
Basic Health of the pregnancy. Her maternity benefits
will be covered through Basic Health Plus. You must
notify Basic Health within 60 days of the end of her
pregnancy by completing and returning the Family Changes
Form or the Change Form included with your billing
statement to continue the newborn’s coverage. To continue
coverage for her newborn, your daughter may also need to
enroll on

			
	 	 	 
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her own account.

Member costs

Each member enrolled in Basic Health is responsible for
sharing health care cost of coverage, as follows:

Copayment – A set dollar amount you pay when receiving
specific services. In most cases, this will be $15,
except for prescription drugs and emergency room visits.

Deductible – The amount you pay before your health plan
starts to pay for covered services. You are responsible
for paying the first $150 of certain covered medical
costs before your health plan pays the 80% coinsurance.
The $150 deductible has to be met every calendar year for
each family member enrolled in Basic Health. Your
deductible does not apply towards your out-of-pocket
maximum. You may receive a bill from your health plan
and/or provider.

Coinsurance – For certain services, you will be
responsible for paying 20% of the cost. Your health plan
pays the remaining 80%. You may receive a bill from your
health plan and/or provider.

Out-of-pocket maximum – Your coinsurance costs apply
toward your out-of-pocket maximum of $1,500 per person,
per calendar year. When you reach your out-of-pocket
maximum, you do not have to pay any further coinsurance
costs for covered benefits and services received during
that year. Your health plan will pay 100% of the
coinsurance for all covered benefits and services. The
$1,500 out-of-pocket maximum applies to each family member
enrolled in Basic Health.

If you change health plans any time during the year, the
amount you’ve paid toward your deductible and
out-of-pocket maximum for covered family members will
start over with your new health plan.

See the “Schedule of Benefits” on page 27.

If you receive a bill for covered services

If you receive care from a provider who contracts with
your health plan, the provider will usually bill the
health plan directly.

You will receive a bill from a provider who has provided
services to you that require a deductible and coinsurance.
In most cases, your health plan will first send you an
Explanation of Benefits (EOB) that will explain what
service you received, what the allowed amount is for that
service, what the health plan has paid, and what you have
to pay. The EOB will also provide you with information
about how much you have paid toward your deductible and
out-of-pocket maximum. The provider or facility where you
have received services will then send you a bill. You must
pay the provider or facility directly. If you receive a
bill but have not yet received an EOB, or if you have
questions about your bill, contact the provider’s office
or your health plan.

In some cases, you may receive a bill from a provider or a
facility that does not contract with your health plan, or
from a provider who did not know about your Basic Health
coverage. (When you fill out

			
	 	 	 
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information for your provider, be sure to list the health
plan that provides your coverage—not Basic Health.) If
you receive a bill for services that you think are
covered by Basic Health but that have not yet been billed
to your health plan, send the bill directly to your
health plan at the address on your ID card. (Call your
health plan at the number listed on the inside cover of
this book for details.) Benefits may be denied if your
health plan receives the bill more than 12 months after
the date you received services.

If a third party is responsible for your injury
or illness

You or your representative are required to notify your
health plan if your provider charges the health plan for
treatment of an injury or illness that is the result of
another person’s or organization’s action or failure to
act (for example, a fall, an auto accident, or an
accident at work). The other person or organization
responsible for your injury or illness is called the
“third party.”

You must notify your health plan promptly,
in writing, of all of the following:

	•	 	The facts of the injury or illness, including
the name and address of any third party you think
may be responsible for the injury or illness.

	•	 	The name and address of the third party’s
insurance company.

	•	 	The name and address of any attorneys who will be
representing the third party.

	•	 	If you plan to file a claim or lawsuit against
the third party, the name and address of the
person who will be representing you.

	•	 	Adequate advance notice of any trial, hearing, or
possible settlement of your claim against the third
party.

	•	 	Any changes in your condition or injury.

	•	 	Any additional information reasonably requested by
the health plan.

If you bring a claim or legal action against a liable
third party, you must seek recovery of the benefits
paid by your health plan.

After you have been fully compensated for all damages you
experienced as a result of the accident, your health plan
has a right to reimbursement up to the amount of the
benefits the health plan has paid, from any recovery you
receive. You are required to pay the health plan only the
amount that is left over after you have been fully
compensated for all of your damages (including pain and
suffering and lost wages), up to the amount of the
benefits paid.

If your health plan seeks to recover benefits directly
from the third party, you must cooperate fully and not do
anything to impair your health plan’s right of recovery.
Your health plan may bring suit against the third party in
your name, or may join as a party in a lawsuit or claim
you have filed. Your health plan will not be required to
pay for legal costs you incur, and you will not be
required to pay legal costs incurred by your health plan.
However, your health plan may agree to share the cost if
they choose to be represented by your attorney.

Basic Health can disenroll you for intentional
misconduct if you:

	•	 	Withhold from your health plan information you
have about a legally responsible third party.
	 
	 	 	or
	 
	•	 	Refuse to help your health plan collect from that
legally responsible third party.

			
	 	 	 
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	 	23  

 

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Appendix A:
Schedule of Benefits

Appendix A:

Schedule of Benefits

This “Schedule of Benefits” lists benefits for Basic Health members. Services are subject to all
provisions of this “Schedule of Benefits,” including limitations, exclusions, deductibles,
coinsurance, and copayments. Except as specifically stated otherwise, all services and benefits
under Basic Health must be provided, ordered, or authorized by the health plan or its contracting
providers. Even if your provider authorizes a service, your health plan may also need to
preauthorize the care.

Services in addition to those listed in this “Schedule of Benefits” may be provided at the sole
discretion of the health plan through the health plan’s medical management or case management
program if providing the service will result in a lower total out-of-pocket cost to the health
plan. Additional services may be subject to copayments, deductibles, coinsurance, and limitations.

If you have a question about the benefits listed, or are not sure if a service is covered, you
should call the health plan’s customer service department.

	I.	 	Medically necessary services, supplies, or interventions
	 
	 	 	Basic Health provides coverage for services, supplies, or interventions that are otherwise
included as a “covered service,” as set forth in Section II, that are not excluded and are
medically necessary. A covered service is “medically necessary” if it is recommended by your
treating provider and your health plan’s medical director or provider designee, and if all of
the following conditions are met:

	 	A.	 	The purpose of the service, supply, or intervention is to treat a medical condition.
	 
	 	B.	 	It is the most appropriate level of service, supply, or intervention considering the
potential benefits and harm to the patien.
	 
	 	C.	 	The level of service, supply, or intervention is known to be effective in improving health
outcomes.
	 
	 	D.	 	The level of service, supply, or intervention recommended for this condition is
cost-effective compared to alternative interventions, including no intervention.
	 
	 	E.	 	For new interventions, effectiveness is determined by scientific evidence. For existing
interventions, effectiveness is determined first by scientific evidence, then by
professional standards, then by expert opinion.

	 	 	A health “intervention” is an item or service delivered or undertaken primarily to treat (i.e.,
prevent, diagnose, detect, treat, or palliate) a medical condition (i.e., disease, illness,
injury, genetic or congenital defect, pregnancy, or a biological or psychological condition that
lies outside the range of normal, age-appropriate human variation), or to maintain or restore
functional ability. For purposes of this definition of “medical necessity,” a health
intervention means not only the intervention itself, but also the medical condition and patient
indications for which it is being applied.
	 
	 	 	“Effective” means that the intervention, supply, or level of service can reasonably be expected
to produce the intended results and to have expected benefits that outweigh potential harmful
effects.
	 
	 	 	An intervention, supply, or level of service may be medically indicated yet not be a covered
benefit or meet the standards of this definition of “medical necessity.” Your health plan may
choose to cover interventions, supplies, or services that do not meet this definition of
“medical necessity”; however, the health plan is not required to do so.
	 
	 	 	“Treating provider” means a health care provider who has personally evaluated the patient.

			
	 	 	 
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Appendix A: Schedule of Benefits

	 	 	“Health outcomes” are results that affect health status as measured by the length or
quality (primarily as perceived by the patient) of a person’s life.
	 
	 	 	An intervention is considered to be new if it is not yet in widespread use for the medical
condition and patient indications being considered.
	 
	 	 	“New interventions” for which clinical trials have not been conducted because of
epidemiological reasons (i.e., rare or new diseases or orphan populations) shall be evaluated
on the basis of professional standards of care or expert opinion (see “existing interventions”
below).
	 
	 	 	“Scientific evidence” consists primarily of controlled clinical trials that either directly or
indirectly demonstrate the effect of the intervention on health outcomes. If controlled
clinical trials are not available, observational studies that demonstrate a causal relationship
between the intervention and health outcomes can be used. Partially controlled observational
studies and uncontrolled clinical series may be suggestive, but do not by themselves
demonstrate a causal relationship unless the magnitude of the effect observed exceeds anything
that could be explained either by the natural history of the medical condition or potential
experimental biases.
	 
	 	 	For “existing interventions,” the scientific evidence should be considered first and, to the
greatest extent possible, should be the basis for determinations of “medical necessity.” If no
scientific evidence is available, professional standards of care should be considered. If
professional standards of care do not exist, or are outdated or contradictory, decisions about
existing interventions should be based on expert opinion. Giving priority to scientific
evidence does not mean that coverage of existing interventions should be denied in the absence
of conclusive scientific evidence. Existing interventions can meet the Basic Health definition
of “medical necessity” in the absence of scientific evidence if there is a strong conviction of
effectiveness and benefit expressed through up-to-date and consistent professional standards of
care or, in the absence of such standards, convincing expert opinion.
	 
	 	 	A level of service, supply, or intervention is considered “cost effective” if the benefits and
harms relative to costs represent an economically efficient use of resources for patients with
this condition. In the application of this criterion to an individual case, the characteristics
of the individual patient shall be determinative. Cost-effective does not necessarily mean
lowest price.

	II.	 	Covered services
	 
	 	 	The following services are covered when they are medically necessary. All services,
supplies, and interventions are subject to the appropriate copayment, deductible, and
coinsurance. (See Section III. Copayments, deductibles, and coinsurance.)

	 	A.	 	Hospital care
	 
	 	 	 	The following hospital services are covered:

	 	1.	 	Semi-private room and board, including meals; private room and special diets;
and general nursing services.
	 
	 	2.	 	Hospital services, including use of operating room and related facilities,
intensive care unit and services, labor and delivery room when eligible for Basic
Health maternity benefits, anesthesia, radiology, laboratory, and other diagnostic
services.
	 
	 	3.	 	Normal newborn baby care following birth while in a contracting facility when
not eligible for coverage under the “Maternity care” benefit. Covered services include,
but are not limited to, nursery and laboratory services.
	 
	 	4.	 	Drugs and medications administered while an inpatient.
	 
	 	5.	 	Special duty nursing.
	 
	 	6.	 	Dressings, casts, equipment, oxygen services, and radiation and inhalation therapy.

			
	 	 	 
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	 	 	 	If a member is hospitalized in a non-contracting facility, the health plan has the right
to require transfer of the member to a contracting health plan facility at the health
plan’s expense, when the member’s condition is sufficiently stable to enable safe
transfer.
	 
	 	 	 	If the member refuses to transfer to a contracting facility, all further costs
incurred during the hospitalization are the responsibility of the member.
	 
	 	 	 	Personal comfort items such as telephone, guest trays, and television are not covered.
	 
	 	B.	 	Medical and surgical care
	 
	 	 	 	The following medical and surgical services are covered. The health plan may require that
certain medical and surgical services be provided on an outpatient basis.

	 	1.	 	Surgical services.
	 
	 	2.	 	Radiology, nuclear medicine, ultrasound, laboratory, and other diagnostic services.
	 
	 	3.	 	Dressings, casts, and use of cast room; anesthesia and anesthesia-related oxygen services.
	 
	 	4.	 	Blood, blood components, and fractions (such as plasma, platelets, packed cells,
and albumin), and their administration.
	 
	 	5.	 	Provider visits, including diagnosis and treatment in the hospital, outpatient
facility, or office; consultations, treatment, and second opinions by the member’s PCP,
or by a referral provider. Normal newborn baby care following birth while in a
contracting facility when not eligible for coverage under the “Maternity care” benefit.
Covered services include, but are not limited to, routine newborn exams and laboratory
services.
	 
	 	 	 	Pharmaceuticals that are or would normally be an intrinsic part of a provider visit
(inpatient or outpatient) are covered as part of the provider visit.
	 
	 	6.	 	Radiation therapy; chemotherapy.
	 
	 	7.	 	Inpatient and outpatient chiropractic, occupational, and physical therapy
services are covered for only post-operative treatment of reconstructive joint surgery
when received within one year following surgery. A combined maximum of 12 visits per
calendar year are covered, but no more than six visits can be covered for chiropractic
care. Diagnostic or other imaging procedures solely for determination of therapy
services are not covered. Covered chiropractic services may be referred or self-referred
to contracted providers.
	 
	 	8.	 	Prescription drugs and medications as defined in “Pharmacy benefit.”
	 
	 	9.	 	Family planning services provided by the member’s PCP or women’s health care
provider. Contraceptive supplies and devices (such as, but not limited to, IUDs,
diaphragms, cervical caps, and long-acting progestational agents) determined most
appropriate by the PCP or women’s health care provider for use by the member are also
covered. Over-the-counter supplies such as condoms and spermicides are covered only when
part of a health plan protocol at the health plan’s discretion. Elective sterilization
is covered.

	 	C.	 	Maternity care
	 
	 	 	 	For pregnant Basic Health members who are determined to be eligible for medical assistance
through the Department of Social and Health Services (DSHS), Basic Health only covers
maternity care services for a period not to exceed 30 days following diagnosis of pregnancy.
	 
	 	 	 	The following maternity care services are covered for members who are determined to be
ineligible for medical assistance through DSHS. These services are not subject to copays,
coinsurance, or deductibles: diagnosis of pregnancy; full prenatal care after pregnancy is
confirmed; delivery; postpartum care; care for complications of pregnancy; preventive care;
physician services; hospital services; operating or other special procedure rooms; radiology
and laboratory services; medications;

			
	 	 	 
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	 	 	 	anesthesia; normal newborn care following birth, such as, but not limited to, nursery
services and pediatric exams; and termination of pregnancy (including voluntary
termination of pregnancy).
	 
	 	D.	 	Chemical dependency
	 
	 	 	 	Members are eligible to receive residential and outpatient chemical dependency treatment from a
health plan-contracting approved treatment program to a maximum benefit of $5,000 in a 24
consecutive calendar month period up to a lifetime benefit maximum of $10,000. Covered
residential and outpatient treatment includes services such as diagnostic evaluation and
education, and organized individual and group counseling. The hospital inpatient deductible and
coinsurance applies to intensive inpatient services. Health plans may use lower copayments, if
applicable, for group sessions.
	 
	 	 	 	(NOTE: Court-ordered treatment will be covered only if determined by the health plan to meet
the Basic Health definition of “Medical Necessity.”)
	 
	 	 	 	In determining the $5,000 limit, the health plan reserves the right to take credit for chemical
dependency benefits paid by any other group medical plan on behalf of a member during the
immediate preceding 24 consecutive calendar month period. In determining the $10,000 lifetime
limit, the health plan reserves the right to take credit for chemical dependency benefits paid
under Basic Health on behalf of the member from January 1, 1988.
	 
	 	E.	 	Mental health services
	 
	 	 	 	Mental health services are covered as follows:
	 
	 	 	 	Inpatient care in a participating hospital or other appropriate licensed facility approved by
the health plan is covered in full (subject to deductible and coinsurance) up to 10 days per
calendar year.
	 
	 	 	 	Outpatient care, including individual and family counseling, is covered in full up to 12 visits
per calendar year after the copayment per visit for individual sessions. Health plans may use
lower copayments, if applicable, for group sessions. Visits for the sole purpose of medication
management are exempted from the 12-visit limit, and are instead covered as other provider
visits.
	 
	 	 	 	(NOTE: Court-ordered treatment will be covered only if determined by the health plan to meet
the Basic Health definition of “Medical Necessity.”)
	 
	 	F.	 	Organ transplants
	 
	 	 	 	Services related to organ transplants, including professional and facility fees for inpatient
accommodation, diagnostic tests and exams, surgery, and follow-up care, are covered.
Deductible, coinsurance, and copayments apply by specific service. (See Section III.
Copayments, deductible, and coinsurance.) This benefit includes covered donor expenses.
	 
	 	 	 	Heart, heart-lung, liver, bone marrow including peripheral stem cell rescue, cornea, kidney,
and kidney-pancreas human organ transplants are covered when the Basic Health definition of
“Medical Necessity” is met.
	 
	 	 	 	Organ transplant recipient: All services and supplies related to the organ transplant for the
member receiving the organ, including transportation to and from a health plan-designated
facility (beyond that distance the member would normally be required to travel for most
hospital services), are covered in accordance with the transplant benefit language, provided
the member has been accepted into the treating facility’s transplant program and continues to
follow that program’s prescribed protocol.
	 
	 	 	 	Organ transplant donor: The donor’s initial medical expenses relating to harvesting of the
organ(s), as well as the costs of treating complications directly resulting from the
procedure(s), are covered, provided the organ recipient is a member of the health plan, and
provided the donor is not eligible for such coverage under any other health care plan or
government-funded program.

			
	 	 	 
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	 	 	 	Waiting period: Members must be enrolled in Basic Health for 12 consecutive months before
they are eligible to receive benefits for covered transplant procedures. The waiting period
applies to the transplant procedure including any immediate pre- and post-operative
hospital care related to the transplantation, but does not apply to ongoing follow-up care
including prescription drugs.
	 
	 	 	 	If a member satisfies the 12 consecutive months’ waiting period (no breaks in coverage for 12
consecutive months) and subsequently has a break in Basic Health coverage, full credit will be
given toward the waiting period if the break in coverage is not longer than one month. A member
may not have more than two such one-month breaks in coverage during a 12-month period for full
credit to continue.
	 
	 	 	 	The waiting period will not apply:

	 	1.	 	If the transplant is required due to a condition which is not a preexisting condition;
	 
	 	2.	 	For children enrolled in and continuously covered by Basic Health from birth; or
	 
	 	3.	 	For children placed in the home for purposes of adoption within 60 days of birth and
continuously covered by Basic Health from the date of placement, provided one or both of
the adoptive parents or family members are enrolled in Basic Health at the time of
placement in the home.

	 	 	 	If a newborn child enrolled from birth, or a newborn-adoptive child enrolled within 60 days of
placement, subsequently has a break in Basic Health coverage, full credit will be given toward
the waiting period if the break in coverage is not longer than one month. A member may not have
more than two such one-month breaks in coverage during a 12-month period for full credit to
continue.
	 
	 	 	 	Limitations: Transplants that are not preauthorized or are not performed in a health
plan-designated medical facility are not covered. No benefits are provided for charges related
to locating a donor, such as tissue typing of family members.
	 
	 	 	 	All services are subject to the appropriate copayment, deductible, and coinsurance.

	 	G.	 	Emergency care
	 
	 	 	 	An emergency is a sudden or severe health problem that needs treatment right away; there is not
time to talk to your doctor.
	 
	 	 	 	“Emergency” is defined as:

“The emergent and acute onset of a symptom or symptoms, including severe pain, that would
lead a prudent layperson acting reasonably to believe that a health condition exists that
requires immediate medical attention, if failure to provide medical attention would result
in serious impairment to bodily functions or serious dysfunction of a bodily organ or part,
or would place the person’s health in serious jeopardy.”

	 	 	 	The health plan reserves the right to determine whether the symptoms indicate a medical
emergency. Acute detoxification is covered for up to 72 hours.

	 	1.	 	In-service-area emergency. In the event a member experiences a medical emergency, care
should be obtained from a health plan-contracting provider. If, as a result of such
emergency, the member is not able to use a health plan-contracting provider, the member may
obtain emergency services from non-contracting health care providers. Follow-up care must
be provided or approved by the health plan in advance. In the case of emergency
hospitalization, the member, or person assuming responsibility for the member, must notify
the health plan within 24 hours of admission, or as soon thereafter as is reasonably
possible. If you fail to meet the notification requirements, coverage will be limited to
what would have been payable by the health plan to a health plan-contracting provider had
notification requirements been met. The member will be financially responsible for any
remaining balance.

			
	 	 	 
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	 	2.	 	Out-of-service-area emergency. The health plan shall bear the cost of
out-of-service-area emergency care for covered conditions. In the event of emergency
hospitalization, the member, or person assuming responsibility for the member, must notify
the health plan within 24 hours of admission, or as soon thereafter as is reasonably
possible. If you fail to meet the notification requirements, coverage will be limited to
what would have been payable by the health plan to a health plan-contracting provider, had
notification requirements been met. The member will be financially responsible for any
remaining balance.
	 
	 	 	 	The health plan may, at its discretion, appoint a consultant when out-of-service-area care
is necessary, who will have authority to monitor the care rendered and make recommendations
regarding the treatment plan. The health plan may otherwise secure information which it
deems necessary concerning the medical care and hospitalization provided to the member for
which payment is requested.
	 
	 	3.	 	Transfer and follow-up care. If a member is hospitalized in a non-contracting facility,
the health plan reserves the right to require transfer of the member to a health
plan-contracting facility, when the member’s condition is sufficiently stable to enable
safe transfer. If the member refuses to transfer to a contracting facility, all further
costs incurred during the hospitalization are the responsibility of the member.
	 
	 	 	 	Follow-up care that is a direct result of the emergency must be obtained from a health
plan-contracting provider, unless a health plan-contracting provider has authorized you to
continue to receive follow-up care from another provider in advance.
	 
	 	4.	 	Prescription drugs. Prescription drugs purchased from a non-contracting facility or
pharmacy are covered subject to the applicable pharmacy copayment when dispensed or
prescribed in connection with covered emergency treatment.
	 
	 	5.	 	Emergency ambulance transportation. Medically necessary ambulance transportation is
covered in an emergency, or to transfer a member when preauthorized by the health plan.

	 	H.	 	Skilled nursing and home health care benefits
	 
	 	 	 	As an alternative to hospitalization in an acute care facility, the health plan, at its
discretion, may authorize benefits for the services of a skilled nursing facility or home
health care agency.
	 
	 	I.	 	Hospice services
	 
	 	 	 	Hospice services are covered.
	 
	 	J.	 	Plastic and reconstructive services
	 
	 	 	 	Plastic and reconstructive services (including implants) will be provided only under the
following conditions:

	 	1.	 	To correct a physical functional disorder resulting from a congenital disease or anomaly;
	 
	 	2.	 	To correct a physical functional disorder following an injury or incidental to covered
surgery; and
	 
	 	3.	 	For a member who is receiving benefits in connection with a mastectomy:

	 	a.	 	Reconstruction of the breast on which the mastectomy was performed;
	 
	 	b.	 	Surgery and reconstruction of the other breast to produce a symmetrical appearance; and
	 
	 	c.	 	Prostheses (internal and external) and physical complications of all stages of
mastectomy.

	 	 	 	Treatment of lymphedemas is covered; however, durable medical equipment and supplies used
to treat lymphedemas may be covered only in limited circumstances. Please contact your
health plan for specific coverage information.

			
	 	 	 
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	 	K.	 	Preventive care
	 
	 	 	 	Preventive care services are covered, and will be provided as described in the schedule provided
to you by the health plan.
	 
	 	L.	 	Pharmacy benefit
	 
	 	 	 	The health plan may limit the drugs covered through use of a list called a “formulary.” Each
health plan’s formulary includes all major therapeutic classes of drugs. Drugs not in the
formulary will be covered if the health plan’s medical staff determines that no formulary drugs
are an acceptable medication for the patient.
	 
	 	 	 	In addition to the formulary described above, each health plan will have the following five
therapeutic classes of drugs covered under the first tier, subject to a $10 copay; inhaled
short-acting beta-agonists, inhaled steroids, inhaled anticholinergic bronchodilators,
beta-blockers for severe heart failure, and anti-platelet clotting inhibitors for patients after
intra-arterial stent placement. The members’ copay will be $10 regardless (or independent) of
the drug’s generic or name brand status.
	 
	 	 	 	If you have a question about the pharmacy benefit, are not sure if a drug is covered, or
believe a nonformulary drug should be covered, call the health plan’s customer service
department.
	 
	 	 	 	Basic Health covers drugs of all types, including prescribed creams, ointments, and injections,
at the copayment levels shown. Prescriptions are not subject to the deductible and will not
apply towards the annual out-of-pocket maximum.
	 
	 	 	 	When the actual cost of the drug is less than the $10 copay, members are only responsible for
the cost of the drug.
	 
	 	 	 	Prescriptions are limited to a 30-day supply.
	 
	 	 	 	Drugs for cosmetic purposes are excluded unless preauthorized.
	 
	 	 	 	(See table below for more pharmacy copayment information.)

	 	 	 
	Tier 1 - Copayment: $10	 	Tier 2 - Copayment: 50%
	Covered drugs:
	 	Covered drugs:

			
	 	 	 
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	Generic drugs contained in the health plan’s formulary.
	 	Brand-name drugs in the health plan’s formulary.
	 	 	 
	All oral contraceptives in the health plan’s formulary.	 	 
	 	 	 
	Diabetic supplies, including syringes and needles,	 	 
	diabetic test strips, lancets, and insulin.	 	 
	 	 	 
	Inhaled short-acting beta-agonists.	 	 
	 	 	 
	Inhaled steroids.	 	 
	 	 	 
	Inhaled anticholinergic bronchodilators.	 	 
	 	 	 
	Beta-blockers for severe heart failure.	 	 
	 	 	 
	Anti-platelet clotting inhibitors for patients after	 	 
	intra-arterial stent placement.	 	 

	 	M.	 	Oxygen
	 
	 	 	 	Oxygen will be covered when prescribed by a contracted provider and when authorized by a
contracted health plan. The health plan, at its discretion, may require an assessment to
determine if oxygen therapy is still an appropriate treatment before authorizing continued
oxygen treatment.
	 
	 	 	 	Coverage for oxygen will include the rental of oxygen equipment, oxygen contents, and
supplies for the delivery of oxygen.
	 
	 	 	 	Portable oxygen is not covered when provided only as a backup to a stationary oxygen system.
	 
	 	 	 	Oxygen is not subject to a copay or coinsurance, and is excluded from the Durable Medical
Equipment exclusion.

			
	 	 	 
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Appendix A: Schedule of Benefits

Benefits and services NOT subject to the deductible and coinsurance

The $150 annual deductible and $1,500 out-of-pocket maximum per person, per calendar year DO
NOT apply to the following benefits and services.

	 	 	 	 	 
	 	 	Member’s payment	 	 
	Benefit/service	 	responsibility	 	Notes
	Preventive care

	 	No copay
	 	Includes routine
physicals,
immunizations, PAP
tests, mammograms,
and other screening
and testing when
provided as part of
the preventive care
visit.
	 
	 	 	 	 
	Office visits

	 	$15 copay
	 	Copay is for office
visit only and
includes
consultations, mental
health and chemical
dependency outpatient
visits, office-based
surgeries, and
follow-up
visits.
	 
	 	 	 	 
	 

	 	 	 	Copays do not
apply to preventive
care, laboratory,
radiology services,
radiation, and
chemotherapy. Some
services will be
subject to
coinsurance.
	 
	 	 	 	 
	Pharmacy*

	 	 	 	30-day supply
	 
	 	 	 	 
	     Tier 1

	 	$10 copay (or cost of
drug, whichever is
less.)
	 	Tier 1 includes
generic drugs in
health plan’s
preferred drug list
(formulary).
	 
	 	 	 	 
	     Tier 2

	 	50% of the drug cost
	 	Tier 2 includes
brand-name drugs in
health plan’s
preferred drug list
(formulary).
	 
	 	 	 	 
	Emergency room visit

	 	$100 copay
	 	No copay if admitted;
hospital coinsurance
and deductible would
apply.
	 
	 	 	 	 
	Out-of-area emergency 

services

	 	$100 copay
	 	No copay if admitted;
hospital coinsurance
and deductible would
apply.
	 
	 	 	 	 
	Urgent care

	 	$15 copay
	 	Copay is for office
visit only, when
provided in an urgent
care setting.
Deductible and
coinsurance apply to
all other services.
	 
	 	 	 	 
	Skilled nursing,
hospice, and home
care

	 	No copay
	 	Covered as an
alternative to
hospital care at the
health plan’s
discretion.
	 
	 	 	 	 
	Maternity care

	 	No copay
	 	If the member is
eligible for the
Maternity Benefits
Program, maternity
services can only be
covered under Basic
Health for 30 days
following diagnosis
of pregnancy. All
other maternity
services are covered
through the
Department of Social
and Health Services.
	 
	 	 	 	 
	Oxygen

	 	No copay
	 	Includes equipment
and supplies. Not
subject to copays,
coinsurance, or
deductible. Requires
health plan
authorization.
	 
	 	 	 	 

 

			
	*	 	Different health plans have different lists of approved prescription
drugs (formularies). To find out if a specific drug is covered in your
pharmacy benefit, contact your health plan.

			
	 	 	 
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Benefits and services subject to the deductible and coinsurance

Before your health plan pays the 80% coinsurance for the following benefits, you must pay your $150
annual deductible. Once you meet your deductible, all coinsurance payments will be applied toward
your $1,500 annual out-of-pocket maximum. Deductibles and out-of-pocket maximums are per person,
per year. Once the $1,500 per person out-of-pocket maximum has been reached, the health plan pays
for all covered benefits and services with a coinsurance. Members are only responsible for copays
for benefits and services as shown on page 35. If you change health plans any time during the year,
the amount you’ve paid toward your deductible and out-of-pocket maximum for covered family members
will start over with your new health plan.

	 	 	 	 	 
	 	 	Member’s payment	 	 
	Benefit/service	 	responsibility	 	Notes
	Hospital, inpatient

	 	20% coinsurance;
deductible applies.
$300 maximum
facility charge per
admittance.
	 	Facility charges may include, but are not limited to, room and
board, prescription drugs provided while an inpatient, and other
services received as an inpatient. No charges for maternity care
or when readmitted for the same condition within 90 days.
	 
	 	 	 	 
	 

	 	 	 	If the member is eligible for the Maternity Benefits Program,
maternity services can only be covered under Basic Health for 30
days following diagnosis of pregnancy. All other maternity
services are covered through the Department of Social and Health
Services.
	 
	 	 	 	 
	 

	 	 	 	See “Other professional services” below.
	 
	 	 	 	 
	Hospital, outpatient

	 	20% coinsurance;
deductible applies.	 	 
	 
	 	 	 	 
	Other professional 

services

	 	20% coinsurance;
deductible applies.
	 	Includes services received as an inpatient including, but not
limited to, surgeries, anesthesia, chemotherapy, radiation, and
other types of inpatient and outpatient services.
	 
	 	 	 	 
	Mental health

	 	20% coinsurance;
deductible applies
to inpatient. $300
maximum facility
charge per
admittance.
	 	Limited to 10 inpatient days a year and 12 outpatient visits a
year. Office visits to manage medication do not count towards
12-visit maximum.

Outpatient visits are subject to $15 copay (see
“Office visits”).
	 
	 	 	 	 
	Laboratory

	 	No copay or
coinsurance for
outpatient
services.
	 	Deductible applies to services with coinsurance.
	 
	 	 	 	 
	 

	 	20% coinsurance for
inpatient
hospital-based
laboratory
services.	 	 
	 
	 	 	 	 
	Radiology

	 	20% coinsurance,
except for
outpatient x-ray
and ultrasound.
	 	Deductible applies to services with coinsurance.
	 
	 	 	 	 
	Ambulance services

	 	20% coinsurance;
deductible applies.
	 	Includes approved transfers from one facility to another. No
coinsurance if transfer is required by the health plan.
	 
	 	 	 	 
	Chiropractic/physical 

therapy/occupational 

therapy

	 	20% coinsurance;
deductible applies.
	 	Up to a combined maximum of 12 visits per year. (Of those, no
more than six can be for chiropractic care.) Visits qualify only
when used as post-operative treatment following reconstructive
joint surgery. Visits must be within one year of surgery.
	 
	 	 	 	 
	Chemical dependency

	 	20% coinsurance and
deductible apply to
inpatient.
	 	Limited to $5,000 every 24-month period; $10,000 lifetime
maximum.
	 
	 	 	 	 
	 

	 	$300 maximum
facility charge per
admittance.
	 	Outpatient visits are subject to $15 copay (see “Office visits”).
	 
	 	 	 	 
	Organ transplants

	 	Deductible,
coinsurance, and
copays apply by
specific service.
	 	12-month waiting period, except for newborns or for a condition
that is not preexisting.

			
	 	 	 
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III. Copayments, deductibles, and coinsurance

Each member is responsible for paying a $150 deductible per calendar year before some benefits
and services will be covered (see page 36). For those services with a coinsurance, once the
deductible has been met, the health plan pays 80% of allowed charges and the member pays 20% of
allowed charges. All coinsurance payments will be applied towards the annual out-of-pocket
maximum. For each member, the out-of-pocket maximum is $1,500 per calendar year. No amount paid
toward the $150 deductible will be applied towards the out-of-pocket maximum. Once the
out-of-pocket maximum has been reached, the health plan pays 100% towards all covered benefits
and services with a coinsurance.

The member is responsible for paying any required copayment, deductible, and/or coinsurance
directly to the provider of a covered service unless instructed by the health plan to make
payment to another party. Copayments, deductibles, and coinsurance payments must be paid in
full, or service may be denied or rescheduled.

Only the cost sharing specifically listed in the following tables will be charged to members for
covered services. Members may be charged a missed appointment fee by a provider if they
continually fail to keep appointments, or if they repeatedly fail to give timely notice when it
is necessary to cancel appointments.

	IV.	 	Limitations and exclusions

	 	A.	 	Limitations

	 	1.	 	Preexisting condition waiting period

	 	a.	 	A preexisting condition is defined as: “Any illness, injury, or condition
for which, in the six months immediately preceding a member’s effective date of
enrollment in Basic Health:

	 	(1)	 	Treatment, consultation, or a diagnostic test was recommended
for or received by the member; or
	 
	 	(2)	 	Medication was prescribed or recommended for the member; or
	 
	 	(3)	 	Symptoms existed which would ordinarily cause a reasonably prudent
individual to seek medical diagnosis, care, or treatment.”

	 	b.	 	Waiting period
	 
	 	 	 	Basic Health will not provide benefits for services or supplies rendered for any
preexisting condition during the first nine consecutive months following the member’s
effective date of coverage. A member will not be required to begin a new nine
consecutive-month waiting period if:

	 	(1)	 	Coverage is suspended for not longer than one month during the waiting period, and
	 
	 	(2)	 	The member does not have more than two (2) one-month breaks in
coverage during the waiting period.
	 
	 	 	 	Coverage for preexisting conditions will not be available until the member is actually
covered by Basic Health for a total of nine months.
	 
	 	 	 	If the member is confined in a health care facility for treatment of a preexisting
condition at the time the member’s nine-month waiting period ends, benefits for that
condition will be provided only for covered services rendered after the end of the
waiting period.

	 	c.	 	Exceptions to waiting period

	 	(1)	 	The following services are not subject
to the waiting period:

	 	•	 	Maternity care.

			
	 	 	 
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	 	•	 	Prescription drugs as defined in “Pharmacy Benefit.”
	 
	 	•	 	Oxygen.

	 	(2)	 	Children born on or after the parent’s or sibling’s effective date of
coverage who are enrolled within 60 days of the date of birth, and adopted children
who are placed for adoption after the adoptive parent’s or sibling’s effective date
of coverage who are enrolled within 60 days of placement with the adoptive parents,
are not subject to the nine-month waiting period for preexisting conditions.

	 	d.	 	Credit toward the waiting period
	 
	 	 	 	Credit toward the waiting period will be given:

	 	(1)	 	If Basic Health delays your enrollment (up to a maximum of three
months) due to budgetary constraints, and you have been determined
eligible.
	 
	 	(2)	 	For any continuous period of time during which a member was covered
under similar health coverage if:

	 	•	 	That coverage was in effect at any time during the
three-month period immediately preceding the date of reservation or
application for coverage under Basic Health, or within the three-month
period immediately preceding enrollment in Basic Health; and
	 
	 	•	 	The coverage terminated not later than the first of the month
following the effective date of coverage in Basic Health.

	 	 	 	If similar coverage was in effect both prior to the date of application or
reservation and the date of enrollment, credit will be given for the longer period
of continuous coverage.
	 
	 	 	 	“Similar coverage” includes Basic Health, all DSHS programs which have the Medicaid
scope of benefits, the DSHS program for the medically indigent, Indian Health Services,
most coverages offered by health carriers, and most self-insured plans.

	 	2.	 	Major Disaster or Epidemic
	 
	 	 	 	If the health plan is prevented from performing any of its obligations hereunder in whole or
part as a result of a major epidemic, act of God, war, civil disturbance, court order, labor
dispute, or any other cause beyond its control, the health plan shall make a good faith
effort to perform such obligations through its then-existing and contracting providers and
personnel. Upon the occurrence of any such event, if the health plan is unable to fulfill
its obligations either directly or through contracting providers, it shall arrange for the
provision of alternate and comparable performance.
	 
	 	3.	 	Coordination of Benefits
	 
	 	 	 	The benefits available under Basic Health shall be secondary to the benefits payable
under the terms of any health plan, which provides benefits for a Basic Health member
except where in conflict with Washington State or federal law.

	 	B.	 	Exclusions
	 
	 	 	 	The services listed below are not covered:

	 	1.	 	Services that do not meet the Basic Health definition of “Medical Necessity” for the
diagnosis, treatment, or prevention of injury or illness, or to improve the functioning of
a malformed body member, even though such services are not specifically listed as
exclusions.
	 
	 	2.	 	Services not provided, ordered, or authorized by the member’s health plan or its
contracting providers, except in an emergency.
	 
	 	3.	 	Services received before the member’s effective date of coverage.

			
	 	 	 
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Table of Contents

Appendix A: Schedule of Benefits

	 	4.	 	Custodial or domiciliary care, or rest cures for which facilities of an acute care general
hospital are not medically required. Custodial care is care that does not require the regular
services of trained medical or allied health care professionals and that is designed primarily
to assist in activities of daily living. Custodial care includes, but is not limited to, help in
walking, getting in and out of bed, bathing, dressing, preparation and feeding of special diets,
and supervision of medications which are ordinarily self-administered.
	 
	 	5.	 	Hospital charges for personal comfort items; or a private room unless authorized by the
member’s health plan; or services such as telephones, televisions, and guest trays.
	 
	 	6.	 	Emergency facility services for nonemergency conditions.
	 
	 	7.	 	Charges for missed appointments or for failure to provide timely notice for cancellation of
appointments; charges for completing or copying forms or records.
	 
	 	8.	 	Sleep studies, except the initial sleep study authorized by the contracted health plan.
Only one sleep study per member per calendar year is covered.
	 
	 	9.	 	Transportation except as specified under “Organ transplants” and “Emergency care.”
	 
	 	10.	 	Immunizations, except as covered under preventive care. Immunizations for the purpose of
travel, employment, or required because of where you reside are not covered.
	 
	 	11.	 	Implants, except: cardiac devices, artificial joints, intraocular lenses (limited to the
first intraocular lens following cataract surgery), and implants as defined in the “Plastic
and reconstructive services” benefit.
	 
	 	12.	 	Sex change operations.
	 
	 	13.	 	Investigation of or treatment for infertility or impotence.

	 
	 	14.	 	Reversal of sterilization.
	 
	 	15.	 	Artificial insemination.
	 
	 	16.	 	In-vitro fertilization.
	 
	 	17.	 	Eyeglasses, contact lenses (except the first intraocular lens following cataract surgery);
routine eye examinations, including eye refraction, except when provided as part of a routine
examination under “Preventive care.”
	 
	 	18.	 	Hearing aids.
	 
	 	19.	 	Orthopedic shoes and routine foot care.
	 
	 	20.	 	Speech and recreation therapy.
	 
	 	21.	 	Medical equipment and supplies not specifically listed in this “Schedule of Benefits” except
while the member is hospitalized (including, but not limited to, hospital beds, wheelchairs,
and walk aids).
	 
	 	22.	 	Dental services, including orthodontic appliances, and services for temporomandibular joint
problems, except for repair necessitated by accidental injury to sound natural teeth or jaw,
provided that such repair begins within ninety (90) days of the accidental injury or as soon
thereafter as is medically feasible, provided the member is eligible for covered services at
the time that services are provided.
	 
	 	23.	 	Medical services, drugs, supplies, or surgery directly related to the treatment of obesity,
including morbid obesity (such as, but not limited to, gastroplasty, gastric stapling, or
intestinal bypass).
	 
	 	24.	 	Weight loss programs.
	 
	 	25.	 	Cosmetic surgery, including treatment for complications of cosmetic surgery, except as
otherwise provided in this “Schedule of Benefits.”

			
	 	 	 
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Table of Contents

Appendix A: Schedule of Benefits

	 	26.	 	Medical services received from or paid for by the Veterans Administration or by state or
local government, except where in conflict with Washington State or federal law or
regulation; or the portion of expenses for medical services payable under the terms of any
insurance policy that provides payment toward the member’s medical expenses without a
determination of liability to the extent that payment would result in double recovery.
	 
	 	27.	 	Conditions resulting from acts of war (declared or not).
	 
	 	28.	 	Direct complications arising from excluded services.
	 
	 	29.	 	Replacement of lost or stolen medications.
	 
	 	30.	 	Evaluation and treatment of learning disabilities, including dyslexia.
	 
	 	31.	 	Any service or supply not specifically listed as a covered service unless medically
necessary, prescribed by a contracting provider, and authorized in advance by the health
plan.

	 	C.	 	Changes to covered services and premiums
	 
	 	 	 	Basic Health may from time to time revise this “Schedule of Benefits.” In designing and revising
this “Schedule of Benefits,” Basic Health will consider the effects of particular benefits,
copayments, deductibles, coinsurance, out-of-pocket maximums, limitations, and exclusions on
access to medically necessary basic health care services, as well as the cost to members and to
the state. Generally accepted practices of the health insurance and managed health care
industries will also be taken into account.
	 
	 	 	 	Basic Health will provide you with written notice of any planned revisions to your Basic Health
premiums or the benefit plan at least 30 days prior to the effective date of the change. This
notice may be included with your premium statement, open enrollment materials or other mailing,
or may be a separate notice. For purposes of this provision, notice shall be deemed complete
upon depositing the written revisions in the United States mail, first-class postage paid,
directed to you at the mailing address you provided to Basic Health.

			
	 	 	 
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Table of Contents

 

Appendix B:
Health Coverage Tax Credit (HCTC)-Basic Health

Appendix B:

Health Coverage Tax Credit

(HCTC) — Basic Health

Program overview

The Health Coverage Tax Credit (HCTC) is a federal income tax credit that pays 65 percent of the
health plan premium for eligible people enrolled in “qualified health plans.” In Washington State,
Basic Health is a qualified health plan. However, in Basic Health materials, “health plan” refers
to the company that provides your health care coverage (Columbia United Providers, Community Health
Plan of Washington, Group Health Cooperative, Kaiser Foundation Health Plan of the Northwest, or
Molina Healthcare of Washington). For information on other qualified plans in Washington, call the
HCTC Customer Contact Center or visit the Internal Revenue Service (IRS) Web site (see “HCTC
contact information” on page i).

Eligibility

To be eligible for the HCTC, you do not need to be eligible for Basic Health. You may be eligible
if you are a displaced worker, enroll in a qualified health plan (such as Basic Health), and:

	•	 	Receive Trade Readjustment Allowance (TRA) under the Trade Adjustment Assistance (TAA)
Act or Alternative Trade Adjustment Assistance
(ATAA).
	 
	•	 	Would be eligible to receive TRA but have not yet used all of your unemployment insurance benefits,
or
	 
	•	 	Are age 55 or over, receive pension benefits from the Pension Benefits Guaranty Corporation, and
are not entitled to Medicare Part A.

To find out if you are eligible or to register for the tax credit, contact the HCTC Customer
Contact Center or visit the HCTC Web site (see “HCTC contact information” on page i).

Premiums

If you are eligible for the HCTC, you may claim it as an advance credit to help pay your premiums,
or you may claim it when you file your federal income tax return. Either way, the tax credit will
pay 65 percent of your HCTC-Basic Health premium. You pay the other 35 percent.

HCTC-Basic Health members are billed the full cost of their coverage, plus an administrative fee.
Premiums are adjusted according to age, choice of health plan, and the county where services are
provided. If you are claiming the HCTC advance tax credit for your Basic Health enrollment, you
will receive a monthly invoice from the IRS. You will pay the IRS your share of the premium each
month, and the IRS will pay Basic Health for your coverage. If you do not pay your share of the
premium to the IRS on time, the IRS will not pay your premium and you will lose coverage for one
month. You may be able to continue your coverage by paying the full premium directly to Basic
Health for up to two months or applying for subsidized Basic Health coverage. Basic Health cannot
accept your direct payment prior to enrolling in HCTC-Basic Health.

Making changes

HCTC-Basic Health members must report family changes, address changes, and changes in their HCTC
eligibility to Basic Health. If you ask to have members added or removed from your account, Basic
Health will send you a premium change notice; you must forward that notice to the IRS. To tell us
about a change to your account, call 1-800-660-9840, fax a letter to 360-923-2910, or send a letter
to HCTC-Basic Health at PO Box 42703, Olympia, WA 98504-2703. Be sure to include your HCTC-Basic
Health ID number on all correspondence.

			
	 	 	 
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	 	Basic Health 2008 Member Handbook

 

Table of Contents

Appendix B:
Health Coverage Tax Credit (HCTC)-Basic Health

If you move and your current health plan is not available in your new area, you will be required to
choose a health plan that serves your new area. Otherwise, you may change health plans only during
open enrollment, or when you move and your current health plan will cost more or a health plan is
available that was not previously available. An exception may be made in some cases if you can
prove that you need to continue a current course of treatment with a specific provider. When you
change health plans, remember that each health plan contracts with different providers and has its
own list of covered prescription drugs. Call the health plan or your provider to find out if your
provider contracts with the health plan you are considering. If you take any prescription
medications, you also should contact the health plan to see if your medications will be covered.

If you live outside Washington State, you will be asked to choose a county within Washington where
you will receive your medical services. You must choose a health plan within that county. If you
move, please call Basic Health at 1-800-660-9840 to discuss whether you will remain with the same
health plan and in the same county of service. If you are covering a child who is away from home
attending college, that child must also get HCTC-Basic Health services through the health plan and
in the Washington State county you have chosen. Only emergency services are covered outside of the
health plan’s service area.

If you change health plans, any services you had approved under your previous health plan will need
to be reviewed and approved again by your new health plan. Also, your deductible and out-of-pocket
maximum will start over with the new health plan. Check with your health plan for further
information.

Basic Health is committed to making sure your health plan is available throughout the year.
However, if your health plan becomes unavailable during the year, you will be able to choose among
the other plans in your county. If only one health plan remains, you will be assigned to that plan.

If you want to add or remove a family member to your HCTC-Basic Health account, please call Basic
Health. We will send you an updated monthly premium notice that you can forward to the HCTC
program. Please note that we will need a signature from anyone age 18 or over who is added to your
account. It is important that you contact us before you want a change to be effective. Because
premiums for your HCTC-Basic Health coverage are paid for by the IRS, and HCTC-Basic Health cannot
cover a family member until the premium is received from the IRS, you should allow plenty of time.

Suspension, disenrollment, and reenrollment

If Basic Health does not receive your premium from the IRS by the first of the month, you will not
have coverage for that month. (Any payments you have made toward your deductible and out-of-pocket
maximums will remain intact.) In this case, you may pay the full cost of your own coverage.
However, because nonpayment from the IRS can mean you are no longer eligible for the program, you
will only be able to pay your own premium for two months before you will be disenrolled from
HCTC-Basic Health. If you have not already been notified by the IRS of the reason for not paying
your HCTC-Basic Health premium, call the HCTC Customer Care Center at 1-866-628-4282.

You may also be disenrolled from HCTC-Basic Health if you:

	•	 	Take part in any form of abuse, intentional misconduct, or fraud against Basic Health or
your health plan or its providers, or knowingly
give information to Basic Health that is false or
misleading;
	 
	•	 	Intentionally withhold information required by
HCTC or Basic Health;
	 
	•	 	Pose a risk to the safety or property of Basic Health
or your health plan, or their staff, providers,
patients, or visitors;
	 
	•	 	Refuse to follow procedures or treatment
recommended by your provider and determined
by your health plan’s medical director to be
essential to your health or the health of your child,
and you have been told by your health plan that
no other treatment is available;
	 
	•	 	Repeatedly do not pay copayments, coinsurance,
or other payments on time; or

			
	 	 	 
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Table of Contents

Appendix B:
Health Coverage Tax Credit (HCTC)-Basic Health

	•	 	Withhold from your health plan information you have about a legally responsible third party,
or refuse to help your health plan collect from that legally responsible third party.

If you want to disenroll from HCTC-Basic Health, contact Basic Health. However, if you plan to
change your HCTC coverage to another qualified health plan, you should contact the HCTC Customer
Contact Center first.

Rights,
responsibilities, and privacy

All information in Chapter Five (Rights, Responsibilities, and Privacy) applies to HCTC-Basic
Health members, except as noted below.

	•	 	As an HCTC-Basic Health member, you have the
right to file an appeal with your health plan or
with the federal HCTC program if you are not
satisfied with their decision. You will not have an
appeals process with Basic Health unless you have
paid 100 percent of your premium for the time in
question.
	 
	•	 	As an HCTC-Basic Health member, you do not
have to provide Basic Health with information
about your income. 
	 
	•	 	 As an HCTC-Basic Health member, you are not required to pay your premium directly to Basic
Health, unless notified. The IRS will send your monthly premium to Basic Health. You will pay 35
percent of that amount directly to the HCTC program.

HCTC-Basic
Health grievances and appeals 
If you have a grievance or appeal about services from your
health plan, its providers, or benefits, contact your health plan directly. You can find the
toll-free numbers on the inside front cover of this book. For more information on grievances with
your health plan, read “Grievances against your health plan” on page 19.

If you disagree with a decision that you are not eligible for the HCTC program, contact the HCTC
Customer Contact Center.

If you have paid 100 percent of your Basic Health premium, and have a complaint about something
Basic Health did during the time you paid your own premium, go to page 20.

Whenever you call any of these organizations, be sure you note the date of the call, the name of
the person you talked to, and whether that person was with the HCTC program, your health plan, or
Basic Health.

Health plans and providers

All of Chapter Seven applies to HCTC-Basic Health members.

Covered services

Benefits for HCTC-Basic Health members are the same as for all Basic Health members (see page 27),
with the following exceptions:

	•	 	The nine-month waiting period for treatment of preexisting conditions will be waived if you
had at least three months of creditable coverage before enrolling in Basic Health, with no
more than a 62-day break in coverage when you applied for HCTC-Basic Health. If you had a
break in coverage of 63 days or more at the time of your application to Basic Health, or if
you did not have three

			
	 	 	 
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	 	Basic Health 2008 Member Handbook

 

Table of Contents

Appendix B:
Health Coverage Tax Credit (HCTC)-Basic Health

	 	 	months of creditable coverage, the nine-month waiting period will apply the same as for all other
Basic Health members. For HCTC purposes, creditable coverage includes a group health plan
(including COBRA, Temporary Continuation of Coverage [TCC], or state continuation coverage) or
health insurance (including individual coverage, college or school insurance, or short-term
limited duration insurance).
	 
	•	 	HCTC-Basic Health covers maternity benefits without requiring that you apply for the DSHS
Maternity Benefits Program. Covered maternity services are listed on pages 29 and 30.

Member costs

Each member enrolled in HCTC-Basic Health will share the cost for his or her health care coverage.
See the sections “Member costs,” “If you receive a bill for covered services,” and “If a third
party is responsible for your injury or illness” on pages 25-26 for details.

Continuation rights

If you leave Basic Health and enroll in coverage through an employer or privately purchased health
plan in Washington State, the time you were enrolled through the HCTC program may be considered
creditable coverage for purposes of shortening or waiving the waiting period for treatment of a
preexisting condition. However, unlike COBRA coverage, if you apply for private insurance coverage
in Washington State, your HCTC-Basic Health enrollment will not exempt you from the health plan’s
use of the standard health questionnaire for screening applicants.

Schedule of benefits

The Schedule of Benefits in Appendix A applies to HCTC-Basic Health members, except as noted in
“Covered Services” on page 43.

HCTC contact information

Customer Contact Center (toll-free): 

1-866-628-4282 (TTY: 1-866-626-4282)

Web site: www.irs.gov (IRS keyword: HCTC)

			
	 	 	 
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Table of Contents

 

Appendix C:
Definitions of Terms

Appendix C:

Definitions of Terms

Appeal

A formal request for the health plan or Basic Health to review its decision.

Basic Health

A health care coverage program administered by the Health Care Authority (HCA).

Basic Health Plus

A program jointly administered by the Department of Social and Health Services (DSHS) and Basic
Health for children under age 19 from low-income families. It provides expanded benefits (such
as dental and vision care). Eligibility for Basic Health Plus is determined by DSHS.

Certificate of coverage

A description of your health care coverage and benefits. This handbook serves as your
certificate of coverage.

Coinsurance

A percentage you pay for certain services after you have paid your annual deductible.

Copayment or copay

A set dollar amount you pay when you receive specific services. Copays are not subject to a
deductible and do not apply toward your deductible, coinsurance, or out-of-pocket maximum.

Department of Social and Health Services (DSHS)

The state agency that administers Medicaid and
(along with the Health Care Authority) jointly administers Basic Health Plus and the Maternity
Benefits Program.

Deductible

The amount you pay before your health plan starts to pay for services with coinsurance. The
deductible will not apply toward your out-of-pocket maximum.

Dependents

Same as family members.

Disenrollment

Losing Basic Health coverage without the option of reenrolling the following month. This can be
due to nonpayment by the due date given in the suspension notice; more than two suspensions in a
12-month period; loss of eligibility; or for failure to abide by any of your responsibilities as
a Basic Health member.

Emergency

The emergent and acute onset of a symptom or symptoms, including severe pain, that would lead a
prudent layperson acting reasonably to believe that a health condition exists that requires
immediate medical attention, if failure to provide medical attention would result in serious
impairment to bodily functions or serious dysfunction of a bodily organ or part, or would place
the person’s health in serious jeopardy.

			
	 	 	 
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	 	Basic Health 2008 Member Handbook

 

Table of Contents

Appendix C:
Definitions of Terms

Enrollment

The process of submitting completed application forms, being determined eligible, and being
accepted into Basic Health, Basic Health Plus, or the Maternity Benefits Program.

Explanation of benefits (EOB)

Each health plan is required to send an EOB each time you receive medical services. The EOB is a
detailed statement that explains the service(s) you received, the allowed amount for each
service, the amount the health plan pays, and the amount you are responsible to pay. The EOB
will also track the amount you have paid towards each covered family member’s annual deductible
and out-of-pocket maximum.

Family members

Family members who should be listed as dependents on your account (whether or not they are
enrolling for coverage) include:

	 	•	 	Your spouse living in the same household and not legally separated from you.
	 
	 	•	 	Your unmarried child, including stepchild, legally adopted child, and a child placed in
your home for purposes of adoption or under your legal guardianship who is:

	 	•	 	Under age 19; or
	 
	 	•	 	Under age 23 and a full-time student at an accredited school. You are required to
send proof from the school each year when your dependent is age 19 through 22, to show
that he or she is a full-time student. If your dependent over age 18 is no longer a
full-time student, you must notify Basic Health within 30 days of this change.

	 	•	 	Your unmarried child under age 19, enrolling for coverage and in your custody under an
informal guardianship agreement that is signed by the child’s parent(s) and authorizes you
to obtain medical care for the child. To request coverage for a child living with you under
such an agreement, you must provide a copy of the guardianship agreement and proof that you
are providing at least 50 percent of the child’s support. If a child is
placed in your home under a foster care agreement, DSHS is generally the guardian, so you
will not be allowed to list that child.
	 
	 	•	 	Your unmarried child, stepchild, legally adopted child, or other legal dependent of
any age who is incapable of self-support due to disability. You must provide proof of
disability. If the dependent with a disability is not your birth or adopted child, you must
also provide proof of legal guardianship.

If you are a Health Coverage Tax Credit eligible enrollee, list all dependents that are
eligible for coverage through that program.

Family size

The number of family members eligible to be listed on a Basic Health account. Family size is
considered when determining eligibility and premiums.

Formulary

A list of approved prescription drugs developed by each health plan.

Grievance

A written or an oral complaint submitted by or on behalf of a covered person to their health
plan or Basic Health.

Health Care Authority (HCA)

The state agency responsible for Basic Health administration and coordinating with DSHS to
provide Basic Health Plus and the Maternity Benefits Program.

Health Coverage Tax Credit eligible member (or
HCTC-Basic Health member)

An individual or qualified dependent enrolled in Basic Health and determined by the federal
Department of Treasury to be eligible for the tax credit created by the Trade Act of 2002 (PL.
107-210).

Health plan

An organization that offers health care coverage

			
	 	 	 
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	 	43  

 

Table of Contents

Appendix C:
Definitions of Terms

and contracts with the HCA to provide your care. You choose your health plan when you join
Basic Health.

Income

Your and your family’s gross income (before deductions).

Income band

Income levels A through H, as listed on page 6. These are updated in July of each year. (Look
for a notice of the changes in May.) These levels, based on gross monthly income and family
size, help determine monthly premiums.

Income guidelines

The guidelines used to determine your eligibility for Basic Health and Basic Health Plus, and
your monthly premium payments for Basic Health coverage. These income guidelines change
annually. See page 5 for more information.

Inpatient

A patient who is admitted for an overnight or longer stay at a health care facility and is
receiving covered services.

Maternity Benefits Program

The program coordinated with DSHS for eligible pregnant women. This program includes all
Medicaid benefits, including maternity benefits, maternity support services, and maternity case
management. Eligibility for the program is determined by DSHS.

Medicare

The federal health benefit program for people who are age 65 and over, and for some people with
disabilities. (If you are eligible for free or purchased Medicare coverage, you are not eligible
for Basic Health.)

Member

A person enrolled in and receiving health care coverage through Basic Health, Basic Health Plus,
or the Maternity Benefits Program.

Non-compliance

Failure to provide documentation or information requested by Basic Health by the due date.

Out-of-pocket maximum

The most coinsurance you will have to pay each year for each covered family member. Only your
coinsurance costs apply toward your out-of-pocket maximum. After you have paid the out-of-pocket
maximum, you do not have to pay coinsurance costs for the remainder of the calendar year.

Outpatient

A nonhospitalized patient receiving covered services away from a hospital, such as in a
physician’s office or the patient’s own home, or in a hospital outpatient or hospital emergency
department or surgical center.

Personal eligibility statement (PES)

The notice Basic Health sends you showing the current status of your account. You will receive a
PES when there is a change to your account. This statement may include a bill for additional
premiums you must pay as a result of a change.

Preexisting condition

An illness, injury, or condition for which, in the six months immediately preceding a member’s
effective date of enrollment in Basic Health:

	 	•	 	Treatment, consultation, or a diagnostic test was recommended for or received by the
member;
	 
	 	•	 	Medication was prescribed or recommended for the member; or
	 
	 	•	 	Symptoms existed which would ordinarily cause a reasonably prudent individual to seek
medical diagnosis, care, or treatment.

Premium

Your monthly payment for Basic Health coverage.

			
	 	 	 
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	 	Basic Health 2008 Member Handbook

 

Table of Contents

Appendix C:
Definitions of Terms

Primary care provider (PCP)

Your personal health care provider. Your primary care provider can be a family or general
practitioner, internist, pediatrician, or other provider approved by your health plan. To
receive benefits, your primary care provider must provide or coordinate your care. If you need
to see a specialist, your primary care provider will refer you.

Provider

A health care professional (such as a doctor, nurse, internist, etc.) or facility (such as
a hospital, clinic, etc.).

Recertification

Periodic review of your family’s income and eligibility. During recertification, you must
submit current income and residency documentation to verify your eligibility and/or level of
premium subsidy.

Recoupment

When Basic Health bills you for the amount you owe the state because you did not accurately
report your income.

Service area

The geographic area served by a health plan that provides coverage for Basic Health members.

Specialist

A provider of specialized medicine, such as a cardiologist or a neurosurgeon.

Student

A person enrolled full time in an accredited secondary school, college, university, technical
college, or school of nursing, as determined by the school registrar.

Subscriber

The person on a Basic Health account who is responsible for payment of premiums and other cost
sharing, and to whom Basic Health sends all notices and communications. The subscriber may
be a Basic Health member or the spouse, parent, or guardian of an enrolled dependent and may or
may not be enrolled for coverage.

Subsidy

The portion of the premium that Washington State pays for enrolled Basic Health members.

Suspension of coverage

The process of losing health coverage for one month after a monthly premium has not been paid or
has been paid in full after the due date. If your coverage is suspended more than two times in a
12-month period, you will be disenrolled and cannot reenroll for at least 12 months.

Tier

A category of drugs related to the pharmacy benefit. Your cost for prescriptions depends on the
category (or tier) the prescription falls within. Tier 1 is the category of prescriptions that
costs you the least.

Washington resident

A person physically residing and maintaining a residence in the state of Washington. You must be
a Washington resident to be eligible for Basic Health. To be considered a Washington resident,
members who are temporarily out of Washington for any reason:

	 	•	 	May be required to prove their intent to return to Washington State; and
	 
	 	•	 	May not be out of Washington State for more than three consecutive calendar months.

Dependent children who are attending school out of state may be considered residents if they are
out of state during the school year, as long as their primary residence is in Washington State
and they return to Washington State during breaks. Dependent children attending school out of
state may be required to provide proof that they pay out-of-state tuition, vote in Washington,
and file income taxes using a Washington address.

Your residence may be a home you own or are purchasing or renting, a shelter or other physical

			
	 	 	 
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Table of Contents

Index

Index

Adding members to your account, ii, 8, 9

Address changes, ii, 7

     Address changes (HCTC), 41

Adoption, 9, 31, 37, 46

Appeal, i, 15, 19, 20, 45

     Appeal (HCTC), 43

Basic Health Plus, 1, 3, 4, 13, 14, 16, 17, 24

Child support, 9

Chiropractic, 22, 29, 36

Coinsurance, 14, 16, 25, 27, 28, 30, 31, 34–36, 45, 47

     Coinsurance (HCTC), 42

Complaints, 19, 20

Copay, 14, 16, 24, 25, 27, 29-31, 33-36, 45

     Copay (HCTC), 42

Cost sharing, 25, 33

Coverage begins, 9, 23

Covered services, ii, 15, 22, 23, 25, 28, 29,

     Appendix A

Creditable coverage, 8, 23

     Creditable coverage (HCTC), 43, 44

Deductible, 7, 13, 16, 25, 27, 28, 31, 34, 35, 36, 45

     Deductible (HCTC), 42

Denial, 19, 20

Dental care, 4, 24

Dependent, 1, 3, 8, 9, 10, 13, 22-25, 45

     Dependent (HCTC), 42

Disability, 3, 5, 9, 20, 46

Disenrollment, 11, 13, 14, 15, 20, 45

     Disenrollment (HCTC), 42

Divorce, 8, 9

DSHS, 4, 10, 14, 17, 24, 29, 36, 45, 47

     DSHS (HCTC), 44

Eligiblity, 1, 3-11, 16, 19, 20, 21, 24

     Eligiblity (HCTC), 41

Emergency, 8, 16, 21, 22, 23, 25, 31, 32, 45

     Emergency (HCTC), 42

Enrolling a new family member, 8, 9

Exclusions, 15, 27, 37-39

Family member, 1, 3, 8, 9, 10, 13, 22-25, 46

     Family member, (HCTC), 42

Family size, 5, 6, 8, 9, 12, 46

Financial sponsors, 4,14

Formulary, 33

Foster care, 3, 46

Foster parent, 4, 17

Fraud, 11, 13, 16

     Fraud (HCTC), 42

Grievance, 19, 20, 46

     Grievance (HCTC), 43

Guardianship, 3, 46

Health Coverage Tax Credit (HCTC), cover, i, 1, 3, 4, 19, 41–44, 46

Health plan, 1, 7, 8, 15, 21, 22, 25, 30, 33, 34, 46

     Health plans (HCTC), 41–44

Home care agency, ii, 4, 14, 17

ID cards, 16, 21, 26

Income changes, ii, 9, 10

Independent Review Organization, 19

Informed consent, 16

Internal Revenue Service (IRS), i, 3, 4, 5,10, 11

     Internal Revenue Service (HCTC), 3, 4, 41–44

IRS documentation, 10

Limitations and exclusions, 23, 37–39

Marriage, 8, 9

Maternity coverage, 3, 4, 14, 16, 17, 23, 24, 28, 29, 35–37, 47

     Maternity coverage (HCTC), 44

Medicare, 3, 13, 47

     Medicare (HCTC), 41

Newborn, 9, 24, 28, 29, 31

			
	 	 	 
	  46
	 	Basic Health 2008 Member Handbook

 

Table of Contents

Index

Open enrollment, 7, 8

     Open enrollment (HCTC), 42

Organ transplant, 23, 30

Out-of-pocket maximum, 7, 8, 13, 25, 33–36, 47

     Out-of-pocket maximum (HCTC), 42

Personal care worker, 4, 17

Physical therapy, 4, 24, 29, 36

Preexisting conditions, 23, 36

     Preexisting conditions (HCTC), 43

Pregnancy, 3, 4, 14, 16, 17, 23, 24, 28, 29, 34, 35–37, 47

     Pregnancy (HCTC), 44

Prescriptions, 21, 33–35

Primary care provider, ii, 15, 16, 21, 22, 23, 47

Recertification, 10, 11, 48

Recoupment, 11, 48

Reenrollment, 12, 13

     Reenrollment (HCTC), 42

Referrals, ii, 22 

Rental income, 5, 9, 11

Resident, 1, 7, 8, 48

Retirement, 9

Second opinion, 15, 29

Self-employment, 5, 9, 11

Separation, 9

Specialist, ii, 16, 21, 22, 48

Spouse, 3, 5, 9, 10, 24, 46

Student, 3, 9, 46, 48,

Subscriber, 1, 5, 48

Subsidy, 11, 48

Suspension, 13, 45, 48

     Suspension (HCTC), 42

Third party, 14, 26

     Third party (HCTC), 43

Vision, 4, 24, 39

Waiting period, ii, 23, 31, 37

      Waiting period (HCTC), 43

Women’s health care, 22

			
	 	 	 
	Basic Health 2008 Member Handbook
	 	47  

 

Table of Contents

Keep

Hot Policy Pages

and other updates here

Hot Policy Pages are important updates to this Member Handbook and are one way Basic Health
provides you with official notice of program changes; you will receive them periodically,
usually with your monthly billing statement.
Keep these updates handy, along with this Member Handbook
and other information you receive from Basic Health, so that you have the
information you need to make the most of your Basic Health coverage.

			
	 	 	 
	  48
	 	Basic Health 2008 Member Handbook

 

Table of Contents

	 	 	 	 	 
	

	 	2008 Member Handbook
	 	PRSRT STD
US POSTAGE PAID

WASHINGTON STATE
DEPT OF PRINTING
	Washington State Health Care Authority
	 	 	 	 
	Basic Health
	 	 	 	 
	PO Box 42683
	 	 	 	 
	Olympia, WA 98504
	 	 	 	 
	HCA 22-405 (1/08)
	 	 	 	 
	 
	 	 	 	 
	Change Service Requested
	 	 	 	 

 

Table of Contents

Exhibit 3: Basic Health — 2008 Performance Standards

2008 Performance Standards

	 	 	 	 	 
	Performance Standards	 	Standard Definition
	 

	 	Claims Quality	 	 
	 
	 	 	 	 
	Standard 1

	 	Financial Payment (Dollar) Accuracy:
	 	The percentage of claim dollars paid accurately.
	 
	 	 	 	 
	 

	 	98.5%
	 	Calculated as the total paid dollars minus the absolute
value of over- and underpayments, divided by total paid
dollars.
	 
	 	 	 	 
	Standard 2

	 	Payment Incidence Accuracy:
	 	The percentage of claims processed without payment error.
	 
	 	 	 	 
	 

	 	97.0%
	 	Calculated as the total number of claims (pays and no
pays) minus the number of claims processed with payment
error, divided by the total number of claims.
	 
	 	 	 	 
	 

	 	 	 	Error is defined as any error, regardless of cause
(e.g., coding, procedural, system) that results in an
overpayment or an underpayment. Each type of error is
counted as one full error but no more than one error can
be assigned to one claim.
	 
	 	 	 	 
	Standard 3

	 	Claims Rework: 
 

Plan will guarantee the number of
claims requiring rework will be
6.0% or less.
	 	Rework is defined as any claim that requires an
adjustment to the initial adjudication determination due
to an error on the part of the carrier (e.g., incorrect
plan provision) at the time the claim was processed.
	 
	 	 	 	 
	 

	 	Claims Turnaround Time	 	 
	 
	 	 	 	 
	Standard 4

	 	Percent within 30 calendar days for
clean claims and 60 calendar days
for all claims:
	 	TAT is measured from the date a claim is received by the
administrator (either via paper or electronic data
interchange) to the date it is processed for payment or
denied.
	 

	 	Plan will pay 95% of clean claims
within 30 calendar days and 98% of
all claims (paid or denied) within
60 calendar days.	 	 

For Standards 1-4: If CONTRACTOR does not currently have a process in place to measure Basic Health independently
from other lines of business, it will need to develop and implement such process by July 1, 2008. It is the HCA’s
intent to measure each CONTRACTOR’s full book of business against the Basic Health line of business for the 2009
contract year.

					
	 	 	 	 	 
	2008 Basic Health Contract — Exhibit 3
	 	Page 1 of 3 	 	 

 

Table of Contents

Exhibit 3: Basic Health — 2008 Performance Standards

	 	 	 	 	 
	Performance Standards	 	Standard Definition
	 

	 	Customer Service	 	 
	 
	 	 	 	 
	Standard 5

	 	Call Abandonment Rate:

≤
3%
	 	Percentage of calls that reach the CONTRACTOR and are
placed in member services queue, but are not answered
because caller hangs up before a customer service
representative (CSR) becomes available. Any calls that
abandon within 10 seconds of being placed in queue need
not be counted. Calculated as the number of calls in
member services queue that are abandoned divided by
number of calls placed in queue.
	 
	 	 	 	 
	 

	 	 	 	Note: Calls that are answered by automated responses
(e.g., claim status, eligibility) should not be included
in measurement (i.e., added to the count of calls that
reach facility and are placed in queue).
	 
	 	 	 	 
	Standard 6

	 	Annual Member Satisfaction Survey:

CONTRACTOR’S performance on Member
Satisfaction will meet or exceed
the average regional health plan
performance based on the 2008 CAHPS
survey
	 	Respondents who answer Q42 (CAHPS 4.0H) with an 8, 9, or
10. The standard will be based on calendar year 2007
data, to be reported in the summer of 2008.
	 
	 	 	 	 
	 

	 	(client-specific)	 	 
	 
	 	 	 	 
	Standard 7

	 	Account Management: 

Average score of 3.0 or better on
scorecard elements
	 	It is the HCA’s expectation that all CONTRACTORS will
participate in the evaluation of account management
support to the Basic Health program. Performance
criteria/survey elements to be determined in 2008 for
the 2009 contract.
	 
	 	 	 	 
	Standard 8

	 	Call Quality
	 	Call Quality: It will be the HCA’s expectation that all
CONTRACTORS will be measuring and monitoring call
quality. Performance measures will be identified and
required with the 2009 contract.
	 
	 	 	 	 
	 

	 	 	 	If the CONTRACTOR is currently measuring call quality,
reports of those measures should be submitted with the
other required customer service performance measures.

For Standards 5-7: If CONTRACTOR does not currently have a process in place to measure Basic Health independently
from other lines of business, with the exception of 7) Account Management, it will need to develop and implement
such process by July 1, 2008. It is the HCA’s intent to measure each CONTRACTOR’s full book of business against
the Basic Health line of business for the 2009 contract year.

					
	 	 	 	 	 
	 
	 	Page 2 of 3 	 	 

 

Table of Contents

Exhibit 3: Basic Health — 2008 Performance Standards

	 	 	 	 	 
	 

	 	Administration	 	 
	 
	 	 	 	 
	Standard 10

	 	Identification Cards:
	 	1. Open Enrollment
	 
	 	 	 	 
	 

	 	97% of ID cards sent
within 15 business days
of receipt of
eligibility.

(client-specific)
	 	97% of ID cards mailed within 15 business days, but not
later than two weeks prior to the contract effective
date. In order to be counted in this measure, receipt
of HCA enrollment must be received by CONTRACTOR 21
business days prior to the contract effective date.
	 
	 	 	 	 
	 

	 	 	 	2. On-Going Enrollments (Outside of Open Enrollment)
	 
	 	 	 	 
	 

	 	 	 	97% mailed within 15 business days of receipt of
confirmation of enrollment from HCA.
	 
	 	 	 	 
	Standard 11

	 	Certificates of Coverage:

97% of the Certificates
of Coverage (COC) mailed
within 15 business days
of receipt of
confirmation of
enrollment from the HCA.
	 	97% of the Certificates of Coverage (COC) mailed within
15 business days of receipt of confirmation of
enrollment from the HCA.
	 
	 	 	 	 
	 

	 	(client-specific)	 	 
	 
	 	 	 	 
	Standard 12

	 	Enrollment Processing
	 	90% of enrollment data available to Participating
Providers within 5 business days of receipt of
enrollment confirmation from HCA.

For standards 10, 11 and 12: If CONTRACTOR does not currently have a process in place to measure Basic
Health independently from other lines of business, it will need to develop and implement such process by
July 1, 2008. It is the HCA’s intent to measure each CONTRACTOR’s full book of business against the
Basic Health line of business for the 2009 contract year.

					
	 	 	 	 	 
	 
	 	Page 3 of 3 	 	 

 

Table of Contents

Exhibit 4

Basic Health 2008 Contract

Quality Improvement Standards

The CONTRACTOR shall comply with these Quality Improvement Program Standards. The standards are
adopted primarily from NCQA’s Standards for the Accreditation of Managed Care Organizations. HCA
reserves the right to revise the Quality Improvement Program Standards to ensure that no standard
is in conflict with the Washington State Patient Bill of Rights (PBOR), Health Insurance
Portability and Accountability Act (HIPAA), or any other applicable state or federal statute or
regulation. In the event of conflict between the Quality Improvement Program Standards and the
standards of PBOR, HIPAA or state or federal statute or regulation, the standard which, in the sole
judgment of HCA, is most favorable to enrollees shall have precedence.

HCA agrees that any CONTRACTOR that meets or exceeds a TEAMonitor score of “met” on a specific
quality standard (Quality Management and Improvement, Utilization Management, Credentialing and
Recredentialing, Members’ Rights and Responsibilities, and Preventive Health Services) for 2
consecutive audit years will be assumed to be in compliance with that specific standard and will be
“deemed” for the next audit year. Exceptions to deeming will be: Clinical and Service Quality
Improvement Indicatives and the sections of Utilization Management that are related to file review
of appeals, denials and complaints/grievances. If HCA has evidence that subsequent performance has
been deficient, the CONTRACTOR shall be subject to audit on all standards. In determining whether
a CONTRACTOR’S performance has been deficient with respect to the Quality Improvement Standards,
HCA will consider NCQA Reports, enrollee complaints, appeals and denials, and any other substantial
data or information.

The above process shall not apply to areas specifically required for annual review by the Federal
Medicaid Act (Social Security Act, 42. US. C. Sec. 1396 et seq.), applicable federal regulations,
The Healthy Options Waiver 1115b, Guidelines for Addressing Fraud and Abuse in Medicaid Managed
Care, The Balanced Budget Act of 1997 and any published, applicable BBA regulations, applicable
RCWs and applicable WACs.

Managed care plans contracting with the Department of Social and Health Services and the Health
Care Authority shall comply with the National Committee of Quality Assurance (NCQA) standards
listed on the next pages. These standards are adopted from the NCQA Standards for the
Accreditation of Managed Care Organizations, effective July 1, 2007 — June 30, 2008.

The following NCQA definitions apply to terms used in this document:

Appeal: A formal request by a practitioner or covered person for reconsideration of a decision
such as a utilization review recommendation, a benefit payment, an administrative action, quality
of care or service issue, with the goal of finding a mutually acceptable solution.

Practitioner: Any individual who is qualified to practice a profession. Practitioners are usually
required to be licensed as defined by law.

Provider: An institution or organization that provides services for your organization’s members.
Examples of providers include hospitals and home health agencies.

Page 1 

Table of Contents

	 	 	 	 	 
	BH 2008 QI Contract Requirements
	 	 
	 
	 	 	 	 
	QUALITY MANAGEMENT AND IMPROVEMENT
	 	 
	 
	 	 	 	 
	QI 1

	 	PROGRAM STRUCTURE	 	 
	 

	 	The organization clearly defines its quality improvement (QI) structures and processes and assigns
responsibility to appropriate individuals.	 	 
	 

	 	ELEMENT A: Quality Improvement Program Structure	 	 
	 

	 	The organization’s QI program structure includes the following factors:	 	 
	1

	 	a written description of the QI program
	 	ü
	2

	 	behavioral health care is specifically addressed in the program description
	 	ü
	3

	 	patient safety is specifically addressed in the program description
	 	ü
	4

	 	the QI program accountable to the governing body
	 	ü
	5

	 	a designated physician has substantial involvement in the QI program
	 	ü
	6

	 	a designated behavioral health practitioner is involved in the implementation of the behavioral health
care aspects of the QI program.
	 	ü
	7

	 	a QI committee oversees the QI functions of the organization
	 	ü
	8

	 	The specific role, structure, and function of the QI committee and other committees, including meeting
frequency, are addressed in the program description
	 	ü
	9

	 	an annual work plan
	 	ü
	10

	 	A description of resources that the organization devotes to the needs of the QI program.
	 	ü
	 

	 	ELEMENT B: Annual Evaluation	 	 
	 

	 	There is an annual written evaluation of the QI program that includes:	 	 
	1

	 	a description of completed and ongoing QI activities that address the quality and safety of clinical care
and quality of service
	 	ü
	2

	 	trending of measures to assess performance in the quality and safety of clinical care and quality of
service
	 	ü
	3

	 	analysis of the results of QI initiatives, including barrier analysis
	 	ü
	4

	 	evaluation of the overall effectiveness of the QI program, including progress toward influencing
network-wide safe clinical practices.
	 	ü
	QI 2

	 	PROGRAM OPERATIONS	 	 
	 

	 	The organization’s quality improvement program is fully operational.	 	 
	 

	 	ELEMENT A: QI Committee Responsibilities	 	 
	 

	 	The organization’s QI committee:	 	 
	1

	 	recommends policy decisions
	 	ü
	2

	 	analyzes and evaluates the results of QI activities
	 	ü
	3

	 	ensures practitioner participation in the QI program through planning, design, implementation or review
	 	ü
	4

	 	institutes needed actions
	 	ü
	5

	 	ensures follow-up, as appropriate.
	 	ü
	 

	 	ELEMENT B: Committee Minutes	 	 
	 

	 	QI committee meeting minutes reflect all committee decisions and actions, and are signed and dated
	 	ü
	 

	 	ELEMENT C: Notification of QI Information	 	 
	 

	 	The organization annually makes information about its QI program
	 	ü
	1

	 	members
	 	ü
	2

	 	practitioners
	 	ü
	QI 3

	 	HEALTH SERVICES CONTRACTING	 	 
	 

	 	The organization’s contracts with individual practitioners and providers, including those making UM
decisions, specify that contractors cooperate with the organization’s QI program.	 	 
	 

	 	ELEMENT A: Practitioner Contracts	 	 
	 

	 	Contracts with practitioners specifically require that:	 	 
	1

	 	practitioners cooperate with QI activities
	 	ü
	2

	 	the organization has access to practitioner medical records, to the extent permitted by state and federal
law
	 	ü
	3

	 	practitioners maintain the confidentiality of member information and records
	 	ü
	 

	 	ELEMENT B: Affirmative Statement	 	 
	 

	 	Contracts with practitioners and providers include an affirmative statement indicating that practitioners
may freely communicate with patients about their treatment, regardless of benefit coverage limitations.
	 	ü
	 

	 	ELEMENT C: Provider Contracts	 	 
	 

	 	Contracts with organization providers specifically require that:	 	 
	1

	 	providers cooperate with QI activities
	 	ü
	2

	 	the organization has access to provider medical records, to the extent permitted by state and federal law.
	 	ü
	3

	 	providers maintain the confidentially of member information and records.
	 	ü
	 

	 	ELEMENT D: Notification of Specialist Termination	 	 
	 

	 	Contracts with specialists and specialty group practitioners require timely notification to organization
members affected by the termination of a specialist or the entire specialty group.
	 	ü
	QI 4

	 	AVAILABILITY OF PRACTITIONERS	 	 
	 

	 	The organization ensures that its network is sufficient in numbers and types of primary care and
specialty care practitioners.	 	 
	 

	 	ELEMENT A: Cultural Needs and Preferences	 	 
	 

	 	The organization assesses the cultural, ethnic, racial, and linguistic needs of its members and adjusts
the availability of practitioners within its network, if necessary.
	 	ü
	 

	 	ELEMENT B: Ensuring Availability of PCP’s	 	 
	 

	 	To ensure the availability of primary care practitioners (PCP) within its delivery system, the
organization:	 	 
	1

	 	defines which practitioners serve as PCPs
	 	ü
	2

	 	establishes quantifiable and measurable standards for the number of PCPs
	 	ü
	3

	 	establishes quantifiable and measurable standards for the geographic distribution of PCPs
	 	ü
	4

	 	analyzes performance against the standards annually.
	 	ü
	 

	 	ELEMENT C: Ensuring Availability of SCPs	 	 
	 

	 	To ensure the availability of specialty care practitioners (SCP) within its delivery system, the
organization:	 	 
	1

	 	defines which practitioners serve as high volume SCPs
	 	ü
	2

	 	establishes quantifiable and measurable standards for the number of SCPs
	 	ü
	3

	 	establishes quantifiable and measurable standards for the geographic distribution of SCPs
	 	ü
	4

	 	analyzes performance against the standards annually.
	 	ü

 

Table of Contents

	 	 	 	 	 
	 

	 	ELEMENT D: Ensuring Availability of BHPs	 	 
	 

	 	To ensure the availability of behavioral health practitioners (BHP) within its delivery system, the
organization:
	 	ü
	1

	 	defines which practitioners serve as BHPs
	 	ü
	2

	 	establishes quantifiable and measurable standards for the number of BHPs
	 	ü
	3

	 	establishes quantifiable and measurable standards for the geographic distribution of BHPs
	 	ü
	4

	 	analyzes performance against the standards annually.
	 	ü
	QI 5

	 	ACCESSIBILITY OF SERVICES	 	 
	 

	 	The organization establishes mechanisms to assure the accessibility of primary care services.	 	 
	 

	 	ELEMENT A: Assessment Against Access Standards	 	 
	 

	 	The organization collects and performs an annual analysis of data to measure its performance against
standards for access to:	 	 
	1

	 	regular and routine care appointments
	 	ü
	2

	 	urgent care appointments;
	 	ü
	3

	 	after-hours care.
	 	ü
	4

	 	Member Services by telephone
	 	ü
	 

	 	ELEMENT B: BH Access Standards
	 	 
	 

	 	Using valid methodology, the organization collects and performs an annual analysis of data to measure its
performance against standards for behavioral health access to:
	 	ü
	1

	 	care for a non-life-threatening emergency within 6 hours
	 	ü
	2

	 	urgent care within 48 hours
	 	ü
	3

	 	an appointment for a routine office visit within 10 business days.
	 	ü
	 

	 	ELEMENT C: BH Telephone Access Standards
	 	 
	 

	 	Using valid methodology, the organization collects and performs an analysis of data to measure its
performance against the following behavioral health telephone access standards at least once in the past
year:
	 	ü
	1

	 	the quarterly average for screening and triage calls shows that telephones are answered by a nonrecorded
voice within 30 seconds
	 	ü
	2

	 	the quarterly average for screening and triage calls reflects a telephone abandonment rate within 5
percent.
	 	ü
	QI 6

	 	MEMBER SATISFACTION	 	 
	 

	 	The organization implements mechanisms to assure member satisfaction.	 	 
	 

	 	ELEMENT A: Annual Assessment	 	 
	 

	 	To assess member satisfaction, the organization conducts annual evaluations of member complaints and
appeals by:	 	 
	1

	 	identifying the appropriate population
	 	ü
	2

	 	drawing appropriate samples from the affected population, if a sample is used
	 	ü
	3

	 	collecting valid data
	 	ü
	4

	 	performing the assessment annually
	 	ü
	 

	 	ELEMENT B: Opportunities for Improvement	 	 
	1

	 	The organization identifies opportunities for improvement, sets priorities and decides which
opportunities to pursue based upon the analysis of:	 	 
	 

	 	member complaint and appeal data
	 	ü
	2

	 	The CAHPS® 4.0H survey.
	 	ü
	QI 7

	 	COMPLEX CASE MANAGEMENT	 	 
	 

	 	The organization coordinates services for members with complex conditions and help them access needed
resources.	 	 
	 

	 	ELEMENT A: Identifying Member for
Case Management Chronic Conditions	 	 
	 

	 	The organization uses the following data sources to identify member for case management:
	 	ü
	1

	 	claims or encounters data
	 	ü
	2

	 	hospital discharge data
	 	ü
	3

	 	pharmacy data
	 	ü
	4

	 	data collected through the UM management process, if applicable.
	 	ü
	 

	 	ELEMENT B — Access to Case Management
	 	 
	 

	 	The organization has multiple avenues for members to be considered for case management services,
including:
	 	ü
	1

	 	health information line referral
	 	ü
	2

	 	DM program referral
	 	ü
	3

	 	discharge planner referral
	 	ü
	4

	 	UM referral, if applicable
	 	ü
	5

	 	member self-referral
	 	ü
	6

	 	practitioner referral
	 	ü
	 

	 	ELEMENT C- Case Management Systems
	 	 
	 

	 	The organization uses case management systems that support:
	 	ü
	 

	 	using evidence-based clinical guidelines or algorithms to conducts assessment and management
	 	ü
	 

	 	automatic documentation of individual and the date and time when the organization acted on the case or
interacted with the member
	 	ü
	 

	 	automated prompts for follow-up, as required by the case management plan
	 	ü
	 

	 	ELEMENT D — Case management process
	 	 
	 

	 	the organization’s case management procedures address:
	 	ü
	1

	 	members’ right to decline participation or disenroll from case management programs and services offered
by the organization
	 	ü
	2

	 	initial assessment of members’ health status, including condition-specific issues
	 	ü
	3

	 	documentation of clinical history, including medications
	 	ü
	4

	 	initial assessment of mental health status, including cognitive functioning
	 	ü
	5

	 	initial assessment of life planning activities
	 	ü
	6

	 	evaluation of cultural and linguistic needs, preferences or limitations
	 	ü
	7

	 	evaluation caregiver resources
	 	ü
	8

	 	evaluation of available benefits
	 	ü
	9

	 	development of a case management plan, including long- and short-term goals
	 	ü
	10

	 	development of a schedule for follow-up and communication with the member
	 	ü
	11

	 	development and communication of self management plans for members
	 	ü
	12

	 	process to assess progress against the case management plans for members
	 	ü
	 

	 	ELEMENT E — Initial Assessment
	 	 
	 

	 	An NCQA review of a sample of the organization’s case management files demonstrates that the organization
follows its documented processes for:
	 	ü
	1

	 	initial assessment of members’ health status, including condition-specific issues
	 	ü
	2

	 	documentation of clinical history, including medications
	 	ü
	3

	 	initial assessment of activities of daily living
	 	ü
	4

	 	initial assessment of mental health status, including cognitive function
	 	ü
	5

	 	evaluation of cultural and linguistic needs, preferences or limitations
	 	ü
	6

	 	evaluation of caregiver resources
	 	ü
	7

	 	evaluation of available benefits
	 	ü
	8

	 	assessment of life planning activities
	 	ü

 

Table of Contents

	 	 	 	 	 
	 

	 	ELEMENT F — Case Management-Ongoing Management
	 	 
	 

	 	The NCQA review of a sample of the organization’s case management files demonstrates that the
organization follows its documented process for:
	 	ü
	1

	 	development of case management plans, including long- and short-term goals
	 	ü
	2

	 	identification of barriers to meeting goals or compliance with case management plans
	 	ü
	3

	 	development of schedules for follow-up and communication with members
	 	ü
	4

	 	development and communication of self-management plans for members
	 	ü
	5

	 	assessment of progress against case management plans and goals and modification
	 	ü
	 

	 	ELEMENT G — Satisfaction with Case Management
	 	 
	1

	 	obtaining feedback from members
	 	ü
	2

	 	analyzing member complaints and inquiries
	 	ü
	 

	 	ELEMENT H — Measuring Effectiveness
	 	 
	 

	 	the organization measures the effectiveness of its case management program using three measures. For each
measure, the organization:
	 	ü
	1

	 	identifies a relevant process or outcome
	 	ü
	2

	 	uses valid methods that provide quantitative results
	 	ü
	3

	 	sets a performance goal
	 	ü
	4

	 	has clearly identified measure specifications
	 	ü
	5

	 	analyzes results
	 	ü
	6

	 	identifies opportunities for improvement, if applicable
	 	ü
	7

	 	develops a plan for intervention and remeasurement
	 	ü
	 

	 	ELEMENT I — Action and Remeasurement
	 	 
	 

	 	Based on the results of its measurement and analysis of case management effectiveness,
	 	ü
	1

	 	implements at least one intervention to improve performance
	 	ü
	2

	 	remeasures to determine performance
	 	ü
	QI 8

	 	DISEASE MANAGEMENT	 	 
	 

	 	The organization actively works to improve the health status of its members with chronic conditions	 	 
	 

	 	ELEMENT A- Identifying Chronic Conditions	 	 
	 

	 	The organization identifies two chronic conditions that its disease management (DM) programs address.
	 	ü
	 

	 	ELEMENT B — Program content
	 	 
	 

	 	The content of the organization’s programs address the following for each condition:	 	 
	1

	 	condition monitoring
	 	ü
	2

	 	patient adherence to the program’s treatment plans
	 	ü
	3

	 	consideration of other health conditions
	 	ü
	4

	 	lifestyle issues as indicated by practice guidelines (e.g. goal-setting techniques, problem solving).
	 	ü
	 

	 	ELEMENT C: Identifying Eligible Members for DM Programs	 	 
	 

	 	The organization identifies members who qualify for DM programs using the following data sources:
	 	ü
	1

	 	claims or encounter data
	 	ü
	2

	 	pharmacy data, if applicable
	 	ü
	3

	 	health risk appraisal results
	 	ü
	4

	 	laboratory results, if applicable
	 	ü
	5

	 	data collected through the UM or case management process, if applicable
	 	ü
	6

	 	member and practitioner referral
	 	ü
	 

	 	ELEMENT D — Frequency of Member Identification	 	 
	 

	 	Annually, the organization systematically identifies members who qualify for its DM programs.
	 	ü
	 

	 	ELEMENT E: Providing Eligible Members With Information	 	 
	 

	 	The organization provides eligible members with written program information regarding:	 	 
	1

	 	how to use the services
	 	ü
	2

	 	how members become eligible to participate
	 	ü
	3

	 	how to opt in or opt out.
	 	ü
	 

	 	ELEMENT F: Interventions Based on Stratification	 	 
	 

	 	The organization provides interventions to members based on stratification.
	 	ü
	 

	 	ELEMENT G: Eligible Member Participation	 	 
	 

	 	The organization annually measures and reports member participation rates
	 	ü
	 

	 	ELEMENT H: Informing and Educating Practitioners	 	 
	 

	 	The organization has a documented process for providing practitioners with written program information,
including:	 	 
	1

	 	instructions on how to use the DM services
	 	ü
	2

	 	how the organization works with a practitioner’s members in the program.
	 	ü
	 

	 	ELEMENT I — Integrating Member Information
	 	 
	 

	 	The organization integrates information from the following systems to facilitate access to member health
information for continuity of care:
	 	ü
	1

	 	a health information line
	 	ü
	2

	 	a DM program
	 	ü
	3

	 	a case management program
	 	ü
	4

	 	a UM program, if applicable.
	 	ü
	 

	 	ELEMENT J — Satisfaction with Disease Management
	 	 
	1

	 	obtaining feedback from members
	 	ü
	2

	 	analyzing member complaints and inquiries
	 	ü
	 

	 	ELEMENT K: Measuring Effectiveness	 	 
	 

	 	The organization employs and tracks one performance measure for each DM program. Each measurement:	 	 
	1

	 	addresses a relevant process or outcome
	 	ü
	2

	 	produces a quantitative result
	 	ü
	3

	 	is population based
	 	ü
	4

	 	uses data and methodology that are valid for the process or outcome measured
	 	ü
	5

	 	has been analyzed in comparison to a benchmark or goal.
	 	ü
	QI 9

	 	CLINICAL PRACTICE GUIDELINES	 	 
	 

	 	The organization is accountable for adopting and disseminating nonpreventive health clinical practice
guidelines relevant to its membership for the provision of non preventive health acute and chronic
medical services and for nonpreventive and preventive behavioral health services.
	 	ü
	 

	 	ELEMENT A: Adoption and Distribution of Guidelines
	 	 
	 

	 	The organization ensures that practitioner are using relevant clinical practice guidelines by:
	 	ü
	1

	 	adopting guidelines for at least two medical conditions and at least two behavioral health conditions
	 	ü
	2

	 	establishing the clinical basis for the guidelines
	 	ü
	3

	 	updating the guidelines at least every two years
	 	ü
	4

	 	distributing the guidelines to appropriate practitioners
	 	ü
	 

	 	ELEMENT B: Relation to Disease Management Programs
	 	 
	 

	 	At least two of the organization’s adopted clinical practice guidelines are the clinical basis for DM
programs in QI 8: Disease Management
	 	ü

 

Table of Contents

	 	 	 	 	 
	 

	 	ELEMENT C — Performance Measurement
	 	 
	 

	 	The organization has annually measured performance against at least two important aspects of:
	 	ü
	1

	 	a clinical practice guideline for an acute or chronic medical condition
	 	ü
	2

	 	a second clinical practice guideline for acute or chronic medical condition
	 	ü
	3

	 	a clinical practice guideline for behavioral health condition
	 	ü
	4

	 	a second clinical practice guideline for behavioral health condition
	 	ü
	QI 10 9

	 	CONTINUITY AND COORDINATION OF MEDICAL CARE	 	 
	 

	 	The organization monitors the continuity and coordination of care that members receive and takes actions,
as necessary, to ensure and improve continuity and coordination of care across the health care network.	 	 
	 

	 	ELEMENT A: Opportunities for Improvement	 	 
	 

	 	The organization identifies and acts on opportunities to improve coordination of medical care by:	 	 
	1

	 	collecting data
	 	ü
	2

	 	conducting quantitative and causal analysis of data to identify improvement opportunities
	 	ü
	3

	 	identifying and selecting one opportunity for improvement
	 	ü
	4

	 	identifying and selecting a second opportunity for improvement
	 	ü
	5

	 	taking action on the first opportunity
	 	ü
	6

	 	taking action on the second opportunity
	 	ü
	 

	 	ELEMENT B: Notification of PCP Termination	 	 
	 

	 	The organization notifies members affected by the termination of a primary care practitioner at least 30
calendar days prior to effective termination date and helps them select a new practitioner.
	 	ü
	 

	 	ELEMENT C: Continued Access to Practitioners	 	 
	 

	 	If the practitioner’s contract is discontinued, the organization allows affect members continued access
to the practitioner, as follows:
	 	ü
	1

	 	continuation of treatment through the lesser of the current period of active treatment, or for up to 90
calendar days for members undergoing active treatment for a chronic or acute medical condition
	 	ü
	2

	 	continuation of care through the postpartum period for members in their second or third trimester of
pregnancy.
	 	ü
	 

	 	ELEMENT D — Transition to Other care
	 	 
	 

	 	The organization assists with a member’s transition to other care, if necessary, when benefits end.
	 	ü
	QI 11

	 	CONTINUITY AND COORDINATION BETWEEN MEDICAL AND BEHAVIORAL HEALTH CARE	 	 
	 

	 	The organization collaborates with behavioral health specialists to monitor and improve coordination
between medical and behavioral health care.
	 	ü
	 

	 	ELEMENT A: Data Collection
	 	 
	 

	 	The organization collects data, at least once in the last two years, about the following opportunities
for collaboration between medical and behavioral health care:
	 	ü
	1

	 	exchange of information
	 	ü
	2

	 	appropriate diagnosis, treatment and referral of behavioral health disorders commonly seen in primary care
	 	ü
	3

	 	appropriate uses of psychopharmacological medications
	 	ü
	4

	 	management of treatment access and follow-up for members with coexisting medical and behavioral disorders
	 	ü
	5

	 	primary or secondary preventive behavioral health program implementation.
	 	ü
	 

	 	ELEMENT B: Collaborative Analysis	 	 
	 

	 	The organization collaborates with its behavioral health specialists to identify opportunities and take
action to improve coordination of behavioral health care with general medical care. There is
documentation of the following factors:	 	 
	1

	 	collaboration with behavioral health specialists
	 	ü
	2

	 	quantitative and causal analysis of data to identify improvement opportunities
	 	ü
	3

	 	identification and selection of at least one opportunity for improvement.
	 	ü
	4

	 	the organization takes collaborative action to address at least 1 identified opportunity for improvement
	 	ü
	QI 12 11

	 	CLINICAL QUALITY IMPROVEMENTS	 	 
	 

	 	The organization demonstrates improvements in the clinical care of members.	 	 
	 

	 	ELEMENT A: Clinical Improvements	 	 
	 

	 	The organization demonstrates three clinical improvements, one of which is in the behavioral health area
and each of which is of either of the following types:	 	 
	1

	 	significant improvement in one audited HEDIS clinical measure
	 	ü
	2

	 	Meaningful improvement in a QI clinical activity not addressed by a HEDIS measure in an area relevant to
the organization’s population.
	 	ü
	QI 13 12

	 	SERVICE QUALITY IMPROVEMENTS	 	 
	 

	 	The organization demonstrates improvements in the service it renders to members.	 	 
	 

	 	ELEMENT A: Service Improvements	 	 
	 

	 	The organization demonstrates two service improvements, each of which is one of the following types:	 	 
	1

	 	significant improvement in a CAHPS® 4.0H composite or rating result or question
	 	ü
	2

	 	meaningful improvement in a QI service activity not using the CAHPS® 4.0H results in an area of service
identified as an opportunity and relevant to the organization’s population.
	 	ü
	QI 14 13

	 	STANDARDS FOR MEDICAL RECORD DOCUMENTATION	 	 
	 

	 	The organization establishes medical record standards to facilitate communication, coordination and
continuity of care and to remote efficient and effective treatment	 	 
	 

	 	ELEMENT A: Medical Record Criteria	 	 
	 

	 	The organization has policies and procedures that address the following factors, and distributes them to
practice sites:	 	 
	1

	 	confidentiality of medical records
	 	ü
	2

	 	medical record documentation standards
	 	ü
	3

	 	an organized medical record keeping system and standards for availability of medical records
	 	ü
	4

	 	performance goals to assess the quality of medical record keeping.
	 	ü
	 

	 	ELEMENT B: Improving Medical Record Keeping	 	 
	 

	 	The organization has implemented a method to improve medical record keeping
	 	ü
	QI 14

	 	DELEGATION OF QI	 	 
	 

	 	If the organization delegates any QI activities, there is evidence of oversight of the delegated activity.	 	 
	 

	 	ELEMENT A: Written Delegation Agreement	 	 
	 

	 	There is a written delegation document that:	 	 
	1

	 	is mutually agreed upon
	 	ü
	2

	 	describes the responsibilities of the organization and the delegated entity
	 	ü
	3

	 	describes the delegated activities
	 	ü
	4

	 	requires at least semiannual reporting to the organization
	 	ü
	5

	 	describes the process by which the organization evaluates the delegated entity’s performance
	 	ü
	6

	 	describes the remedies, including revocation of the delegation, available to the organization if the
delegated entity does not fulfill its obligations.
	 	ü

 

Table of Contents

	 	 	 	 	 
	 

	 	ELEMENT B: Provisions for PHI	 	 
	 

	 	If the delegation arrangement includes the use of protected health information (PHI) by the delegate, the
delegation document also includes the following provisions:	 	 
	1

	 	a list of the allowed uses of protected health information
	 	ü
	2

	 	a description of delegate safeguards to protect the information from inappropriate use of further
disclosure
	 	ü
	3

	 	a stipulation that the delegate ensures that sub delegates have similar safeguards
	 	ü
	4

	 	a stipulation that the delegate provide individuals with access to their protected health information
	 	ü
	5

	 	a stipulation that the delegate informs the organization if inappropriate uses of the information occur
	 	ü
	6

	 	a stipulation that the delegate ensures protected health information is returned, destroyed or protected
if the delegation agreement ends.
	 	ü
	 

	 	ELEMENT C: Approval of QI Program	 	 
	 

	 	The organization approves its delegates QI program annually.
	 	ü
	 

	 	ELEMENT D: Pre-Delegation Evaluation	 	 
	 

	 	For delegation agreements that have been in effect for less than 12 months, the organization evaluated
delegate capacity to meet NCQA requirements before delegation began.
	 	ü
	 

	 	ELEMENT E: Annual Evaluation	 	 
	 

	 	For delegation arrangements in effect for 12 months or longer, the organization annually evaluated
delegate performance against its expectations and NCQA standards for delegated activities.
	 	ü
	 

	 	ELEMENT F: Reporting	 	 
	 

	 	For delegation arrangements in effect 12 months or longer, the organization evaluated regular reports, as
specified in Element A.
	 	ü
	 

	 	ELEMENT G: Opportunities for Improvement	 	 
	 

	 	For delegation arrangements that have been in effect for more than 12 months, at least once each of the
past 2 years that delegation has been in effect, the organization has identified and followed up on
opportunities for improvement, if applicable.
	 	ü
	UM
	 	 
	UM 1

	 	Utilization Management Structure	 	 
	 

	 	The organization clearly defines the structures and processes within its utilization management (UM)
program and assigns responsibility appropriate individuals.	 	 
	 

	 	ELEMENT A: Written Program Description	 	 
	 

	 	The organization’s UM program description includes the following factors:	 	 
	1

	 	program structure
	 	ü
	2

	 	behavioral health care aspects of the program
	 	ü
	3

	 	involvement of a designated senior physician in UM program implementation
	 	ü
	4

	 	involvement of a designated behavioral health care practitioner in the implementation of the behavioral
health care aspects of the UM program
	 	ü
	5

	 	program scope and the processes and information sources used to make determinations of benefit coverage
and medical necessity.
	 	ü
	 

	 	ELEMENT B: Physician Involvement	 	 
	 

	 	A senior physician is actively involved in implementing the organization’s UM program.
	 	ü
	 

	 	ELEMENT C: Behavioral Health Practitioner Involvement	 	 
	 

	 	A behavioral health practitioner is actively involved in implementing the behavioral health aspects of
the UM program.
	 	ü
	 

	 	ELEMENT D: Annual Evaluation	 	 
	 

	 	The organization annually evaluates and updates the UM program, as necessary.
	 	ü
	UM 2

	 	Clinical Criteria for UM Decisions	 	 
	 

	 	To make utilization decisions, the organization uses written criteria based on sound clinical evidence
and specifies procedures for appropriately applying the criteria.	 	 
	 

	 	ELEMENT A: UM Criteria	 	 
	 

	 	The organization:	 	 
	1

	 	has written UM decision-making criteria that are objective and based on medical evidence
	 	ü
	2

	 	has written policies for applying the criteria based on individual needs
	 	ü
	3

	 	has written policies for applying the criteria based on an assessment of the local delivery system
	 	ü
	4

	 	involves appropriate practitioners in developing, adopting and reviewing criteria
	 	ü
	5

	 	reviews the UM criteria and the procedures for apply them annually and updates the criteria when
appropriate.
	 	ü
	 

	 	ELEMENT B: Availability of Criteria	 	 
	 

	 	The organization:	 	 
	1

	 	states in writing how practitioners can obtain UM criteria
	 	ü
	2

	 	makes the criteria available to its practitioners upon request
	 	ü
	 

	 	ELEMENT C: Consistency in Applying Criteria	 	 
	 

	 	At least annually, the organization:	 	 
	1

	 	evaluates the consistency with which health care professionals involved in UM apply criteria in decision
making
	 	ü
	2

	 	acts on opportunities to improve consistency, if applicable.
	 	ü
	UM 3

	 	Communication Services	 	 
	 

	 	The organization provides access to staff for members and practitioners seeking information about the UM
process and the authorization of care.
	 	ü
	 

	 	ELEMENT A: Access to Staff
	 	 
	 

	 	The organization provides the following communication services for practitioners and members:
	 	ü
	1

	 	staff are available at least eight hours a day during normal business days for inbound calls regarding UM
issues
	 	ü
	2

	 	ability of staff to receive inbound communication after normal business hours regarding UM issues
	 	ü
	3

	 	staff can send outbound communication inquiries about UM during normal business hours, unless otherwise
agreed upon
	 	ü
	4

	 	staff members identify themselves by name, title and organization name when initiating or returning calls
regarding UM issues
	 	ü
	5

	 	a toll-free number or staff that accept collect calls regarding UM issues
	 	ü
	6

	 	access to staff for callers with questions about the UM process.
	 	ü
	UM 4

	 	Appropriate Professionals	 	 
	 

	 	Qualified licensed health professionals assess the clinical information used to support UM decisions.	 	 
	 

	 	ELEMENT A: Licensed Health Professionals	 	 
	 

	 	The organization has written procedures:	 	 
	1

	 	requiring appropriately licensed professionals to supervise all medical necessity decisions
	 	ü
	2

	 	specifying the type of personnel responsible for each level of UM decision making.
	 	ü
	 

	 	ELEMENT B: Use of Practitioners for UM Decisions	 	 
	 

	 	The organization has a written job description with qualifications for practitioners who review denials
of care based on medical necessity. Practitioners are reuired to have:	 	 
	1

	 	education, training or professional experience in medical or clinical practice
	 	ü
	2

	 	current license to practice without restriction.
	 	ü
	 

	 	ELEMENT C: Practitioner Review of Non-BH Denials	 	 
	 

	 	The organization ensures that a physician, dentist or pharmacist, as appropriate, reviews any
non-behavioral health denial of care based on medical necessity.
	 	ü
	 

	 	ELEMENT D: Practitioner Review of BH Denials	 	 
	 

	 	The organization ensures that a physician, appropriate behavioral health practitioner or pharmacist, as
appropriate, reviews any behavioral health denial of care based on medical necessity.
	 	ü
	 

	 	ELEMENT E: Use of Board-Certified Consultants	 	 
	 

	 	The organization has written procedures for using board-certified consultants to assist in making medical
necessity determinations.
	 	ü
	UM 5

	 	Timeliness of UM Decisions	 	 

 

Table of Contents

	 	 	 	 	 
	 

	 	The organization makes utilization decisions in a timely manner to accommodate the clinical urgency of
the situation.	 	 
	 

	 	ELEMENT A: Timeliness of Non-BH UM Decision Making	 	 
	 

	 	The organization adheres to the following standards for timeliness of UM decision making:	 	 
	1

	 	for non-urgent preservice decisions, the organization makes decisions within 15 calendar days of receipt
of the request [HCA — require nonurgent, preservice decisions within 14 days}
	 	ü
	2

	 	for urgent pre-service decisions, the organization makes decisions within 72 hours of receipt of the
request
	 	ü
	3

	 	for urgent concurrent review, the organization makes decisions within 24 hours of receipt of the request
	 	ü
	4

	 	for post-service decisions, the organization makes decisions within 30 calendar days of receipt of the
request.
	 	ü
	 

	 	ELEMENT B: Notification of Non-BH Decisions	 	 
	 

	 	The organization adheres to the following standards for notification of non-behavioral health UM decision
making:	 	 
	1

	 	for non-urgent preservice denial decisions, the organization gives electronic or written notification of
the decision to practitioners and members within 15 calendar days of the request. [HCA — require
nonurgent, preservice decisions within 14 days}
	 	ü
	2

	 	for urgent preservice denial decisions, the organization gives electronic or written notification of the
decision to practitioners and members within 72 hours of the request
	 	ü
	6

	 	for urgent concurrent denial decisions, the organization gives electronic or written notification of the
decision to practitioners and members within 24 hours of the request
	 	ü
	7

	 	for postservice denial decisions, the organization gives electronic or written notification of the
decision to practitioners and members within 30 calendar days of the request.
	 	ü
	 

	 	ELEMENT C: Timeliness of BH UM Decision Making	 	 
	 

	 	The organization adheres to the following standards for timeliness of behavioral health UM decision
making:
	 	ü
	1

	 	for non-urgent pre-service decisions, the organization makes decisions within 15 calendar days of receipt
of the request. [HCA — require nonurgent, preservice decisions within 14 days}
	 	ü
	2

	 	for urgent pre-service decisions, the organization makes decisions within 72 hours of receipt of the
request
	 	ü
	3

	 	for urgent concurrent review, the organization makes decisions within 24 hours of receipt of the request
	 	ü
	4

	 	for post-service decisions, the organization makes decisions within 30 calendar days of receipt of the
request.
	 	ü
	 

	 	ELEMENT D: Notification of BH Decisions	 	 
	 

	 	The organization adheres to the following standards for notification of behavioral health UM decision
making:	 	 
	1

	 	for non-urgent pre-service denial decisions, the organization gives electronic or written notification of
the decision to practitioners and members within 15 calendar days of the request
	 	ü
	2

	 	for urgent preservice denial decisions, the organization gives electronic or written notification of the
decision to practitioners and members within 72 hours of the request
	 	ü
	3

	 	for urgent concurrent denial decisions, the organization gives electronic or written notification of the
decision to practitioners and members within 24 hours of the request
	 	ü
	7

	 	for post-service denial decisions, the organization gives electronic or written notification of the
decision to practitioners and members within 30 calendar days of the request.
	 	ü
	UM 6

	 	Clinical Information	 	 
	 

	 	When making a determination of coverage based on medical necessity, the organization obtains relevant
clinical information and consults with the treating physician.	 	 
	 

	 	ELEMENT A: Information for UM Decision Making	 	 
	 

	 	The organization has a written description that identifies the information that is needed to support UM
decision making in place for at least 12 months.
	 	ü
	 

	 	ELEMENT C: Documentation of Non-BH Information	 	 
	 

	 	There is documentation that relevant clinical information is gathered consistently to support
non-behavioral health UM decision making.
	 	ü
	 

	 	ELEMENT D: Documentation of BH Information	 	 
	 

	 	There is documentation that relevant clinical information is gathered consistently to support behavioral
health UM decision making.
	 	ü
	UM 7

	 	Denial Notices	 	 
	 

	 	The organization clearly documents and communicates the reasons for each denial.	 	 
	 

	 	ELEMENT A: Notification of Reviewer Availability	 	 
	 

	 	The organization notifies practitioners of:	 	 
	1

	 	its policy for making a reviewer available to discuss any UM denial decision
	 	ü
	2

	 	how to contact a reviewer.
	 	ü
	 

	 	ELEMENT B: Discussing a with Reviewer	 	 
	 

	 	The organization provides practitioners with the opportunity to discuss any non-behavioral health UM
denial decision with a physician or pharmacist reviewer.
	 	ü
	 

	 	ELEMENT C: Reason for Non-BH Denial	 	 
	 

	 	The organization provides written notification of the non-behavioral health denial that contains the
following:	 	 
	1

	 	the specific reasons for the denial, in easily understandable language
	 	ü
	2

	 	a reference to the benefit provision, guideline, protocol or other similar criterion on which the denial
decision is based
	 	ü
	3

	 	notification that the member can obtain a copy of the actual benefit provision, guideline, protocol or
other similar criterion on which the denial decision was based, upon request.
	 	ü
	 

	 	ELEMENT D: Non-BH Notice of Appeal Rights/Process	 	 
	 

	 	The organization provides written notification of the non-behavioral health denial that contains the
following:	 	 
	1

	 	description of appeal rights, including the right to submit written comments, documents or other
information relevant to the appeal
	 	ü
	2

	 	explanation of the appeal process, including the right to member representation and time frames for
deciding appeals
	 	ü
	3

	 	if a denial is an urgent preservice or urgent concurrent denial, a description of the expedited appeal
process.
	 	ü
	 

	 	ELEMENT E: Discussing a BH Denial with Reviewer.	 	 
	 

	 	The organization provides practitioners with the opportunity to discuss any behavioral health UM denial
decision with a physician, appropriate behavioral health or pharmacist reviewer.
	 	ü

 

Table of Contents

	 	 	 	 	 
	 

	 	ELEMENT F: Reason for BH Denial	 	 
	 

	 	The organization provides written notification of the behavioral health denial that contains the
following:	 	 
	1

	 	the specific reasons for the denial, in easily understandable language
	 	ü
	2

	 	a reference to the benefit provision, guideline, protocol or other similar criterion on which the denial
decision was based
	 	ü
	3

	 	notification that the member can obtain a copy of the actual benefit provision, guideline, protocol or
other similar criterion on which the denial decision was based, upon request.
	 	ü
	 

	 	ELEMENT G: BH Notification of Appeals/Rights process	 	 
	 

	 	The organization provides written notification of the behavioral health denial that contains the
following:	 	 
	1

	 	description of appeal rights, including the right to submit written comments, documents or other
information relevant to the appeal
	 	ü
	2

	 	explanation of the appeal process, including the right to member representation and time frames for
deciding appeals
	 	ü
	3

	 	if a denial is an urgent preservice or urgent concurrent denial, a description of the expedited appeal
process.
	 	ü
	UM 8

	 	Policies for Appeals	 	 
	 

	 	The organization has written policies and procedures for the thorough, appropriate, and timely resolution
of member appeals. [HCA — Contractors are required to follow the Washington State “Patient Bill of
Rights” (PBOR)]	 	 
	UM 9

	 	Appropriate Handling of Appeals	 	 
	 

	 	The organization adjudicates member appeals in a thorough, appropriate and timely manner. [HCA —
Contractors are required to follow the Washington State “Patient Bill of Rights” (PBOR)]	 	 
	UM 10

	 	Evaluation of New Technology	 	 
	 

	 	The organization evaluates the inclusion of new technologies and the new application of existing
technologies in the benefit plan. This includes medical and behavioral health procedures,
pharmaceuticals and devices.	 	 
	 

	 	ELEMENT A: Written Process	 	 
	 

	 	The organization’s written process for evaluating new technologies and the new application of existing
technologies for inclusion in its benefit plan includes an evaluation of the following factors:	 	 
	1

	 	medical procedures
	 	ü
	2

	 	behavioral health procedures
	 	ü
	3

	 	pharmaceuticals
	 	ü
	4

	 	devices.
	 	ü
	 

	 	ELEMENT B: Description of the Evaluation Process
	 	ü
	 

	 	The organization’s written evaluation process includes the following factors:
	 	ü
	1

	 	the process and decision variables the organization uses to make determinations
	 	ü
	2

	 	a review of information from appropriate government regulatory bodies
	 	ü
	3

	 	a review of information from published scientific evidence
	 	ü
	4

	 	a process for seeking input from relevant specialists and professionals who have expertise in the
technology.
	 	ü
	 

	 	ELEMENT C: Implementation of New Technology	 	 
	 

	 	The organization implements a decision on coverage from its assessment of new technologies and new
applications of existing technologies or from review of special cases.
	 	ü
	UM 11

	 	Satisfaction with the UM Process	 	 
	 

	 	The organization evaluates member and practitioner satisfaction with the utilization management process.
	 	ü
	UM 12

	 	Emergency Services	 	 
	 

	 	The organization provides, arranges for or otherwise facilitates all needed emergency services, including
appropriate coverage of costs.	 	 
	 

	 	ELEMENT A: Policies and Procedures	 	 
	 

	 	The organization’s policies and procedures require:	 	 
	1

	 	coverage of emergency services to screen and stabilize the member without prior approval where a prudent
layperson, acting reasonably, would have believed an emergency medical condition existed
	 	ü
	2

	 	coverage of emergency services if an authorized representative, acting for the organization, has
authorized the provision of emergency services.
	 	ü
	 

	 	ELEMENT C: Organization’s Authorized Representative	 	 
	 

	 	The organization covers emergency services approved by an authorized representative.
	 	ü
	UM 13

	 	Procedures for Pharmaceutical Management	 	 
	 

	 	The organization ensures that its procedures for pharmaceutical management, if any, promote the
clinically appropriate use of pharmaceuticals.	 	 
	 

	 	ELEMENT A: Policies and Procedures	 	 
	 

	 	The organization’s policies and procedures for pharmaceutical management include:	 	 
	1

	 	the criteria used to adopt pharmaceutical management procedures
	 	ü
	2

	 	a process that uses clinical evidence from appropriate external organizations.
	 	ü
	 

	 	ELEMENT B: Pharmaceutical Restrictions/Preferences
	 	ü
	 

	 	The organization maintains a list of pharmaceuticals, including restrictions and preferences, and has
policies that address:
	 	ü
	1

	 	how to use the pharmaceutical management process
	 	ü
	2

	 	an explanation of any limits or quotas
	 	ü
	3

	 	an explanation of how prescribing practitioners must provide information to support an exceptions request
	 	ü
	4

	 	the organization’s process for generic substitution, therapeutic interchange and step-therapy protocols.
	 	ü
	 

	 	ELEMENT C: Pharmaceutical Patient Safety Issues
	 	ü
	 

	 	The organization’s pharmaceutical procedures include:
	 	ü
	1

	 	adopting or creating a system for point-of -dispensing communicatoins identify and classify drug-to-drug
interactoins by severity
	 	ü
	2

	 	notifying dis\pensing roviders at the point-of-dispensing of specific interactins when they meet the
organization’s severity threshold.
	 	ü
	3

	 	identifying and notifying members and prescribing practitioners affected by a Class II recall or
voluntary drug withdrawals from the market for safety reasons within 30 calendar days of the FDA
notification.
	 	ü
	4

	 	an expedited process for prompt identification and notification of members and prescribing practitioners
affected by a Class I recall.
	 	ü
	 

	 	ELEMENT D: Review and Update of Procedures	 	 
	 

	 	The organization reviews pharmaceutical management procedures at least annually and updates them as new
pharmaceutical information becomes available.
	 	ü
	 

	 	ELEMENT E: Pharmacist and Practitioner Involvement	 	 
	 

	 	The organization involves the following in the development and periodic updates of its pharmaceutical
management procedures:	 	 
	1

	 	pharmacists
	 	ü
	2

	 	appropriate practitioners
	 	ü

 

Table of Contents

	 	 	 	 	 
	 

	 	ELEMENT F: Availability of Procedures
	 	 
	 

	 	Annually and when it makes changes, the organization provides pharmaceutical management procedures to
practitioners.
	 	ü
	 

	 	ELEMENT G: Considering Exceptions	 	 
	 

	 	The organization has exceptions policies and procedures that describe the process for:	 	 
	1

	 	making an exceptions request based on medical necessity
	 	ü
	2

	 	obtaining medical necessity information from prescribing practitioners
	 	ü
	3

	 	using appropriate pharmacists and practitioners to consider exception requests
	 	ü
	4

	 	timely request handling
	 	ü
	5

	 	communicating the reason for a denial and an explanation of the appeals process when it does not approve
an exception request.
	 	ü
	UM 14

	 	Ensuring Appropriate Utilization	 	 
	 

	 	The organization facilitates the delivery of appropriate care and monitors the impact of its utilization
management program to detect and correct potential under- and overutilization of services.	 	 
	 

	 	ELEMENT A: Relevant Utilization Data	 	 
	 

	 	The organization chooses at least four relevant types of utilization data, including one type related to
behavioral health to monitor for each product line.
	 	ü
	 

	 	ELEMENT B: Under/Overutilization Thresholds	 	 
	 

	 	The organization sets thresholds for the four data types for each product line, including behavioral
health, and annually quantitqtively analyzes data against the established thresholds to detect under- and
overutilization
	 	ü
	 

	 	ELEMENT C: Qualitative Data Analysis	 	 
	 

	 	The organization conducts qualitative analysis to determine the cause and effect of all data not within
thresholds.
	 	ü
	 

	 	ELEMENT D: Site-Level Monitoring	 	 
	 

	 	The organization analyzes data not within threshold by practice sites.
	 	ü
	 

	 	ELEMENT E: Interventions	 	 
	 

	 	The organization takes action to address identifies problems of under- and overutilization.
	 	ü
	 

	 	ELEMENT F: Evaluating Intervention Effectiveness	 	 
	 

	 	The organization measures the effectiveness of interventions to address under- and overutilization.
	 	ü
	UM 15

	 	Triage and Referral for Behavioral Health Care	 	 
	 

	 	The organization has written standards to ensure that any centralized triage and referral functions for
behavioral health services are appropriately implemented, monitored and professionally managed. Note:	 	 
	 

	 	This standard applies only to organizations with a centralized triage and referral process for behavioral
health, both delegated and nondelegated	 	 
	 

	 	ELEMENT A: Triage and Referral Protocols
	 	 
	 

	 	The organization’s protocols for behavioral health care triage and referral:
	 	ü
	1

	 	address all relevant mental health and substance abuse situations
	 	ü
	2

	 	define level of urgency
	 	ü
	3

	 	define appropriate setting of care
	 	ü
	4

	 	have been reviewed or revised within the past two years
	 	ü
	 

	 	ELEMENT B: Clinical Decisions
	 	 
	 

	 	Licensed practitioners make decisions that require clinical judgment.
	 	ü
	 

	 	ELEMENT C: Supervision and Oversight
	 	 
	 

	 	Supervision and oversight for triage and referral decisions meet the following factors:
	 	ü
	1

	 	staff who make clinical decisions are supervised by a licensed master’s-level practitioner with five
years of post-master’s experience
	 	ü
	2

	 	A licensed psychiatrist or a licensed doctoral-level clinical psychologist oversees triage and referral
decisions.
	 	ü
	UM 16

	 	Delegation of UM	 	 
	 

	 	If the managed care organization delegates any UM activities, there is evidence of oversight of the
delegated activity.	 	 
	 

	 	ELEMENT A: Written Delegation Agreement	 	 
	 

	 	The written delegation document:
	 	ü
	1

	 	is mutually agreed-upon	 	 
	2

	 	describes the responsibilities of the organization and the delegated entity
	 	ü
	3

	 	describes the delegated activities
	 	ü
	4

	 	requires at least semi-annual reporting to the organization
	 	ü
	5

	 	describes the process by which the organization evaluates the delegated entity’s performance
	 	ü
	6

	 	describes the remedies, including revocation of the delegation, available to the organization if the
delegated entity does not fulfill its obligations.
	 	ü
	 

	 	ELEMENT B: Provision for PHI	 	 
	 

	 	If the delegation arrangement includes the use of protected health information by the delegate, the
delegation document also includes the following provisions:	 	 
	1

	 	a list of the allowed uses of protected health information
	 	ü
	2

	 	a description of delegate safeguards to protect the information from inappropriate use or further
disclosure
	 	ü
	3

	 	a stipulation that the delegate will ensure that subdelegates have similar safeguards
	 	ü
	4

	 	a stipulation that the delegate will provide individuals with access to their protected health information
	 	ü
	5

	 	a stipulation that the delegate will inform the organization if inappropriate uses of the information
occur
	 	ü
	6

	 	a stipulation that the delegate will ensure protected health information is returned, destroyed or
protected if the delegation agreement ends.
	 	ü
	 

	 	ELEMENT C: Approval of UM Program	 	 
	 

	 	Annually, the organization approves its delegate’s UM program.
	 	ü
	 

	 	ELEMENT D: Predelegation Evaluation	 	 
	 

	 	For delegation agreements that have been in effect for less than 12 months, the organization evaluated
delegate capacity before delegation began.
	 	ü
	 

	 	ELEMENT E: Annual Evaluation	 	 
	 

	 	For delegation arrangements in effect 12 months or longer, the organization annually evaluated delegate
performance against its expectations and NCQA standards.
	 	ü
	 

	 	ELEMENT F: Reporting	 	 
	 

	 	For delegation arrangements in effect 12 months or longer, the organization evaluated regular reports, as
specified in Element A.
	 	ü
	 

	 	ELEMENT G: Opportunities for Improvement	 	 
	 

	 	For delegation arrangements that have been in effect for more than 12 months, at least once in each of
the past 2 years that delegation has been in effect, the organization has identified and followed up on
opportunities for improvement, if applicable.
	 	ü

 

Table of Contents

	 	 	 	 	 
	CREDENTIALING AND RECREDENTIALING
	 	 
	CR 1

	 	Credentialing Policies	 	 
	 

	 	The organization has a well-defined credentialing and recredentialing process for evaluating and
selecting licensed independent practitioners to provide care to its members.	 	 
	 

	 	ELEMENT A: Practitioner Credentialing Guidelines	 	 
	 

	 	The organization’s credentialing policies and procedures specify:	 	 
	1

	 	types of practitioners to credential and recredential
	 	ü
	2

	 	verification sources used
	 	ü
	3

	 	criteria for credentialing and recredentialing
	 	ü
	4

	 	the process for making credentialing and recredentialing decisions
	 	ü
	5

	 	the process for managing credentialing files that meet the organization’s established criteria
	 	ü
	6

	 	the process to delegate credentialing or recredentialing
	 	ü
	7

	 	the process ensuring that credentialing and recredentialing are conducted in a non-discriminatory manner
	 	ü
	8

	 	the process for notifying a practitioner if information obtained during the organization’s credentialing
process that varies substantially from the information provided to the organization by the practitioner
	 	ü
	9

	 	the process to for ensuring that practitioners are notified of the credentialing or recredentialing
decision within 60 calendar days of the committee’s decision
	 	ü
	10

	 	the medical director’s or other designated physician’s direct responsibility and participation in the
credentialing program
	 	ü
	11

	 	the process for ensuring the confidentiality of all information obtained in the credentialing process,
except as otherwise provided by law
	 	ü
	12

	 	the process for ensuring that listings in practitioner directories and other materials for members are
consistent with credentialing data, including education, training, certification and specialty
	 	ü
	 

	 	ELEMENT B: Practitioner Rights	 	 
	 

	 	The organization’s policies and procedures include the following practitioner rights:	 	 
	1

	 	the right of practitioners to review information submitted to support their credentialing applications
	 	ü
	2

	 	the right of practitioner’s to correct erroneous information
	 	ü
	3

	 	the right of practitioners, upon request, to be informed of the status of their credentialing or
recredentialing application
	 	ü
	4

	 	notification of these rights.
	 	ü
	CR 2

	 	Credentialing Committee	 	 
	 

	 	The organization designates a credentialing committee that uses a peer review process to make
recommendations regarding credentialing decisions.	 	 
	 

	 	ELEMENT A: Credentialing Committee	 	 
	 

	 	The Credentialing Committee includes representation from a range of participating practitioners.
	 	ü
	 

	 	ELEMENT B: Credentialing Committee Decisions	 	 
	 

	 	The organization provides evidence of:
	 	ü
	1

	 	Credentialilng Committee review of credentials for practitioners who do not meet established thresholds.
	 	ü
	2

	 	medical director or equally qualified individual review and approval of clean files.
	 	 
	CR 3

	 	Initial Credentialing Verification	 	 
	 

	 	The organization verifies credentialing information through primary sources, unless otherwise indicated.	 	 
	 

	 	ELEMENT A: Licensure Verification	 	 
	 

	 	the organization verifies that a current, valid license to practice is present and within the prescribed
timelines
	 	ü
	 

	 	ELEMENT B: Initial Primary Source Verification	 	 
	 

	 	The organization verifies that the following factors are present and within the prescribed time limits:	 	 
	1

	 	a valid DEA or CDS certificate, if applicable
	 	ü
	2

	 	education and training including board certification, if the practitioner states on the application that
he/she is board certified
	 	ü
	3

	 	work history
	 	ü
	4

	 	history of professional liability claims that resulted in settlements or judgments paid by on behalf of
the practitioner.
	 	ü
	CR 4

	 	Application and Attestation	 	 
	 

	 	Practitioners completes an application for network participation that includes a current and signed
attestation regarding the applicant’s health status and any history of loss or limitation of licensure or
privileges:.	 	 
	 

	 	ELEMENT A: Contents of the Application	 	 
	 

	 	The application includes a current and signed attestation and addresses:	 	 
	1

	 	reasons for any inability to perform the essential functions of the position, with or without
accommodation
	 	ü
	2

	 	lack of present illegal drug use
	 	ü
	3

	 	history of loss of license and felony convictions
	 	ü
	4

	 	history of loss or limitation of privileges or disciplinary activity
	 	ü
	5

	 	current malpractice insurance coverage
	 	ü
	6

	 	the correctness and completeness of the application.
	 	ü
	CR 5

	 	Initial Sanction Information	 	 
	 

	 	The organization receives informton on practitioner sanctions before making a credentialing decision.	 	 
	 

	 	ELEMENT A: Sanction Information	 	 
	 

	 	The organization verifies the following sanction informaion for initial credentialing:	 	 
	1

	 	state sanctions, restrictions on licensure and/ or limitations on scope of practice
	 	ü
	2

	 	Medicare and Medicaid sanctions.
	 	ü
	CR 6

	 	Initial Credentialing Site Visits
	 	 
	 

	 	The organization has a process that ensures for ensuring that the offices of all primary care
practitioners, obstetricians/gynecologists and high volume behavioral health care practitioners meet the
organization’s office site standards
	 	ü
	 

	 	ELEMENT A: Performance Standards and Thresholds
	 	 
	 

	 	The organization:
	 	ü
	1

	 	sets standards and performance thresholds for office site criteria .
	 	ü
	2

	 	setts standards and performance thresholds for medical/treatment record keepoing criteria.
	 	ü
	 

	 	ELEMENT B: Site Visits and Medical Record-Keeping
	 	 
	 

	 	For PCPs, OB/GYNs and high-volume behavioral health specialists, the organization conducts:
	 	ü
	1

	 	an initial site visit
	 	ü
	2

	 	an initial evaluation of medical/treatment record-keeping practices at each site.
	 	ü
	 

	 	ELEMENT C: Follow-Up for Initial Deficiencies
	 	 
	 

	 	The organization implements ongoing monitoring and takes appropriate interventions by:
	 	ü
	1

	 	instituting actions for improving PCPs, OB/GYNs and high-volume behavioral health sites that do not meet
the thresholds sites.
	 	ü
	2

	 	evaluating the effectiveness of the actions at least every six months, until deficient sites meet the
thresholds
	 	ü
	3

	 	monitoring of all PCPs, OB/GYNs and high-volume behavioral health sites for deficiencies subsequent to
the initial site visit, at least every six months.
	 	ü
	4

	 	documenting follow-up visits for those sites that had subsequent deficiencies.
	 	ü

 

Table of Contents

	 	 	 	 	 
	CR 7

	 	Recredentialing Verification	 	 
	 

	 	The organization formally recredentials its practitioners at least every 36 months through information
verified from primary sources, unless otherwise indicated.	 	 
	 

	 	ELEMENT A: Licensure Verification	 	 
	 

	 	the organization verifies that a current, valid license to practice is present and within the prescribed
timelines
	 	ü
	 

	 	ELEMENT B: Recredentialing Verification	 	 
	 

	 	The organization verifies the following factors within the prescribed time limits:	 	 
	1

	 	a valid DEA or CDS certificate, as applicable
	 	ü
	2

	 	board certification, if the practitioner states that he/she is board certified
	 	ü
	3

	 	history of professional liability claims that resulted in settlements or judgments paid by or on behalf
of the practitioner.
	 	ü
	 

	 	ELEMENT C: Contents of the Application	 	 
	 

	 	The application includes a current and signed attestation and addresses:	 	 
	1

	 	reasons for any inability to perform the essential functions of the position, with or without
accommodation
	 	ü
	2

	 	lack of present illegal drug use
	 	ü
	3

	 	history of loss or limitation of privileges or felony convictions
	 	ü
	4

	 	a history of loss or limitatin of privileges or disciplinary action
	 	 
	5

	 	current malpractice insurance coverage
	 	ü
	6

	 	correctness and completeness of the application.
	 	ü
	 

	 	ELEMENT D: Sanction Information	 	 
	 

	 	The organization verifies the following sanctions information for recredentialing:
	 	ü
	1

	 	state sanctions, restrictions on licensure and/ or limitations on scope of practice
	 	ü
	2

	 	Medicare and Medicaid sanctions.
	 	ü
	CR8

	 	Recredentialing Cycle Length
	 	ü
	 

	 	The organization formally recredentials its practitioners at least every 36 months
	 	ü
	 

	 	ELEMENT A: Recredentialing Cycle Length
	 	 
	1

	 	The length of the recredentialing cycle is within the required 36-month time frame.
	 	ü
	CR 9

	 	Ongoing Monitoring of Sanctions, Complaints and Quality Issues	 	 
	 

	 	The organization develops and implements policies and procedures for ongoing monitoring of practitioner
sanctions, complaints and quality issues between recredentialing cycles and takes appropriate action
against practitioners when it identifies occurrences of poor quality.	 	 
	 

	 	ELEMENT A: Ongoing Monitoring and Interventions	 	 
	 

	 	The organization implements ongoing monitoring and takes appropriate interventions by:	 	 
	1

	 	collecting and reviewing Medicare and Medicaid sanctions
	 	ü
	2

	 	collecting and reviewing sanctions and limitations on licensure
	 	ü
	3

	 	collecting and reviewing complaints.
	 	ü
	4

	 	collecting and reviewing information from identified adverse events
	 	ü
	5

	 	Implementing appropriate interventions when it identifies instances of poor quality, when appropriate
	 	ü
	CR 10

	 	Notification to Authorities and Practitioner Appeal Right	 	 
	 

	 	An organization that has taken actions against a practitioner for quality reasons reports the action to
the appropriate authorities and offers the practitioner a formal appeal process.	 	 
	 

	 	ELEMENT A: Written Policy and Procedures	 	 
	 

	 	The organization has policies and procedures for:	 	 
	1

	 	the range of actions available to the organization
	 	ü
	2

	 	procedures for reporting to authorities
	 	ü
	3

	 	a well-defined appeal process
	 	ü
	4

	 	making the appeal process known to practitioners.
	 	ü
	 

	 	ELEMENT B: Reporting to Appropriate Authorities	 	 
	 

	 	There is documentation that the organization reports practitioner suspension or termination to the
appropriate authorities.
	 	ü
	 

	 	ELEMENT C: Practitioner Appeal Process	 	 
	 

	 	The organization has an appeal process for instances in which it chooses to alter the condition of the
practitioner’s participation based on issues of quality of care and/or service. The organization informs
practitioners of the appeal process.
	 	ü
	CR 11

	 	Assessment of Organizational Providers	 	 
	 

	 	The organization has written policies and procedures for the initial and ongoing assessment of providers
with which it intends to contract.	 	 
	 

	 	ELEMENT A: Review and Approval of Provider	 	 
	 

	 	The organization’s policy for assessing health care delivery providers specifies that it:	 	 
	1

	 	confirms that the provider is in good standing with state and federal regulatory bodies
	 	ü
	2

	 	confirms that the provider has been reviewed and approved by an accrediting body
	 	ü
	3

	 	conducts an on-site quality assessment, if there is no accreditation status
	 	ü
	4

	 	Confirms, at least every 3 years, that the provider continues to be in good standing with state and
federal regulatory bodies and, if applicable, is reviewed and approved by an accrediting body.
	 	ü
	 

	 	ELEMENT B: Medical Providers	 	 
	 

	 	The organization includes at least the following medical providers:	 	 
	1

	 	hospitals
	 	ü
	2

	 	home health agencies
	 	ü
	3

	 	skilled nursing facilities
	 	ü
	4

	 	free-standing surgical centers.
	 	ü
	 

	 	ELEMENT C: Mental Health and Substance Abuse
	 	+
	 

	 	The organization includes behavioral health facilities providing mental health or substance abuse

services in the following settings:
	 	+
	1

	 	inpatient
	 	+
	2

	 	residential
	 	+
	3

	 	ambulatory.
	 	+
	 

	 	ELEMENT D: Assessing Medical Care Providers	 	 
	 

	 	The organization has documentation of assessment of contracted medical health care delivery providers.
	 	ü
	 

	 	ELEMENT E: Assessing Behavioral Health Care Providers
	 	+
	 

	 	The organization has documentation of assessment of contracted behavioral health care delivery providers.
	 	+
	CR 12

	 	Delegation of Credentialing	 	 
	 

	 	If the organizatin delegates andy NCQA-required credentialing activities, there is evidence of oversight
of the delegated activities. If the organization delegates any credentialing and recredentialing
activities, there is evidence of oversight of the delegated activity.	 	 
	 

	 	ELEMENT A: Written Delegation Agreement	 	 
	 

	 	The written delegation document is:	 	 
	1

	 	mutually agreed-upon
	 	ü
	2

	 	describes the responsibilities of the organization and the delegated entity
	 	ü
	3

	 	describes the delegated activities
	 	ü
	4

	 	requires at least semi-annual reporting to the organization
	 	ü
	5

	 	describes the process by which the organization evaluates delegated entity’s performance
	 	ü
	6

	 	describes the remedies, including revocation of the delegation, available to the organization if the
delegated entity does not fulfill its obligations.
	 	ü

 

Table of Contents

	 	 	 	 	 
	 

	 	ELEMENT B: Provisions for PHI	 	 
	 

	 	If the delegation arrangement includes the use of protected health information by the delegate, the
delegation document also includes the following provisions:	 	 
	1

	 	a list of the allowed uses of protected health information
	 	ü
	2

	 	a description of delegate safeguards to protect the information from inappropriate use or further
disclosure
	 	ü
	3

	 	a stipulation that the delegate will ensure that subdelegates have similar safeguards
	 	ü
	4

	 	a stipulation that the delegate will provide individuals with access to their protected health information
	 	ü
	5

	 	a stipulation that the delegate will inform the organization if inappropriate uses of the information
occur
	 	ü
	6

	 	a stipulation that the delegate will ensure protected health information is returned, destroyed or
protected if the delegation agreement ends.
	 	ü
	 

	 	ELEMENT C: Right to Approve and to Terminate	 	 
	 

	 	The organization retains the right, based on quality issues, to approve, suspend and terminate individual
practitioners, providers and sites in situations where it has delegated decision making. This right is
reflected in the delegation documents.
	 	ü
	 

	 	ELEMENT D: Predelegation Evaluation	 	 
	 

	 	For delegation agreements that have been in effect for less than 12 months, the organization evaluated
delegate capacity before delegation began.
	 	ü
	 

	 	ELEMENT E: Annual File Audit	 	 
	 

	 	For delegation arrangements in effect for 12 months or longer, the organization has audited files against
NCQA standards for each year that the delegation has been in effect.
	 	ü
	 

	 	ELEMENT F: Annual Evaluation	 	 
	 

	 	For delegation arrangements in effect for more than 12 months, the organization has performed an annual
substantive evaluation of delegated activities against delegated NCQA standards and organizational
expectations.
	 	ü
	 

	 	ELEMENT G: Reporting	 	 
	 

	 	For delegation arrangements in effect for 12 months or longer, the organization evaluated regular reports.
	 	ü
	 

	 	ELEMENT H: Opportunities for Improvement	 	 
	 

	 	For delegation arrangements that have been in effect for more than 12 months, at least once in each of
the past 2 years that delegation has been in effect, the organization has identifies and followed up on
opportunities for improvement, if applicable.
	 	ü
	MEMBERS’ RIGHTS AND RESPONSIBILITIES
	 	 
	RR 1

	 	Statement of Members’ Rights and Responsibilities	 	 
	 

	 	The organization has a written policy that states its commitment to treating members in a manner that
respects their rights and its expectations of members’ responsibilities.	 	 
	 

	 	ELEMENT A B: Statement of Members’ Rights and Responsibilities	 	 
	 

	 	The organization’s members’ rights and responsibilities policy states that members have:	 	 
	1

	 	a right to receive information about the organization, its services, its practitioners and providers and
members’ rights and responsibilities
	 	ü
	2

	 	a right to be treated with respect and recognition of their dignity and right to privacy
	 	ü
	3

	 	a right to participate with practitioners in decision-making regarding their health care
	 	ü
	4

	 	a right to a candid discussions of appropriate or medically necessary treatment options for their
conditions, regardless of cost or benefit coverage
	 	ü
	5

	 	a right to voice complaints or appeals about the organization or the care provided
	 	ü
	6

	 	a right to make recommendations regarding the organization’s members’ rights and responsibilities policies
	 	ü
	7

	 	a responsibility to supply information (to the extent possible) that the organization and its
practitioners and providers need in order to care
	 	ü
	8

	 	a responsibility to follow plans and instructions for care that they have agreed on with their
practitioners
	 	ü
	9

	 	a responsibility to understand their health care problems and participate in developing mutually agreed
upon treatment goals to the degree possible.
	 	ü
	RR 2

	 	Distribution of Rights Statements to Members and Practitioners	 	 
	 

	 	The organization distributes its policy on members’ rights and responsibilities to its members and
participating practitioners.	 	 
	 

	 	ELEMENT A: Distribution of Rights Statement to Members and Practitioners	 	 
	 

	 	The organization distributes its members’ rights and responsibilities statement to:	 	 
	1

	 	existing members
	 	ü
	2

	 	new members
	 	ü
	3

	 	existing practitioners
	 	ü
	4

	 	new practitioners.
	 	ü
	RR 3

	 	Policies for Complaints and Appeals	 	 
	 

	 	The organization has written policies and procedures for the thorough, appropriate and timely resolution
of member complaints and appeals. [HCA — Contractors are required to follow the Washington State
“Patient Bill of Rights” (PBOR)]
	 	ü
	RR 4

	 	Subscriber Information	 	 
	 

	 	The organization provides each subscriber with information needed to understand benefit coverage and
obtain care.	 	 
	 

	 	ELEMENT A: Subscriber Information	 	 
	 

	 	The organization provides written information to its subscriber addresses the following factors:	 	 
	1

	 	benefits and services included in, and excluded from, coverage
	 	ü
	2

	 	pharmaceutical management procedures, if they exist
	 	ü
	3

	 	copayments and other charges for which the member is responsible
	 	ü
	4

	 	restrictions on benefits that apply to services obtained outside the organization’s system or service area
	 	ü
	5

	 	how to submit a claim for covered services, if applicable
	 	ü
	6

	 	how to obtain information about practitioners who participate in the organization
	 	ü
	7

	 	how to obtain primary care services, including points of access
	 	ü
	8

	 	how to obtain specialty care, behavioral health services and hospital services
	 	ü
	9

	 	how to obtain care after normal office hours
	 	ü
	10

	 	how too obtain emergency care, including the organization’s policy on when to directly access emergency
care or use 911 services
	 	ü
	11

	 	how to obtain care and coverage when out of the organization’s service area
	 	ü
	12

	 	how to voice a complaint
	 	ü
	13

	 	how to appeal a decision that adversely affects a member’s coverage, benefits or relationship to the
organization
	 	ü
	14

	 	how the organization evaluates new technology for inclusion as a covered benefit.
	 	ü
	 

	 	ELEMENT B: Translation Services	 	 
	 

	 	The organization provides translation services within its member services telephone function based on the
linguistic needs of its members.
	 	ü
	RR 5

	 	Physician and Hospital Directories	 	 
	 

	 	The organization provides information to help members and prospective members choose physicians and
hospitals.
	 	ü

 

Table of Contents

	 	 	 	 	 
	 

	 	Element A — Physician Directory Data	 	 
	 

	 	The organization has a Web-based physician directory that includes the following information to assist
members and prospective members in choosing physicians:
	 	ü
	1

	 	name
	 	ü
	2

	 	gender
	 	ü
	3

	 	specialty
	 	ü
	4

	 	hospital affiliations
	 	ü
	5

	 	medical group affiliations, if applic
	 	ü
	6

	 	board certification with expiration date
	 	ü
	7

	 	acceptance of new patients
	 	ü
	8

	 	languages spoken by the practitioner or clinical sta
	 	ü
	9

	 	office locations.
	 	ü
	 

	 	Element B — Physician Directory Updates	 	 
	 

	 	The organization has a process for updating physician directory information when new information is
provided by the physician.
	 	ü
	 

	 	Element D — Searchable Physician Web-based Directory	 	 
	 

	 	The organization’s Web-based directory includes search functions with instructions on searching for:
	 	ü
	1

	 	name
	 	ü
	2

	 	gender
	 	ü
	3

	 	specialty
	 	ü
	4

	 	hospital affiliations
	 	ü
	5

	 	medical group affiliations, if applic
	 	ü
	6

	 	board certification with expiration date
	 	ü
	7

	 	acceptance of new patients
	 	ü
	8

	 	languages spoken by the practitioner or clinical sta
	 	ü
	9

	 	office locations.
	 	ü
	 

	 	Element E — Hospital Directory Data	 	 
	 

	 	The organization has a Web-based hospital directory that includes the following information to assist
members and prospective members in choosing hospitals:
	 	ü
	1

	 	facility name
	 	ü
	2

	 	location
	 	ü
	3

	 	accreditation.
	 	ü
	 

	 	Element H — Searchable Hospital Web-based Directory	 	 
	 

	 	The organization’s Web-based directory includes search functions on specific data types and instructions
for searching for:
	 	ü
	1

	 	facility name
	 	ü
	1

	 	location.
	 	ü
	 

	 	Element I — Usability Testing	 	 
	 

	 	The organization evaluates its Web-based physician and hospital directories for understandability and
usefulness to members and prospective members including:
	 	ü
	1

	 	font size
	 	ü
	2

	 	reading level
	 	ü
	3

	 	intuitive content organization
	 	ü
	4

	 	ease of navigation
	 	ü
	5

	 	directories in additional languages, if applicable to the membership.
	 	ü
	 

	 	Element J — Availability of Directories	 	 
	 

	 	The organization makes information from the Web-based physician and hospital directories available to
members and prospective members through alternate media which include:
	 	ü
	1

	 	print
	 	ü
	2

	 	telephone.
	 	ü
	RR 6

	 	Privacy and Confidentiality	 	 
	 

	 	The organization protects the confidentiality of member information and records.	 	 
	 

	 	ELEMENT A: Adopting Written Policies	 	 
	 

	 	The organization adopts written policies and procedures regarding protected health information (PHI) that
addresses:	 	 
	1

	 	information included in notifications of privacy practices
	 	ü
	2

	 	access to PHI
	 	ü
	3

	 	the process for members to request restrictions on use/disclosure of PHI
	 	ü
	4

	 	the process for members to request amendments to PHI
	 	ü
	5

	 	the process for members to request an accounting of disclosures of PHI
	 	ü
	6

	 	internal protection of oral, written and electronic information across the organization.
	 	ü
	 

	 	ELEMENT B: Special Protection for PHI Sent to Plan Sponsors
	 	 
	 

	 	The organization’s policies and procedures prohibit sharing members’ PHI with any sponsor without
certification that the plan sponsor’s documents have been amended to incorporate the following provisions
and the plan sponsor agrees to:
	 	ü
	1

	 	not use or disclose PHI other than as permitted by the plan documents or required by law
	 	ü
	2

	 	ensure that agents and subcontractors of the employer or plan sponsor agree to the same restrictions and
conditions as the employer or plan sponsor with regard to PHI
	 	ü
	3

	 	prohibit the use of PHI by the employer or plan sponsor for employment or other benefit-related decisions
	 	ü
	4

	 	notify the organization of any use or disclosure of PHI that is inconsistent with the uses and
disclosures established in the plan documents
	 	ü
	5

	 	allow individuals access to PHI, including access to amend PHI
	 	ü
	6

	 	make necessary information available to the organization in order to provide individuals with accounting
of disclosures
	 	ü
	7

	 	procedures for return, destruction and restrictions of further use of PHI by employers or plan sponsors
	 	ü
	8

	 	identify the sponsor’s or employer’s employees who have access to PHI
	 	ü
	9

	 	include provisions for actions if sponsor’s or employer’s employees inappropriately use or disclose PHI.
	 	ü
	 

	 	ELEMENT C: Right to Consent
	 	 
	 

	 	The organization has policies and procedures that address a member’s right to authorize or deny the
release of PHI beyond uses for treatment, payment or health care operations.
	 	ü
	 

	 	ELEMENT D: Communication of PHI Use and Disclosure
	 	 
	 

	 	The organization has informed its members, practitioners and providers of its policies and procedures
regarding the collection, use and disclosure of member protected health information. Communication
includes the following five factors:
	 	ü
	1

	 	the organization’s routine uses and disclosures of PHI
	 	ü
	2

	 	use of authorizations
	 	ü
	3

	 	access to PHI
	 	ü
	4

	 	internal protection of oral, written and electronic PHI across the organization
	 	ü
	5

	 	protection of information disclosed to plan sponsors or employers.
	 	ü
	 

	 	ELEMENT E: Chief Privacy Officer/Privacy Committee
	 	 
	 

	 	The organization designates either an internal staff member as chief privacy officer or an internal
privacy committee. The chief privacy officer or the committee has been involved in the development and
implementation of:
	 	ü

 

Table of Contents

	 	 	 	 	 
	RR 7

	 	Marketing Information	 	 
	 

	 	The organization ensures that communications with prospective members correctly and thoroughly represent
the benefits and operating procedures of the organization.	 	 
	 

	 	ELEMENT A: Materials and Presentations	 	 
	 

	 	All organization materials and presentations accurately describe:	 	 
	1

	 	covered benefits
	 	ü
	2

	 	noncovered benefits
	 	ü
	3

	 	practitioner and provider availability
	 	ü
	4

	 	a summary of key UM procedures the organization uses
	 	ü
	5

	 	potential network, services or benefit restrictions
	 	ü
	6

	 	pharmaceutical management procedures.
	 	ü
	 

	 	ELEMENT B: Communicating with Prospective Members	 	 
	 

	 	The organization communicates to prospective members, in easy-to-understand language, a summary of its
policies and practices regarding the collection, use and disclosure of PHI:	 	 
	1

	 	inclusions in routine notifications of privacy practices
	 	ü
	2

	 	the right to approve release of information (use of authorization)
	 	ü
	3

	 	access to medical records
	 	ü
	4

	 	protection of oral, written and electronic information across the organization
	 	ü
	5

	 	information for employers.
	 	ü
	 

	 	ELEMENT C: Assessing Member Understanding
	 	ü
	 

	 	The organization systematically monitors new member understanding of its procedures to ensure that
marketing communications are accurate and acts on opportunities for improvement.
	 	ü
	RR 8

	 	Delegation of RR	 	 
	 

	 	If the managed care organization delegates any RR activities, there is evidence of oversight of the
delegated activity.	 	 
	 

	 	ELEMENT A: Written Delegation Agreement	 	 
	 

	 	The written delegation document:	 	 
	1

	 	is mutually agreed-upon
	 	ü
	2

	 	describes the responsibilities of the organization and the delegated entity
	 	ü
	3

	 	describes the delegated activities
	 	ü
	4

	 	requires at least semi-annual reporting to the organization
	 	ü
	5

	 	describes the process by which the organization evaluates delegated entity’s performance
	 	ü
	6

	 	describes the remedies, including revocation of the delegation, available to the organization if the
delegated entity does not fulfill its obligations.
	 	ü
	 

	 	ELEMENT B: Provisions for PHI	 	 
	 

	 	If the delegation arrangement includes the use of protected health information by the delegate, the
delegation document also includes the following provisions:	 	 
	1

	 	a list of the allowed uses of PHI
	 	ü
	2

	 	a description of delegate safeguards to protect the information from inappropriate use or further
disclosure
	 	ü
	3

	 	a stipulation that the delegate will ensure that subdelegates have similar safeguards
	 	ü
	4

	 	a stipulation that the delegate will provide individuals with access to their PHI
	 	ü
	5

	 	a stipulation that the delegate will inform the organization if inappropriate uses of the information
occur
	 	ü
	6

	 	a stipulation that the delegate will ensure PHI is returned, destroyed or protected if the delegation
agreement ends.
	 	ü
	 

	 	ELEMENT C: Predelegation Evaluation	 	 
	 

	 	For delegation agreements that have been in effect for less than 12 months, the organization evaluated
delegate capacity before delegation began.
	 	ü
	 

	 	ELEMENT D: Reporting	 	 
	 

	 	For delegation arrangements in effect for 12 months or longer, the organization evaluated regular
reports, as specified in Element A.
	 	ü
	 

	 	ELEMENT E: Annual Evaluation	 	 
	 

	 	For delegation arrangements in effect for more than 12 months, the organization has performed an annual
substantive evaluation of delegated activities against delegated NCQA standards and organizational
expectations.
	 	ü
	 

	 	ELEMENT F: Opportunities for Improvement	 	 
	 

	 	For delegation arrangements that have been in effect for more than 12 months, at least once in each of
the past 2 years that delegation has been in effect, the organization has identifies and followed up on
opportunities for improvement, if applicable.
	 	ü
	Preventive Services
	 	ü
	PH 1

	 	Adoption of Preventive Health Guidelines
	 	 
	 

	 	The organization has preventive health (PH) guidelines for prevention and early detection of illness and
disease.
	 	ü
	 

	 	ELEMENT A: Covered Groups
	 	 
	 

	 	The organization’s preventive health guidelines cover at least the following groups:
	 	ü
	1

	 	Prenatal and perinatal care
	 	ü
	2

	 	care for infants up to 24 months old
	 	ü
	3

	 	care for children and adolescents, 2-19 years old
	 	ü
	4

	 	care for adults, 20-64 years old
	 	ü
	5

	 	care for the elderly, 65 years and older.
	 	ü
	 

	 	ELEMENT B: Guideline Content
	 	 
	 

	 	Each preventive health guideline addresses:
	 	ü
	1

	 	prevention or early detection interventions
	 	ü
	2

	 	the recommended frequency and conditions under which the interventions are required.
	 	ü
	 

	 	ELEMENT C: Scientific Evidence
	 	 
	 

	 	The organization documents the scientific basis or recognized source on which it based the preventive
health guidelines.
	 	ü
	 

	 	ELEMENT D: Guidelines form Recognized Sources or Practitioner Involvement
	 	 
	 

	 	When it adopts preventive guidelines, the organization adopts guidelines from recognized sources or
involves appropriate practitioners in the development or adoption of its own preventive health guidelines
that are not from recognized sources.
	 	ü
	 

	 	ELEMENT F: Review and Update
	 	 
	 

	 	The organization reviews and updates the guidelines at least every two years, where appropriate.
	 	ü
	PH 2

	 	Distribution of Guidelines to Practitioners
	 	 
	 

	 	The organization distributes preventive health guidelines and updates to its practitioners.
	 	 
	 

	 	ELEMENT A: Distribution of New Guidelines
	 	 
	 

	 	The organization communicates new guidelines to the appropriate existing practitioners.
	 	ü
	 

	 	ELEMENT B: Distribution of Revised Guidelines
	 	 
	 

	 	The organization communicates revised guidelines to the appropriate existing practitioners.
	 	ü
	 

	 	ELEMENT C: Distribution of Existing Guidelines to New Practitioners
	 	 
	 

	 	The organization communicates existing guidelines to new appropriate parctitioners.
	 	ü
	PH 3

	 	Health Promotion with Members
	 	 
	 

	 	The organization regularly encourages its members to use preventive health services.
	 	 
	 

	 	ELEMENT A: Annual Distribution of Guidelines
	 	 
	 

	 	The organization distributes all preventive health guidelines to members annually.
	 	ü
	 

	 	ELEMENT B: Encouraging Prevention
	 	 
	 

	 	The organization informs and encourages members to use available health promotion, health education and
preventive health services.
	 	ü
	 

	 	ELEMENT C: Targeting Members
	 	 
	 

	 	The organization identifies specific members who, according to demographic and other identifiable health
factors, may be at risk for specific health problems, and urges these members to use appropriate health
promotion and prevention services.
	 	ü

 

Table of Contents

	 	 	 	 	 
	PH 4

	 	Delegation of Preventive Health
	 	 
	 

	 	ELEMENT A: Written Delegation Agreement
	 	 
	 

	 	There is a mutually agreed-upon document that describes all delegated activities.
	 	ü
	 

	 	ELEMENT B: Specific Delegated Activities
	 	 
	 

	 	There is a mutually agreed-upon document that describes all delegated activities.
	 	ü
	1

	 	the responsibilities of the organization and the delegated entity
	 	ü
	2

	 	the delegated activities
	 	ü
	3

	 	at least semi-annual reporting to the organization
	 	ü
	4

	 	the process by which the organization evaluates delegated entity’s performance
	 	ü
	5

	 	the remedies, including revocation of the delegation, available to the organization if the delegated
entity does not fulfill its obligations.
	 	ü
	 

	 	ELEMENT C: Provisions for Protected Health Information
	 	 
	 

	 	If the delegation arrangement includes the use of protected health information by the delegate, the
delegation document also includes the following provisions:
	 	ü
	1

	 	a list of the allowed uses of protected health information
	 	ü
	2

	 	a description of delegate safeguards to protect the information from inappropriate use or further
disclosure
	 	ü
	3

	 	a stipulation that the delegate will ensure that subdelegates have similar safeguards
	 	ü
	4

	 	a stipulation that the delegate will provide individuals with access to their protected health information
	 	ü
	5

	 	a stipulation that the delegate will inform the organization if inappropriate uses of the information
occur
	 	ü
	6

	 	a stipulation that the delegate will ensure protected health information is returned, destroyed or
protected if the delegation agreement ends.
	 	ü
	 

	 	ELEMENT D: Approval of the PH program
	 	 
	 

	 	The organization approves its delegate’s PH program annually.
	 	ü
	 

	 	ELEMENT E: Pre-Delegation Evaluation
	 	 
	 

	 	For delegation agreements that have been in effect for less than 12 months, the organization evaluated
delegate capacity before delegation began.
	 	ü
	 

	 	ELEMENT F: Annual Evaluation
	 	 
	 

	 	For delegation arrangements in effect for more than 12 months, the organization has performed an annual
substantive evaluation of delegated activities against delegated NCQA standards and organizational
expectations.
	 	ü
	 

	 	ELEMENT G: Reporting
	 	 
	 

	 	For delegation arrangements in effect for 12 months or longer, the organization evaluated regular
reports, as specified in Element B.
	 	ü
	 

	 	ELEMENT H: Opportunities for Improvement
	 	 
	 

	 	For delegation arrangements that have been in effect for more than 12 months, at least once in each of
the past 2 years that delegation has been in effect, the organization has identifies and followed up on
opportunities for improvement, if applicable.
	 	ü

 

Table of Contents

EXHIBIT 5

Consumer Assessment of Health Plans (CAHPSTM)

Commercial Survey Data

Each Contractor with HCA for 2008 will provide to HCA a set of data from its 2008 commercial CAHPSTM
4.0 surveys.

The Contractor agrees to:

	1.	 	Conduct a CAHPSTM 4.0 survey of their adult commercial members in managed care products in
which HCA members are enrolled (PEBB and/or BH). HCA members will be eligible to participate
in the survey.

	2.	 	Ensure the survey sample frame consists of all non-Medicare and non-Medicaid adult plan
members (not just subscribers) over the age of 18 with Washington State addresses. The sample
frame for this survey shall exclude BH+ and S-medical (maternity benefits program) members
since they are covered under the Medicaid program.

	3.	 	Contract with an NCQA certified vendor qualified to administer the CAHPSTM 4.0 survey and
conduct the survey according to NCQA protocol.

	4.	 	Use the most recent HEDIS version of the commercial adult questionnaire or as instructed by
NCQA for 2008 CAHPSTM 4.0 surveys.

	5.	 	Add one field at the end of each member level response record for HCA program identification.
Label the field “HCA Identification.” This field will have a minimum of three values: PEBB
member, BH member, Other.

	6.	 	Submit a copy of its Washington State adult commercial response data set according to
NCQA/CAHPSTM standards (with the additional field described in paragraph 5 above) to both the
HCA’s vendor and to the HCA’s Director of Basic Health Purchasing, Bevin Hansell (or her
successor) by June 15, 2008.

	7.	 	Agree to have its data submitted to the National CAHPSTM Benchmarking Database (NCBD). HCA’s
vendor will be responsible for forwarding each data set to the NCBD.

	8.	 	Agree to have its June 2008 premium reduced by the cost of the CAHPS sample audit validation.

 

Table of Contents

2008 Basic Health Service Area Matrix

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	County	 	CUP	 	CHPW	 	Group Health	 	Kaiser	 	Molina
	Adams
	 	 	 	 	 	 	B	 	 	 	 	 	 	 	 	 	 	 	B	 
	Asotin
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	B	 
	Benton
	 	 	 	 	 	 	B	 	 	 	 	 	 	 	 	 	 	 	 	 
	Chelan
	 	 	 	 	 	 	B	 	 	 	 	 	 	 	 	 	 	 	B	 
	Clallam
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	BX
	Clark
	 	 	B	 	 	 	B	 	 	 	 	 	 	 	*B	 	 	 	 	 
	Columbia
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	B	 
	Cowlitz
	 	 	 	 	 	 	B	 	 	 	 	 	 	 	X	 	 	 	 	 
	Douglas
	 	 	 	 	 	 	B	 	 	 	 	 	 	 	 	 	 	 	B	 
	Ferry
	 	 	 	 	 	 	B	 	 	 	 	 	 	 	 	 	 	 	B	 
	Franklin
	 	 	 	 	 	 	B	 	 	 	 	 	 	 	 	 	 	 	 	 
	Garfield
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	B	 
	Grant
	 	 	 	 	 	 	B	 	 	 	 	 	 	 	 	 	 	 	B	 
	Grays Harbor
	 	 	 	 	 	 	B	 	 	 	 	 	 	 	 	 	 	 	B	 
	Island
	 	 	 	 	 	 	B	 	 	 	 	 	 	 	 	 	 	 	 	 
	Jefferson
	 	 	 	 	 	 	B	 	 	 	 	 	 	 	 	 	 	 	 	 
	King
	 	 	 	 	 	 	B	 	 	 	B	 	 	 	 	 	 	 	B	 
	Kitsap
	 	 	 	 	 	 	B	 	 	 	B	 	 	 	 	 	 	 	 	 
	Kittitas
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	B	 
	Klickitat
	 	 	 	 	 	 	B	 	 	 	 	 	 	 	 	 	 	 	 	 
	Lewis
	 	 	 	 	 	 	B	 	 	 	 	 	 	 	 	 	 	 	B	 
	Lincoln
	 	 	 	 	 	 	B	 	 	 	 	 	 	 	 	 	 	 	B	 
	Mason
	 	 	 	 	 	 	B	 	 	 	 	 	 	 	 	 	 	 	 	 
	Okanogan
	 	 	 	 	 	 	B	 	 	 	 	 	 	 	 	 	 	 	B	 
	Pacific
	 	 	 	 	 	 	B	 	 	 	 	 	 	 	 	 	 	 	B	 
	Pend Oreille
	 	 	 	 	 	 	B	 	 	 	 	 	 	 	 	 	 	 	B	 
	Pierce
	 	 	 	 	 	 	B	 	 	 	 	 	 	 	 	 	 	 	B	 
	San Juan
	 	 	 	 	 	 	B	 	 	 	 	 	 	 	 	 	 	 	 	 
	Skagit
	 	 	 	 	 	 	B	 	 	 	 	 	 	 	 	 	 	 	 	 
	Skamania
	 	 	 	 	 	 	B	 	 	 	 	 	 	 	 	 	 	 	 	 
	Snohomish
	 	 	 	 	 	 	B	 	 	 	B	 	 	 	 	 	 	 	 	 
	Spokane
	 	 	 	 	 	 	B	 	 	 	B	 	 	 	 	 	 	 	B	 
	Stevens
	 	 	 	 	 	 	B	 	 	 	 	 	 	 	 	 	 	 	B	 
	Thurston
	 	 	 	 	 	 	B	 	 	 	B	 	 	 	 	 	 	 	B	 
	Wahkiakum
	 	 	 	 	 	 	B	 	 	 	 	 	 	 	 	 	 	 	 	 
	Walla Walla
	 	 	 	 	 	 	B	 	 	 	 	 	 	 	 	 	 	 	B	 
	Whatcom
	 	 	 	 	 	 	B	 	 	 	 	 	 	 	 	 	 	 	B	 
	Whitman
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	B	 
	Yakima
	 	 	 	 	 	 	B	 	 	 	 	 	 	 	 	 	 	 	B	 

 

			
	“B” represents a county where plan will be available to enrollees at the benchmark
rates for 2008.
	 
	“X” represents a county where plan will be available to enrollees above published
benchmark rates for 2008.
	 
	“BX” represents a county where plan came in at a higher rate but will be available to enrollees at the benchmark rate.
	 
	The differential is paid by the HCA.
	 
	*Kaiser continues to be frozen to new enrollment in Clark County

Contractors’ 2008 Legal Names

Columbia United Providers, Inc.

Community Health Plan of Washington

Group Health Cooperative

Kaiser Foundation Health Plan of the Northwest

Molina Healthcare of Washington, Inc.

 

Table of Contents

EXHIBIT 7

Network Accessibility Guidelines

	 	 	 	 	 	 	 	 	 	 	 
	Report	 	Format	 	Enrollees	 	Provider Type	 	Access Guideline	 	Sort
	1

9

17

	 	Provider Map
	 	none
	 	PCPs
	 	none
	 	none
	 
	 	 	 	 	 	 	 	 	 	 
	2

10

18

	 	Provider Map
	 	none
	 	Hospitals
	 	none
	 	none
	 
	 	 	 	 	 	 	 	 	 	 
	3

11

19

	 	Accessibility Detail
	 	Enrollees by

Program:

Urban/Suburban
	 	PCPs

Capacity: specific by

PCP for each program
	 	2 PCPs in

10 miles
	 	County
	 
	 	 	 	 	 	 	 	 	 	 
	4

12

20

	 	Accessibility Detail
	 	Enrollees by

Program:

Rural
	 	PCPs

Capacity: specific by

PCP for each program
	 	1 PCP in 25 miles
	 	County
	 
	 	 	 	 	 	 	 	 	 	 
	5

13

21

	 	Accessibility Detail
	 	Enrollees by

Program:

All
	 	Obstetrical Practitioners

Capacity <= 9999
	 	1 Obstetric

Practitioner in 25

miles
	 	County
	 
	 	 	 	 	 	 	 	 	 	 
	6

14

22

	 	Accessibility Detail
	 	Enrollees by

Program:

All
	 	Hospitals

Capacity <= 9999
	 	1 Hospital in

25 miles
	 	County
	 
	 	 	 	 	 	 	 	 	 	 
	7

15

23

	 	Accessibility Detail
	 	Enrollees by

Program:

All
	 	Pharmacies

Capacity <= 9999
	 	1 Pharmacy in

25 miles
	 	County
	 
	 	 	 	 	 	 	 	 	 	 
	8

16

24

	 	Provider Count

Detail
	 	Enrollees by

Program:

All
	 	Group 1 — PCPs

Group 2 — OB Prac

Group 3 — Hospitals

Group 4 — Pharmacies

	 	none
	 	County/

City

 

Table of Contents

Exhibit 8

Experience Data Reporting

Instructions for Basic Health and HCTC

The information that you are about to provide is vital to HCA. The Basic Health (BH) program will
use this data to better understand utilization and healthcare cost trends for our population. It
is essential that the data you submit be accurate. Please be sure to follow the definitions
provided within this document when completing the worksheets.

General Procedures

The following are general instructions for completing the required reports. The primary objective
of these instructions is to promote uniform reporting by all health plans.

Health plans will complete Experience Worksheets based on each health plan’s financial and
utilization experience with BH enrollees. Note that some of the reports require the information
reported to be broken out between BH and HCTC.

This document also contains detailed, standardized definitions of the medical service categories
contained in the worksheets. Health plans will use these standardized service category definitions
to report their experience. HCA, in conjunction with their consultants, have provided health plans
with sufficient detail so that the line items of the exhibits can be completed accurately. This
assures that the data received will be as consistent as possible from health plan to health plan.
The data reported by service category must be mutually exclusive and non-duplicating.

Each health plan must provide an Actuarial Memorandum signed by a Qualified Actuary. The
memorandum must address the following issues:

	1.	 	Claim costs have been reviewed for reasonableness and reconciled to calendar year 2007
financial statements. While the reported experience will not balance exactly to the OIC
financial statements for a variety of reasons, the actuary should understand and be
comfortable with the sources of those differences.

	2.	 	Claim costs reflect best estimates of incurred experience for CY 2007, with no reserve
margins.
	 
	3.	 	Claim costs reflect all offsets, such as third party recoveries and pharmacy rebates.
	 
	4.	 	Administrative expenses reflect the Basic Health block of business to the extent possible.
	 
	5.	 	Administrative expenses include no risk margins or profits.

Reports are due March 31, 2008 for incurred experience in the prior calendar year.

1

Table of Contents

Exhibit 8

Experience Data Reporting

Instructions for Basic Health and HCTC

REPORT 1 — DETAILED INCOME STATEMENT

Report revenues and expenses using the full accrual method according to GAAP.

A. Revenue

Capitation — Capitation Revenue recognized on a prepaid basis for provision of health care
services for eligible participants. Capitated revenue PMPM should be calculated using the
same denominator for member months that is used for all other PMPM line items.

Other Income — Revenue from sources not identified in other revenue categories such as investment
income.

B. Incurred Medical Expense

All expenses must be reported, net of offsetting reimbursement, such as Medicare payments,
other TPL or pharmacy rebates.

Hospital Inpatient — This expense category covers daily room and board and ancillary
services in short-term hospitals. Ancillary services include use of surgical and intensive
care facilities, inpatient nursing care, pathology and radiology procedures, drugs and
supplies. The ancillary charges do not include any professional charges (including
professional charges for physicians on staff at the hospital).

Costs also include daily room and board and ancillary services in an approved nursing
facility, including a skilled nursing facility. The care could be provided in either a
nursing bed in a hospital or an independent skilled nursing facility. Confinements must be
medically necessary; confinements related solely to custodial care are not included.
Ancillary services include inpatient nursing care, pathology and radiology procedures, drugs
and supplies.

Emergency Room services preceding a hospital inpatient admission should be included in the
Hospital Inpatient category.

ER (Emergency Services) — This expense category covers services for outpatient emergency
accident and medical care performed in the emergency area of a hospital outpatient facility.
Costs include facility charges only and do not include professional charges unless
performed by full-time staff of the facility and not billed separately.

Other Outpatient — This expense category covers hospital outpatient services (excluding
emergency room services) performed in a hospital outpatient facility or a freestanding
facility such as surgery, radiology, pathology, pharmacy and blood, cardiovascular, and
PT/OT/ST. Costs include facility charges only and do not include professional charges
unless performed by full-time staff of the facility and not billed separately.

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Exhibit 8

Experience Data Reporting

Instructions for Basic Health and HCTC

Professional — This expense category covers the charges for medical treatments done by a
qualified professional and not otherwise included above. Include all professional fees for
inpatient and outpatient services when billed separately from the facility charge, services
by anesthesiologists, office visits, home visits, consultations, the professional components
of radiology and pathology services when performed in a hospital or freestanding facility,
global radiology and pathology charges when performed in an office or clinic setting,
private
duty nursing, chiropractor, podiatrist, naturopathy, and PT/OT/ST services performed in an
office setting.

RX (Pharmacy) — This expense category covers the charges for prescription drugs. Costs
include material charges only and do not include professional charges or prescription drugs
included in a facility charge.

Other (Specify) — Those outpatient expenses not specifically identified in one of the
categories defined above. Note: This category should only be used if the expense cannot be
allocated to one of the predefined categories. Examples include ambulance, durable medical
equipment, prosthetics, and risk payments not considered as capitated payments. Capitated
expenses covering services in the categories listed above should be allocated accordingly
and should not be placed in the Other category.

C. Incurred Claim Allocation 

The incurred claim subtotal (from Part B) should be allocated such that it equals paid
claims plus ending reserves less beginning reserves for the requested experience period.

Beginning Reserves — Total medical expense reserves as of the start date of the requested
experience period.

Paid Claims — Claims paid during the requested experience period. This includes
capitation, fee-for-service, and provider risk payments.

Ending Reserves — Total medical expense reserves as of the end date of the requested
experience period.

D. Other Claim Information

Reinsurance Premium Paid — Reinsurance Premium Expense.

Reinsurance Recoveries — Amounts recovered and recoverable from reinsurers on losses
incurred during the experience period.

Third-Party Liability (TPL) Recoveries — Include all third party cost offsets.

E. Administrative Expense

Administrative expenses must include all administrative costs associated BH enrollees
incurred by the contracted plan.

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Exhibit 8

Experience Data Reporting

Instructions for Basic Health and HCTC

Rent — Occupancy expenses incurred, such as rent and utilities, on facilities used to
deliver health care services to participants as well as administrative facilities. Deduct
rent under sublease and exclude items for health care delivery.

Salaries, Wages, and Other Benefits — This includes all forms of compensating employees
including salaries and wages, bonuses, benefits, payroll taxes, payments under a program for
pension, stock options, purchases, etc. to personnel.

Legal Fees and Expenses — Fees paid or payable by the health plan for the current period
for court costs, penalties and all fees or retainers for legal services or expenses in
connection with matters before administrative or legislative bodies. Exclude salaries and
expenses of company personnel, legal expenses associated with investigation, litigation
and settlement of policy claims, and legal fees specifically associated with real estate
transactions.

Marketing and Advertising — Expense related to any medium of exchange whereby the intent of
such medium is to promote or increase a health plan’s enrollment such as newspaper, magazine
and trade journal advertising, television or radio broadcasting, and mailings. Exclude
outreach activities designed to inform existing participants of their benefits.

Outsourced Services — Management fees paid or payable by the health plan for the current
period to an outside management company as well as costs for outside data processing
services during the period.

Other Expenses (Specify) — Those administrative expenses not specifically identified in the
categories above such as interest expense, depreciation on assets not used to
deliver health care services to participants, or internal data processing (other than
compensation).

Premium Tax — Exclude any portion of allowances on reinsurance ceded that represents
specific reimbursement of premium taxes.

F. Total Expenses

Equal to total incurred medical expenses plus total administrative expense.

G. Income (Loss) Before Income Taxes

Total revenue less total expenses.

REPORT 2 — EXPERIENCE BY COUNTY

County is defined by subscriber residence.

Members — The member months should be reported on a cumulative basis by coverage group. A
member (participant) is an eligible person who has been enrolled

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Exhibit 8

Experience Data Reporting

Instructions for Basic Health and HCTC

with a health plan for the
provision of health services. A member month is equivalent to one (1) member for whom the
health plan has recognized capitation-based revenue for the month. The number of member
months should correlate to the number of capitated payments received.

Revenue — Revenue includes capitation revenue. It is not necessary to allocate other
revenue by county for this report.

Capitation — Includes incurred capitation expenses to providers for the requested experience
period.

Fee-For-Service Paid — Includes fee-for-service expenses incurred during the requested
experience period.

Other — Includes any risk or incentive payments incurred during the experience period.

REPORT 3 — TREND MONITORING REPORT

The claims included in Report 3 should be consistent with the OIC Service Categories of
Medical/Hospital, Professional and Rx.

Members — A member (participant) is an eligible person who has been enrolled with a health plan
for the provision of health services. The number of members should correlate to the number of
capitated payments received.

Capitation — Includes incurred capitation payments to providers for the members for each
given month and year.

Fee-For-Service Paid — Includes incurred fee-for-service costs the given month and year.

Other — Includes any risk or incentive payments incurred during the three year period.
Please disclose any allocation method used to spread payments by month.

Estimated Incurred — Equals capitation plus fee-for-service plus other.

Estimated Incurred PMPM — Estimated Incurred divided by Members for each month.

REPORT 4 — HIGH COST MEMBERS REPORT

For the requested experience period, report all members with incurred claims in excess of
$100,000 for each of the four coverage groups. Member identification must be scrambled.
The individuals will not be re-identified.

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Exhibit 8

Experience Data Reporting

Instructions for Basic Health and HCTC

REPORT 5 — UTILIZATION SUMMARY

Utilization statistics per 1,000 should be consistent with the incurred claims included in
Report 1. Include capitated and fee-for-service experience. Separate delivery utilization
from other inpatient statistics. As with Report 1, Emergency Room visits should not include
encounters leading to an inpatient admission.

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Exhibit 9

2008 Basic Health HEDIS® Measures

For 2008, the CONTRACTOR shall report the following audited measures in accord with the
current HEDIS® Technical Specifications and official corrections published by NCQA for Basic
Health.

If Basic Health is not included in the CONTRACTOR’S product line that is reported as the
“commercial” rate, then the product line which includes Basic Health must be counted, audited and
reported seperately.

All CONTRACTORS will report the following HEDIS® measures for 2008 using 2007 data:

	 	1.	 	Childhood immunization status
	 
	 	2.	 	Adolescent immunization status
	 
	 	3.	 	Beta-blocker treatment after a heart attack
	 
	 	4.	 	Comprehensive diabetic care Hybrid method only
	 
	 	5.	 	Follow-up after hospitilization for mental illness (30 day follow-up only)
	 
	 	6.	 	Cholesterol management after acute cardiovascular events (screening rates)
	 
	 	7.	 	Antidepressant medication management (all three rates)
	 
	 	8.	 	Chlamydia screening

CONTRACTOR agrees to have its June 2008 premium reduced by the cost of the HEDIS audit, as required
for NCQA validation.

All data will be submitted by June 15, 2008 to:

Bevin Hansell, Director of Basic Health Purchasing (or her successor)

Health Care Authority

PO Box 42683

Olympia, WA 98504-2683

Table of Contents

Health Care Authority — Basic Health 2008 Contract

Exhibit 10: Paid Claims Data Reporting

MINIMUM REPOSITORY DATA LOADING REQUIREMENTS

	 	 	 
	 	 	Claims Data

	 	 	Prefer all data tables sent as delimited text files

	 	 	Prefer all (“Paid”, “Denied”, etc.) claims and service line detail information.

	Required
	 	     -     Claim ID (unique claim identifier)

	Required
	 	     -     Claim or Service Line Number

	Required
	 	     -     Member ID (or Patient ID)

	Required
	 	     -     Claim Status (overall claim status and claim service line status)

	Required
	 	     -     Form Type (for example: UB92, HCFA, ADA, Drug, etc.)

	 	 	     -     Encounter Type (identifies whether capitated or statistical claim)

	Required
	 	     -     Billing Provider ID

	Required
	 	     -     Attending Provider ID

	 	 	     -     Referring Provider ID

	 	 	     -     Admitting Provider ID

	Required
	 	     -     Admit Date (for hospital claims)

	Required
	 	     -     Discharge Date (for hospital claims)

	Required
	 	     -     Service From Date

	 	 	     -     Service To Date

	 	 	     -     Length of Stay (for inpatient claims)

	Required
	 	     -     Service Units (Quantity)

	Required
	 	     -     DRG (for inpatient claims)

	Required
	 	     -     Primary ICD-9 Diagnosis Code

	 	 	     -     Additional ICD-9 Diagnosis Codes (up to 5 additional codes, if available)

	 	 	     -     ICD-9 Procedure Code (up to 8, if available)

	Required
	 	     -     Hospital Revenue Codes

	Required
	 	     -     Procedure Code (CPT-4, HCPCS, NDC as applicable for each service line)

	Required
	 	     -     Procedure Code Modifier (as applicable)

	Required
	 	     -     Place of Service

	Required
	 	     -     Billed Amount

	 	 	     -     Discount Amount

	 	 	     -     Disallowed Amount

	Required
	 	     -     Allowed Amount

	Required
	 	     -     COB/TPL Payment Amount

	Required
	 	     -     Copayment Amount

	Required
	 	     -     Coinsurance Amount

	Required
	 	     -     Deductible Amount

	 	 	     -     Withhold Amount

	Required
	 	     -     Paid Amount

	Required
	 	     -     Claim Paid/Check Date (for paid claims)

	Required
	 	     -     Claim Received Date

	Required
	 	     -     Claim Entry Date

	Required
	 	     -     Service Post Date (for paid or denied claims)

 
Page 1

 

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Health Care Authority — Basic Health 2008 Contract

Exhibit 10: Paid Claims Data Reporting

MINIMUM REPOSITORY DATA LOADING REQUIREMENTS

	 	 	 
	 	 	 

	 	 	Claims Data

	 	 	     -     Discharge Status

	 	 	     -     Admit Type

	 	 	     -     Admit Source

	 	 	     -     Claim Adjudication Code

	 	 	     -     PCP Provider ID

	 	 	 

	 	 	Pharmacy Claims

	 	 	Prefer all (“Paid”, “Suspended”, “Pended”, “Denied”, etc.) claims and service line detail information.

	Required
	 	     -     Claim ID (unique claim identifier)

	 	 	     -     Claim or Service Line Number (if available)

	Required
	 	     -     Member ID (or Patient ID)

	Required
	 	     -     Prescription Fill Date

	Required
	 	     -     National Drug Code (NDC)

	Required
	 	     -     Paid Date

	Required
	 	     -     Number of Scripts

	 	 	     -     New / Refill Code

	 	 	     -     Days Supply

	Required
	 	     -     Billed Amount

	Required
	 	     -     Allowed Amount

	 	 	     -     COB/TPL Payment Amount

	Required
	 	     -     Copayment Amount

	 	 	     -     Coinsurance Amount

	 	 	     -     Deductible Amount

	 	 	     -     Withhold Amount

	Required
	 	     -     Paid Amount

	 	 	     -     Ingredient Cost

	 	 	     -     Dispensing Fee

	 	 	     -     Dispense as Written (DAW) Code

	 	 	     -     Drug Type (i.e., OTC, SSB, MSB, Generic)

	 	 	     -     Formulary Flag

	 	 	 

	 	 	Eligibility

	 	 	Include all eligibility events (such as change in: effective or termination date)

	Required
	 	     -     Member ID or Patient ID (for matching to Claim)

	Required
	 	     -     Relationship to Subscriber (for example: self, spouse, dependent)

	Required
	 	     -     Subscriber ID

	Required
	 	     -     Gender

	Required
	 	     -     Birth date

 
Page 2

 

Table of Contents

Health Care Authority — Basic Health 2008 Contract

Exhibit 10: Paid Claims Data Reporting

MINIMUM REPOSITORY DATA LOADING REQUIREMENTS

	 	 	 
	 	 	     -     Member Name

	 	 	     -     Member Address

	 	 	     -     PCP ID (if applicable)

	Required
	 	     -     Member Effective Date (beginning of coverage event)

	Required
	 	     -     Member Termination Date (end of coverage event, if applicable)

	 	 	 

	 	 	Reference Table Requests

	Required
	 	     -     Provider Specialty Codes Table

	 	 	     -     Claim Status Codes Table

	 	 	     -     Claims Adjudication Codes Table

	Required
	 	     -     Provider Table

 
Page 3

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Exhibit 11

Basic Health 2008 Grievance System Reporting

Grievance System Reporting Instructions

	 	 	 	 	 
	Calendar Quarter:
	 	Quarter in which Grievances were received:	 	 
	 

	 	4th — October-December, 2007	 	1st  — Jan-March, 2008
	 

	 	2nd — April-June, 2008	 	3rd  — July-September, 2008
	 
	 	 	 	 
	Data submission:

	 	4th Quarter, 2007	 	Due: February 1, 2008
	 

	 	1st Quarter, 2008	 	Due: May 1, 2008
	 

	 	2nd Quarter, 2008	 	Due: August 1, 2008
	 

	 	3rd Quarter, 2008	 	Due: November 1, 2008
	 
	 	 	 	 
	 	 	•   Data must be in EXCEL and be submitted electronically through the
secure HCA Valicert web site (https://sft.wa.gov). Submitter must send an upload notification to Bevin Hansell
(bevin.hansell@hca.wa.gov) for Basic Health (including HCTC data).

	 
	 	 	 	 
	 	 	•   Submissions must be labeled with health plan name, reporting year and
quarter, and book of business (Example: HealthPlan Q2/08 BH)

	 
	 	 	 	 
	 	 	•   Data must be reported and loaded separately onto secure web site by
book of business to ensure compliance with HIPAA privacy requirements.

	 	 	     (Example: Basic Health; HO/BH+-S Women/SCHIP; WMIP; GAU; MMIP)

	 
	 	 	 	 
	DEFINITIONS

	 
	 	 	 	 
	Denial:	 	For Basic Health (including HCTC) apply PBOR definition: A nonauthorization of a request for care or services.
	 
	 	 	 	 
	Appeal:	 	An enrollee’s written or oral request that the health plan
reconsider: (a) Its resolution of a complaint made by an enrollee; or (b) its decision to deny, modify, reduce, or
terminate payment, coverage, authorization, or provision of health care services or benefits, including the admission to or continued stay in a health care facility. A carrier must not
require that an enrollee file a complaint prior to seeking appeal of a decision under (b) of this subsection. (RCW 48.43.530 (4))
	 
	 	 	 	 
	Expedited:	 	An appeal must be expedited if the enrollee’s provider or the
carrier’s medical director reasonably determines that the appeal process timelines could seriously jeopardize the
enrollee’s life, health, or ability to regain maximum function. The decision regarding an expedited appeal must be made within
seventy-two hours of the date the appeal is received. (RCW 48.43.530 (c))

BH 2008 Contract — Exhibit 11

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	Grievance:	 	For Basic Health (including HCTC) apply PBOR definition:
“Grievance” means a written or oral complaint submitted by or on behalf of a covered person regarding: (a) denial of payment
for medical services or non-provision of medical services included in the covered person’s health benefit plan, or (b)
service delivery issues other than denial of payment for medical services or non-provision of medical services,
including dissatisfaction with medical care, waiting time for medical services, provider or staff attitude or demeanor, or
dissatisfaction with service provided by the health carrier. (RCW 48.43.530; WAC 284-43-130; WAC 284-43-160)
	 
	 	 	 	 
	 	 	Grievance Example: 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.
	 
	 	 	 	 
	 	 	A grievance is to be registered and counted as such whether the grievance is
remedied by the plan immediately or through its grievance and quality of care and service procedures and regardless of whether it is substantiated. If an
enrollee has a number of different grievances, each one is to be registered separately.
	 
	 	 	 	 
	 	 	Any grievance sent by a state agency (HCA/HRSA/OIC) is to be registered and
counted as a grievance regardless of how it is resolved.
	 
	 	 	 	 
	 	 	Inquiry: A written or verbal question or request for information posed to the
plan with regards to such as issues a benefit questions, contract issues, or organization rules. Inquiries do not reflect enrollee grievance or
disagreements with plan determinations. Inquiries are not to be counted.
	 
	 	 	 	 
	 	 	Example: An ID card request is considered an inquiry unless the enrollee has
requested more than once and is making a grievance about not receiving the ID card.
	 
	 	 	 	 
	Issue:	 	The purpose or catalyst for the grievance, denial/action, or appeal.
	 
	 	 	 	 
	Practitioner:	 	Practitioner involved in the appeal, denial or grievance.
	 
	 	 	 	 
	Resolution:	 	The health plan’s final decision of the grievance or appeal.

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2007 — 2008 Denial /Appeals/ Grievance Contract Requirements

MCO FORMAT REPORTING GUIDELINES

	1.	 	Column A: Health Plan Name — Indicate reporting plan with full name or common abbreviation
	 
	2.	 	Column B: Delegated Entity — Identify the health plan’s delegated entity that
receives denial, appeal, or grievance. The health plan is responsible to integrate the
delegated entity’s data into the health plan’s data. There should be no separate data
submission for the delegated entities. 
	 
	3.	 	Column C: Quarter — Indicate the reporting quarter the initial grievance is received. Reporting format: 1,2,3,4
	 
	4.	 	Column D: Program Name — Specify the program for the data submitted using numbers 1-8 as follows:

	 	1.	 	BH — Indicates Basic Health and HCTC enrollees, does not include BH+ or S-Women
	 
	 	2.	 	PEBB — Includes all enrollees covered by the PEBB contract
	 
	 	3.	 	HO — Includes all HRSA Healthy Options Medicaid Managed Care enrollees (also see Column E)
	 
	 	4.	 	BH+ — Includes BH+ and S-Women enrollees
	 
	 	5.	 	SCHIP — Identifies Children’s Health Insurance Program
enrollees
	 
	 	6.	 	GAU
	 
	 	7.	 	WMIP
	 
	 	8.	 	MMIP

	5.	 	Column E: ESHCN- Identify all enrollees with special health care needs by program with an “X” (HRSA Only)
	 
	6.	 	Column F: Enrollee ID — Populate column with the enrollee’s Social Security Number.
	 
	7.	 	Column G: Enrollee Last Name — Identifies the enrollee. (mandatory for HRSA only)
	 
	8.	 	Column H: Enrollee First Name — Identifies the enrollee. (mandatory for HRSA only)
	 
	9.	 	Column I: Enrollee Middle Initial — Identifies the enrollee. (mandatory for HRSA only)
	 
	10.	 	Column J: Enrollee Birth Date — Format: MM/DD/YYYY (Example: 12/01/1985).
	 
	11.	 	Column K: Provider/Practitioner Last Name — Identifies the serving
provider/practitioner, either as the source of a member’s grievance, was the provider of
service the plan took action upon or denied, or is addressing the enrollee’s service.
	 
	12.	 	Column L: Provider/Practitioner First Name — Identifies the serving
provider/practitioner, either as the source of a member’s grievance, was the provider of
service the plan took action upon or denied, or is addressing the enrollee’s service.

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	13.	 	Column M: Provider/Practitioner Middle Initial — Identifies the serving
provider/practitioner, either as the source of a member’s grievance, provider of service
the plan took action upon or denied, or is addressing the enrollee’s service.
	 
	14.	 	Column N: Provider/Practitioner Category — Identifies type of practitioner. Should
be no more than thirty (30) characters.
	 
	 	 	Examples: Family Practitioner, Chiropractor, Acupuncturist, Surgeon, General Surgeon,
Orthopedist, Urologist, Internal Medicine, Certified Nurse Practitioner, Dermatologist, etc.
	 
	15.	 	Column O: Facility Name — Identifies the facility or clinic the practitioner is
associated or contracted with and which is associated with the grievance, denial/action, or
appeal.
	 
	16.	 	Column P: Type/Level — Specifies the category and the level for the data submitted as follows:
	 
	 	 	1= Grievance
	 
	 	 	2= Denial (BH Only)
	 
	 	 	3= Action (HRSA Only)
	 
	 	 	4= 1st Level Appeal
	 
	 	 	5= 2nd Level Appeal
	 
	 	 	6= Independent Review Organization (IRO)
	 
	 	 	7= State Hearing (HRSA Only)
	 
	17.	 	Column Q: Expedited — Identifies urgency of the grievance or appeal. Reporting
format: “X” for yes.
	 
	18.	 	Column R: Grievance, Denial/Action, Appeal, IRO, or Hearing Issue
—Identifies/describes the “what” or the catalyst for the requested grievance, the service
denied or MCO action taken, or issue driving the appeal by the enrollee or practitioner.
This key descriptive column must be populated for all records.
	 
	 	 	Issue Examples:
	 
	 	 	Grievances: Administrative, Referrals, Waited too long on hold (or Dissatisfaction with
Quality of Service), Provider was rude (Interpersonal Relationships or Dissatisfaction with
Quality of Service), could not access a preferred provider (or Dissatisfaction with Plan
Practices)
	 
	 	 	Denials/Actions: Pain Management, Durable Medical Equipment, Prescription Drug, Chiropractic
Benefits, PT/ST/OT, Emergency Services, Out of Area Care, Psychotherapy, Acupuncture,
	 
	 	 	Appeals, IROs, State Hearings: Reflects what was in the initiating Denial/Action.
	 
	19.	 	Column S: Grievance, Denial/Action, Appeal, IRO, or Hearing Reason: -
Describes the “why” or which best describes the reason behind the member’s dissatisfaction, behind the denied,

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	 	 	reduced, or changed service, or for causing the appeal, IRO, or hearing. This key
descriptive column must be populated for all records.
	 
	 	 	Reason Examples: 
	 
	 	 	Grievances: Referral lost or incomplete, Staff behavior, Perceived lack of caring/concern,
	 
	 	 	Denials/Actions: Not Medically Necessary, Not Medically Indicated, Partial Approval, Not a
Covered Benefit, Contract Exclusion, No Benefit, Limited Benefit/Excluded, , Benefit
Exceeded/Exhausted, Out of Network, Not A Contracted Provider, Non-Preferred Provider, Care
Available from participating provider, No Referral, RX criteria not met,
Investigational/Experimental, etc.
	 
	 	 	Appeals, IROs, State Hearings: Reflects what was in the initiating Denial/Action.
	 
	 	 	(NOTE: “Other” category should be used only as a last resort.)
	 
	20.	 	Column T: Resolution of Grievance, Appeal, or IRO — — Describes the “outcome” — the
grievance, appeal, IRO, or State Hearing determination. This specifies all partial
approvals or a plan changes in a service request. This key descriptive column must be
populated for all records.
	 
	 	 	Resolution Examples: 
	 
	 	 	Grievances: Resolved, Forwarded to Admin/Mgr., Explanation Provided, Adjustment Completed
	 
	 	 	Denials/Actions: Generally Blank.
	 
	 	 	Appeals, IRO/State Hearing Determinations: Upheld, Overturned, Reversed, Partially Upheld,
Partial Payment, Partial Approval, Withdrawn.
	 
	 	 	Grievance — Action/Review/Response Provided, Forwarded to QI, Benefit Explained, Consulted/Advised.
	 
	21.	 	Column U: Date Received — Documents the date the grievance was received, a denial or
action took place, or an appeal, IRO, or State Hearing request was received. Reporting format: MM/DD/YYYY
	 
	22.	 	Column V: Date Resolved — Identifies the date a grievance was responded to, dates
denial notice sent, or date an appeal, IRO, or a denial determination is made. Reporting
format: MM/DD/YYYY
	 
	23.	 	Column W: Date written notification sent to enrollee and practitioner. Reporting format: MM/DD/YYYY
	 
	Note: 	 	Some plans requested examples of denial, appeal, grievance categories and denial reason.
Plans are not required to use the issue and reason examples listed.

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Additional Sample Grievance Issues by Category:

Access

Appointment availability with PCP-Grievance could include such issues as the inability to see a specific PCP; delay in getting an appointment to a PCP; appointment times are inconvenient; inadequate numbers of PCP, location of PCP office is inconvenient.

Appointment availability with specialist — Grievance can cover the same issues as above as they apply to physician specialists.

Appointment availability with ancillary- Grievance can cover the same issues as in above as they apply to ancillary services such as lab, radiology, etc. 

Difficulty obtaining referral and/or covered services.

Difficulty obtaining after hours care- no response or delayed response; incomplete or unsatisfactory response to call made to the health plan or practitioner after normal business hours.

Network- adequacy of the practitioner network.

Quality of Care

Dissatisfaction with quality of medical care.

Dissatisfied with explanation of the problem or issue.

Dissatisfied with quality of clinical provider (such as physicians, nurses, therapists, psychologists) and /or such issues as misdiagnosis by any provider, unsatisfactory outcome of the treatment; unsatisfactory treatment methods, tests were not properly done, were lost, results, were not communicated; medical records could not be obtained; medication errors.

Hospital — dissatisfaction with length of stay; dissatisfaction with hospital treatment or discharge plans.

Dissatisfaction with substance abuse services/treatment; or dissatisfaction with substance abuse provider.

Dissatisfaction with pharmacy — generic drug problem; or the health plan’s drug formulary.

Quality of Service

Dissatisfaction with provider services (non-medical): The physician or office staff behavior or appearance; office or facility appearance; wait time in the provider’s office, exam room, or on the telephone.

Dissatisfaction with the health plan’s service:

Health plan staff behavior, difficulty with telephone access and wait time.

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Eligibility — issuance and/or receipt of I.D. cards, enrollment, disenrollment.

Telephone — Multiple transfers/calls to resolve issue.

Reimbursement/billing disputes- billing errors; enrollee is being billed directly; visits to providers are denied payment.

Pharmacy — dissatisfaction with length of prescription; dissatisfaction with type/locations of vendors; problem with mail order prescriptions.

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Exhibit 12: Basic Health 2008 Contract

Report Due Dates for Basic Health — 2008 Contract

	 	 	 	 	 	 	 
	Name of Report	 	Report Due Date	 	HCA Recipient	 	Other Recipient
	CAHPS (Exhibit 5)
	 	June 15	 	Bevin Hansell	 	 
	Complaints, Grievances, Denials and Appeals 10 — 12/07
	 	February 1	 	Bevin Hansell	 	HCA Valicert
	Complaints, Grievances, Denials and Appeals 1 — 3/08
	 	May 1	 	Bevin Hansell	 	HCA Valicert
	Complaints, Grievances, Denials and Appeals 4 — 6/08
	 	September 1	 	Bevin Hansell	 	HCA Valicert
	Complaints, Grievances, Denials and Appeals 7 — 9/08
	 	November 1	 	Bevin Hansell	 	HCA Valicert
	Contractor’s Non-Business Days for 2008
	 	March 1	 	Bevin Hansell	 	 
	Experience Reports BH & HCTC
	 	March 31	 	Bevin Hansell	 	Milliman
	HEDIS® (Exhibit 9)
	 	June 15	 	Bevin Hansell	 	 
	HEDIS® (Raw Measures)
	 	June 30	 	Bevin Hansell	 	 
	Paid Claims Data — 2008 Monthly
	 	Due within 30 days from end of each month	 	cc: Bevin Hansell	 	Milliman
	Performance Measures January 1 — June 30
	 	July 31	 	Bevin Hansell	 	 
	Performance Measures July 1 — December 31
	 	January 31	 	Bevin Hansell	 	 

2008 Basic Health Contract — Exhibit 12exv10w2

 

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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	 	 	 	 	 	 	Page
	 
	 	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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	 	 	 	 	 	 	Page
	 
	 	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	 	 

v  

 

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.

1

 

	 	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.

2

 

	 	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;

3

 

	 	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

4

 

	 	 	 	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.

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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.

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	 	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:

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	 	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.

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	 	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.

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	 	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.

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	 	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 

30

 

	 	 	 	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

31

 

	 	 	 	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.

32

 

	 	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.

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	 	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.

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	 	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

115

 

	 	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 

116

 

	 	 	 	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.

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