Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-538 - Managed care › Section 182-538-050 - Definitions

Current through Register Vol. 24-14, July 15, 2024
The following definitions and abbreviations and those found
				  in chapter 182-500 WAC apply to this chapter. If conflict exists, this chapter
				  takes precedence.
"Administrative hearing"
means an evidentiary
				  adjudicative proceeding before an administrative law judge or presiding officer
				  that is available to an enrollee under chapter 182-526 WAC according to
				  RCW
				  74.09.741.
"Adverse benefit determination"
means one or
				  more of the following:
(a) The denial or limited authorization of a requested
				  service, including determinations based on the type or level of service,
				  requirements for medical necessity, appropriateness, setting, or effectiveness
				  of a covered benefit;
(b) The reduction, suspension, or termination of a previously
				  authorized service;
(c) The denial, in whole or in part, of payment for a
				  service;
(d) The failure to provide services in a timely manner, as
				  defined by the state;
(e) The failure of a managed care organization (MCO) to act
				  within the time frames provided in
				  42 C.F.R. Sec.
				  438.408(a), (b)(1) and (2)
				  for standard resolution of grievances and appeals; or
(f) For a resident of a rural area with only one MCO, the
				  denial of an enrollee's request to exercise the enrollee's right to obtain
				  services outside the network under
				  42 C.F.R.
				  Sec.
				  438.52(b)(2)(ii).
"Agency"
- See WAC
				  182-500-0010.
"Appeal"
means a review by an MCO of an adverse
				  benefit determination.
"Apple health foster care (AHFC)"
means the
				  managed care program developed by the agency and the department of social and
				  health services to serve children and youth in foster care and adoption support
				  and young adult alumni of the foster care program.
"Assign"
or
"assignment"
means the
				  agency selects an MCO to serve a client who has not selected an MCO.
"Auto enrollment"
means the agency has
				  automatically enrolled a client into an MCO in the client's area of
				  residence.
"Behavioral health"
- See WAC
				  182-538D-0200.
"Behavioral health administrative service organization
				  (BH-ASO)"
means an entity selected by the medicaid agency to administer
				  behavioral health services and programs, including crisis services for all
				  people in an integrated managed care regional service area. The BH-ASO
				  administers crisis services for all people in its defined regional service
				  area, regardless of a person's ability to pay.
"Behavioral health services only (BHSO)"
means
				  the program in which enrollees only receive behavioral health benefits through
				  a managed care delivery system.
"Child or youth with special health care needs"
means a client under age 19 who is:
(a) Eligible for supplemental security income under Title XVI
				  of the Social Security Act;
(b) Eligible for medicaid under section 1902 (e)(3) of the
				  Social Security Act;
(c) In foster care or other out-of-home placement;
(d) Receiving foster care or adoption assistance; or
(e) Receiving services through a family-centered,
				  community-based, coordinated care system that receives grant funds under
				  section 501 (a)(1)(D) of Title V of the Social Security Act.
"Client"
- See WAC
				  182-500-0020.
"Disenrollment"
- See "end enrollment."
"Emergency medical condition"
means a condition
				  meeting the definition in
				  42 C.F.R. Sec.
				  438.114(a).
"Emergency services"
means services defined in
				  42 C.F.R. Sec.
				  438.114(a).
"End enrollment"
means ending the enrollment of
				  an enrollee for one of the reasons outlined in WAC
				  182-538-130.
"Enrollee"
means a person eligible for any
				  Washington apple health program enrolled in managed care with an MCO or PCCM
				  provider that has a contract with the state.
"Enrollee's representative"
means a person with
				  a legal right or written authorization from the enrollee to act on behalf of
				  the enrollee in making decisions.
"Enrollees with special health care needs"
means
				  enrollees having chronic and disabling conditions and the conditions:
(a) Have a biologic, psychologic, or cognitive basis;
(b) Have lasted or are virtually certain to last for at least
				  one year; and
(c) Produce one or more of the following conditions stemming
				  from a disease:
(i) Significant limitation in areas of physical, cognitive,
				  or emotional function;
(ii) Dependency on medical or assistive devices to minimize
				  limitation of function or activities; or
(iii) In addition, for children, any of the following:
(A) Significant limitation in social growth or developmental
				  function;
(B) Need for psychological, educational, medical, or related
				  services over and above the usual for the child's age; or
(C) Special ongoing treatments, such as medications, special
				  diet, interventions, or accommodations at home or school.
"Exemption"
means agency approval of a client's
				  preenrollment request to remain in the fee-for-service delivery system for one
				  of the reasons outlined in WAC
				  182-538-130.
"Fully integrated managed care (FIMC)"
- See
				  integrated managed care.
"Grievance"
means an expression of
				  dissatisfaction about any matter other than an adverse benefit
				  determination.
"Grievance and appeal system"
means the
				  processes the MCO implements to handle appeals of adverse benefit
				  determinations and grievances, as well as the processes to collect and track
				  information about them.
"Health care service"
or
"service"
means a service or item provided for the prevention, cure, or treatment of an
				  illness, injury, disease, or condition.
"Integrated managed care (IMC)"
means the
				  program under which a managed care organization provides:
(a) Physical health services funded by medicaid; and
(b) Behavioral health services funded by medicaid, and other
				  available resources provided for in chapters 182-538B, 182-538C, and 182-538D
				  WAC.
"Managed care"
means a comprehensive health care
				  delivery system that includes preventive, primary, specialty, and ancillary
				  services. These services are provided through either an MCO or PCCM
				  provider.
"Managed care contract"
means the agreement
				  between the agency and an MCO to provide prepaid contracted services to
				  enrollees.
"Managed care organization"
or
"MCO"
means an organization having a certificate of authority or
				  certificate of registration from the office of insurance commissioner that
				  contracts with the agency under a comprehensive risk contract to provide
				  prepaid health care services to enrollees under the agency's managed care
				  programs.
"Mandatory enrollment"
means the agency's
				  requirement that a client enroll in managed care.
"Mandatory service area"
means a service area in
				  which eligible clients are required to enroll in an MCO.
"Nonparticipating provider"
means a person,
				  health care provider, practitioner, facility, or entity acting within their
				  scope of practice and licensure that:
(a) Provides health care services to enrollees; and
(b) Does not have a written agreement with the managed care
				  organization (MCO) to participate in the MCO's provider network.
"Participating provider"
means a person, health
				  care provider, practitioner, or entity acting within their scope of practice
				  and li-censure with a written agreement with the MCO to provide services to
				  enrollees.
"Patient days of care"
means all voluntary
				  patients and involuntarily committed patients under chapter 71.05 RCW,
				  regardless of where in the state hospital the patients reside. Patients who are
				  committed to the state hospital under chapter 10.77 RCW are not included in the
				  patient days of care. Patients who are committed under
				  RCW
				  10.77.088 by municipal or district courts
				  after failed competency restoration and dismissal of misdemeanor charges are
				  not counted in the patient days of care until a petition for 90 days of civil
				  commitment under chapter 71.05 RCW has been filed in court. Patients who are
				  committed under
				  RCW
				  10.77.086 by a superior court after failed
				  competency restoration and dismissal of felony charges are not counted in the
				  patient days of care until the patient is civilly committed under chapter 71.05
				  RCW.
"Primary care case management"
or
"PCCM"
means the health care management activities of a provider
				  that contracts with the agency to provide primary health care services and to
				  arrange and coordinate other preventive, specialty, and ancillary health
				  services.
"Primary care provider"
or
"PCP"
means a person licensed or certified under Title 18 RCW including, but not
				  limited to, a physician, an advanced registered nurse practitioner (ARNP),
				  naturopath, or a physician assistant who supervises, coordinates, and provides
				  health services to a client or an enrollee, initiates referrals for specialist
				  and ancillary care, and maintains the client's or enrollee's continuity of
				  care.
"Regional service area (RSA)"
means a single
				  county or multi-county grouping formed for the purpose of health care
				  purchasing and designated by the agency and the department of social and health
				  services.
"Timely"
concerning the provision of services,
				  means an enrollee has the right to receive medically necessary health care as
				  expeditiously as the enrollee's health condition requires. Concerning
				  authorization of services and grievances and appeals, "timely" means according
				  to the agency's managed care program contracts and the time frames stated in
				  this chapter.
"Wraparound with intensive services (WISe)"
is a
				  program that provides comprehensive behavioral health services and support
				  to:
(a) Medicaid-eligible people age 20 or younger with complex
				  behavioral health needs; and
(b) Their families.
Statutory Authority:
					 RCW
					 41.05.021, 42 C.F.R. 438. 13-02-010, §
											182-538-050, filed 12/19/12,
					 effective 2/1/13. 11-14-075, recodified as §
											182-538-050, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.08.090 and
					 74.09.522. 08-15-110, §
					 388-538-050, filed 7/18/08, effective 8/18/08; 06-03-081, § 388-538-050,
					 filed 1/12/06, effective 2/12/06. Statutory Authority:
					 RCW
					 74.08.090,
					 74.09.522, 2003 E 1 c 25§
					 201(4), 2004 c 276 § 201(4),
					 42 U.S.C.
					 1396 N (section 1915(b) and (c) of the Social
					 Security Act of 1924). 05-01-066, § 388-538-050, filed 12/8/04, effective
					 1/8/05. Statutory Authority:
					 RCW
					 74.08.090,
					 74.09.522. 03-18-109, §
					 388-538-050, filed 9/2/03, effective 10/3/03. Statutory Authority:
					 RCW
					 74.09.080, 74.08.510, [74.08.]522, 74.09.450,
					 1115 Waiver, 42 U.S.C.
					 1396. 02-01-075, § 388-538-050, filed
					 12/14/01, effective 1/14/02. Statutory Authority:
					 RCW
					 74.08.090,
					 74.09.510 and [74.09.]522 and 1115
					 Federal Waiver, 42 U.S.C.
					 1396(a), (e), (p),
					 42 U.S.C.
					 1396r-6(b),
					 42 U.S.C.
					 1396u-2. 00-04-080, § 388-538-050, filed
					 2/1/00, effective 3/3/00. Statutory Authority:
					 RCW
					 74.08.090 and 1995 2nd sp.s. c 18. 95-18-046
					 (Order 3886), § 388-538-050, filed 8/29/95, effective 9/1/95. Statutory
					 Authority:
					 RCW
					 74.08.090. 93-17-039 (Order 3621), §
					 388-538-050, filed 8/11/93, effective
					 9/11/93.