Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-557 - Health homes › Section 182-557-0100 - Health home program-Definitions

Current through Register Vol. 24-14, July 15, 2024
The following terms and definitions and those found in
				  chapter 182-500 WAC apply to this chapter:
Action
- For the purposes of this chapter, means
				  one or more of the following:
(a) The denial of eligibility for health home
				  services.
(b) The denial or limited authorization by the qualified
				  health home of a requested health home service, including a type or level of
				  health home service.
(c) The reduction, suspension, or termination by the
				  qualified health home of a previously authorized health home service.
(d) The failure of a qualified health home to provide
				  authorized health home services or provide health home services as quickly as
				  the participant's condition requires.
Agency
- See WAC
				  182-500-0010.
Chronic condition
- Means mental health
				  conditions, substance use disorders, asthma, diabetes, heart disease, cancer,
				  cerebrovascular disease, coronary artery disease, dementia or Alzheimer's
				  disease, intellectual disability, HIV/AIDS, renal failure, chronic respiratory
				  conditions, neurological disease, gastrointestinal, hematological, and
				  musculoskeletal conditions.
Client
- For the purposes of this chapter, means
				  a person who is eligible to receive health home services under this
				  chapter.
Clinical eligibility tool
- Means an electronic
				  spreadsheet that determines a client's risk score using the client's age,
				  gender, diagnoses, and medications.
Coverage area
- Means a geographical area
				  composed of one or more counties within Washington state. The map of the
				  coverage areas and the list of the qualified health homes is located at
				  https://www.hca.wa.gov/billers-providers/programs-and-services/health-homes.
Fee-for-service (FFS)
- See WAC
				  182-500-0035.
Full dual eligible
- For the purpose of this
				  chapter, means a fee-for-service client who receives qualified medicare
				  beneficiary coverage or specified low-income medicare beneficiary coverage and
				  categorically needy health care coverage.
Grievance
- Means an expression of a
				  participant's dissatisfaction about any matter other than an action. Possible
				  subjects for grievances include the quality of health home services provided
				  when an employee of a qualified health home provider is rude to the participant
				  or shares confidential information about the participant without their
				  permission.
Health action plan
- Means a plan that lists the
				  participant's goals to improve and self-manage their health conditions and
				  steps needed to reach those goals.
Health home care coordinator
- Means staff
				  employed by or subcontracted by the qualified health home to provide one or
				  more of the six defined health home care coordination benefits listed in WAC
				  182-557-0050.
Health home services
- Means services described
				  in WAC 182-557-0050(2)(a) through
				  (f).
Medicaid
- See WAC
				  182-500-0070.
Participant
- Means a client who has agreed to
				  receive health home services under the requirements of this chapter.
Qualified health home
- Means an organization
				  that contracts with the agency to provide health home services to participants
				  in one or more coverage areas and meets the requirements in WAC
				  182-557-0050(4).
Risk score
- Means a measure of the expected
				  costs of the health care a client is likely to incur in the next twelve months
				  that the agency calculates using an algorithm developed by the department of
				  social and health services (DSHS) or the clinical eligibility
				  tool.
Statutory Authority:
					 RCW
					 41.05.021 and
					 2011 c
					 316 . 13-12-002, §
											182-557-0100, filed 5/22/13,
					 effective 7/1/13. 11-14-075, recodified as §
											182-557-0100, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.08.090,
					 74.09.500,
					 74.09.520, and 2007 c 259, §
					 4. 07-20-048, § 388-557-0100, filed 9/26/07, effective
					 11/1/07.