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182-538-050  <<  182-538-060 >>   182-538-061

Managed care and choice.

(1) This chapter does not apply to the subsidized basic health program found in chapters 182-24 and 182-22 WAC unless allowed by specific program rule.
(2) Except as provided in subsection (3) of this section, the medicaid agency requires a client to enroll in managed care when that client:
(a) Is eligible for one of the medical assistance programs for which enrollment is mandatory;
(b) Resides in an area where enrollment is mandatory; and
(c) Is not exempt from managed care enrollment or the agency has not ended the client's managed care enrollment, consistent with WAC 182-538-130, and any related hearing has been held and decided.
(3) American Indian and Alaska native (AI/AN) clients who meet the provisions of 25 U.S.C. 1603 (c)-(d) for federally recognized tribal members and their descendants may choose one of the following:
(a) Enrollment with a managed care organization (MCO) available in their area;
(b) Enrollment with an Indian or tribal primary care case management (PCCM) provider available in their area; or
(c) The agency's fee-for-service system.
(4) To enroll with an MCO or PCCM provider, a client may:
(a) Call the agency's toll-free enrollment line at 800-562-3022;
(b) Mail a postage-paid completed managed care enrollment form (HCA 13-862) to the agency's unit responsible for managed care enrollment; or
(c) Fax the managed care enrollment form (HCA 13-862) to the agency at the number located on the enrollment form.
(5) A client must enroll with an MCO provider available in the area where the client resides.
(6) All family members of an enrollee placed in the patient review and coordination (PRC) program under WAC 182-501-0135 must enroll with the same MCO but may enroll in a different MCO than the family member placed in the PRC program.
(7) When a client requests enrollment with an MCO or PCCM provider, the agency enrolls a client effective the earliest possible date given the requirements of the agency's enrollment system. The agency does not enroll clients retrospectively.
(8) The agency assigns a client who does not choose an MCO or PCCM provider as follows:
(a) If the client has a family member or family members enrolled with an MCO, the client is enrolled with that MCO;
(b) If the client does not have a family member or family members enrolled with an MCO that is currently under contract with the agency, and the client was previously enrolled with the MCO or PCCM provider, and the agency can identify the previous enrollment, the client is reenrolled with the same MCO or PCCM provider;
(c) If the client cannot be assigned according to (a) or (b) of this subsection, the agency assigns the client as follows:
(i) If an AI or AN client does not choose an MCO or PCCM provider, the agency assigns the client to a tribal PCCM provider if that client resides in a zip code served by a tribal PCCM provider. If there is no tribal PCCM provider in the client's area, the client continues to be served by the agency's fee-for-service system. A client assigned under this subsection may request to end enrollment at any time.
(ii) If a client who is not AI or AN does not choose an MCO provider, the agency assigns the client to an MCO available in the area where the client resides. The MCO is responsible for primary care provider (PCP) choice and assignment.
(iii) For clients who are new recipients or who have had a break in eligibility of greater than two months, the agency sends a written notice to each household of one or more clients who are assigned to an MCO or PCCM provider. The assigned client has ten calendar days to contact the agency to change the MCO or PCCM provider assignment before enrollment is effective. The notice includes the name of the MCO or PCCM provider to which each client has been assigned, the effective date of enrollment, the date by which the client must respond in order to change the assignment, and the toll-free telephone number of either:
(A) The MCO (for enrollees assigned to an MCO); or
(B) The agency (for enrollees assigned to a PCCM provider).
(iv) If the client has a break in eligibility of less than two months, the client will be automatically reenrolled with his or her previous MCO or PCCM provider and no notice will be sent.
(9) The agency:
(a) Helps facilitate the choice of a PCP by providing information regarding available providers contracted with the MCOs in the client's service area; and
(b) Upon request, will assist clients in identifying an MCO with which their provider participates.
(10) An MCO enrollee's selection of a PCP or assignment to a PCP occurs as follows:
(a) An MCO enrollee may choose:
(i) A PCP or clinic that is in the enrollee's MCO and accepting new enrollees; or
(ii) A different PCP or clinic participating with the enrollee's MCO for different family members.
(b) The MCO assigns a PCP or clinic that meets the access standards set forth in the relevant managed care contract if the enrollee does not choose a PCP or clinic.
(c) An MCO enrollee may change PCPs or clinics in an MCO for any reason, with the change becoming effective no later than the beginning of the month following the enrollee's request.
(d) An MCO enrollee may file a grievance with the MCO if the MCO does not approve an enrollee's request to change PCPs or clinics.
(e) MCO enrollees required to participate in the agency's PRC program may be limited in their right to change PCPs (see WAC 388-501-0135).
[Statutory Authority: RCW 41.05.021, 42 C.F.R. 438. WSR 13-02-010, § 182-538-060, filed 12/19/12, effective 2/1/13. WSR 11-14-075, recodified as § 182-538-060, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.09.522. WSR 08-15-110, § 388-538-060, filed 7/18/08, effective 8/18/08; WSR 06-03-081, § 388-538-060, filed 1/12/06, effective 2/12/06. Statutory Authority: RCW 74.08.090, 74.09.522, 2003 E1 c 25 § 201(4), 2004 c 276 § 201(4), 42 U.S.C. 1396N (section 1915 (b) and (c) of the Social Security Act of 1924). WSR 05-01-066, § 388-538-060, filed 12/8/04, effective 1/8/05. Statutory Authority: RCW 74.08.090, 74.09.522. WSR 03-18-109, § 388-538-060, filed 9/2/03, effective 10/3/03. Statutory Authority: RCW 74.09.080, 74.08.510, [74.08.]522, 74.09.450, 1115 Waiver, 42 U.S.C. 1396. WSR 02-01-075, § 388-538-060, filed 12/14/01, effective 1/14/02. Statutory Authority: RCW 74.08.090, 74.09.510 and [74.09.]522 and 1115 Federal Waiver, 42 U.S.C. 1396 (a), (e), (p), 42 U.S.C. 1396r-6(b), 42 U.S.C. 1396u-2. WSR 00-04-080, § 388-538-060, filed 2/1/00, effective 3/3/00. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057 and 74.08.090. WSR 98-16-044, § 388-538-060, filed 7/31/98, effective 9/1/98. Statutory Authority: RCW 74.08.090 and 1995 2nd sp.s. c 18. WSR 95-18-046 (Order 3886), § 388-538-060, filed 8/29/95, effective 9/1/95. Statutory Authority: RCW 74.08.090. WSR 93-17-039 (Order 3621), § 388-538-060, filed 8/11/93, effective 9/11/93.]