(1) The purpose of this section is to describe the managed care requirements for clients eligible for the Washington Medicaid Integration Partnership (WMIP).
(2) Unless otherwise stated in this section, all of the provisions of chapter 182-538
WAC apply to clients enrolled in WMIP.
(3) The following sections of chapter 182-538
WAC do not apply to WMIP enrollees:
(a) WAC 182-538-060
. However, WAC 182-538-060
(9), describing enrollees' ability to choose their PCP, does apply to WMIP enrollees;
(b) WAC 182-538-063
(c) WAC 182-538-065
(d) WAC 182-538-068
(e) WAC 182-538-130
. However, WAC 182-538-130
(3) and (4), describing the process used when the agency receives a request from an MCO to remove an enrollee from enrollment in managed care, do apply to WMIP enrollees. Also, WAC 182-501-0135
, describing the MCO's ability to refer enrollees to the agency's "Patient Review and Coordination" program, applies to WMIP enrollees.
(4) The process for enrollment of WMIP clients is as follows:
(a) Enrollment in WMIP is voluntary, subject to program limitations in (b) and (d) of this subsection.
(b) Clients dually eligible for medicare and medicaid can enroll in WMIP if they:
(i) Are aged, blind, or disabled;
(ii) Are twenty-one years of age or older; and
(iii) Receive categorically needy medical assistance.
(c) Clients who are eligible for both medicare and medicaid who meet the eligibility criteria in (b) of this subsection may voluntarily enroll or end enrollment in WMIP at any time. Except as described in (d) of this subsection, all enrollments and disenrollments will be prospective.
(d) The agency will not enroll a client in WMIP, or will end an enrollee's enrollment in WMIP when the client has, or becomes eligible for, CHAMPUS/TRICARE or any other third-party health care coverage that would:
(i) Require the agency to either exempt the client from enrollment in managed care; or
(ii) End the enrollee's enrollment in managed care.
(e) A client or enrollee in WMIP, or the client's or enrollee's representative, may end enrollment from the MCO at any time without cause. The client may then reenroll at any time with the MCO. The agency ends enrollment for clients prospectively to the first day of the month following the request to end enrollment, except as provided in (f) of this subsection.
(f) A client or enrollee may request that the agency retroactively end enrollment from WMIP. On a case-by-case basis, the agency may retroactively end enrollment from WMIP when, in the agency's judgment:
(i) The client or enrollee has a documented and verifiable medical condition; and
(ii) Enrollment in managed care could cause an interruption of on-going treatment that could jeopardize the client's or enrollee's life or health or ability to attain, maintain, or regain maximum function.
(5) In addition to the scope of medical care services described in WAC 182-538-095
, WMIP includes mental health, chemical dependency treatment, and long-term care services.
(6) The agency sends each client written information about covered services when the client is eligible to enroll in WMIP, and any time there is a change in covered services. In addition, the agency requires MCOs to provide new enrollees with written information about covered services. This notice informs the client about the right to end enrollment and how to do so.
[Statutory Authority: RCW 41.05.021, 42 C.F.R. 438. 13-02-010, § 182-538-061, filed 12/19/12, effective 2/1/13. 11-14-075, recodified as § 182-538-061, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.09.522. 08-15-110, § 388-538-061, filed 7/18/08, effective 8/18/08; 06-03-081, § 388-538-061, filed 1/12/06, effective 2/12/06. Statutory Authority: RCW 74.08.090, 74.09.522, 2003 E1 c 25 § 201(4), 2004 c 276 § 201(4), 42 U.S.C. 1396N (section 1915 (b) and (c) of the Social Security Act of 1924). 05-01-066, § 388-538-061, filed 12/8/04, effective 1/8/05.]