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182-538-070  <<  182-538-095 >>   182-538-100

WAC 182-538-095

Agency filings affecting this section

Scope of care for managed care enrollees.

(1) Managed care enrollees are eligible for the scope of services as described in WAC 182-501-0060 for categorically needy clients.
(a) A client is entitled to timely access to medically necessary services as defined in WAC 182-500-0070.
(b) The managed care organization (MCO) covers the services included in the MCO contract for MCO enrollees. MCOs may, at their discretion, cover additional services not required under the MCO contract. However, the agency may not require the MCO to cover any additional services outside the scope of services negotiated in the MCO's contract with the agency.
(c) The agency covers medically necessary services described in WAC 182-501-0060 and 182-501-0065 that are excluded from coverage in the MCO contract.
(d) The agency covers services through the fee-for-service system for enrollees with a primary care case management (PCCM) provider. Except for emergencies, the PCCM provider must either provide the covered services needed by the enrollee, or refer the enrollee to other providers who are contracted with the agency for covered services. The PCCM provider is responsible for instructing the enrollee regarding how to obtain the services that are referred by the PCCM provider. Services that require PCCM provider referral are described in the PCCM contract. The agency informs an enrollee about the enrollee's program coverage, limitations to covered services, and how to obtain covered services.
(e) MCO enrollees may obtain specific services described in the managed care contract from either an MCO provider or from a provider with a separate agreement with the agency without needing to obtain a referral from the PCP or MCO. These services are communicated to enrollees by the agency and MCOs as described in (f) of this subsection.
(f) The agency sends each client written information about covered services when the client is required to enroll in managed care, and any time there is a change in covered services. This information describes covered services, which services are covered by the agency, and which services are covered by MCOs. In addition, the agency requires MCOs to provide new enrollees with written information about covered services.
(2) For services covered by the agency through PCCM contracts for managed care:
(a) The agency covers medically necessary services included in the categorically needy scope of care and rendered by providers who have a current core provider agreement with the agency to provide the requested service;
(b) The agency may require the PCCM provider to obtain authorization from the agency for coverage of nonemergency services;
(c) The PCCM provider determines which services are medically necessary;
(d) An enrollee may request a hearing for review of PCCM provider or agency coverage decisions (see WAC 182-538-110); and
(e) Services referred by the PCCM provider require an authorization number in order to receive payment from the agency.
(3) For services covered by the agency through contracts with MCOs:
(a) The agency requires the MCO to subcontract with a sufficient number of providers to deliver the scope of contracted services in a timely manner. Except for emergency services, MCOs provide covered services to enrollees through their participating providers;
(b) The agency requires MCOs to provide new enrollees with written information about how enrollees may obtain covered services;
(c) For nonemergency services, MCOs may require the enrollee to obtain a referral from the primary care provider (PCP), or the provider to obtain authorization from the MCO, according to the requirements of the MCO contract;
(d) MCOs and their contracted providers determine which services are medically necessary given the enrollee's condition, according to the requirements included in the MCO contract;
(e) The agency requires the MCO to coordinate benefits with other insurers in a manner that does not reduce benefits to the enrollee or result in costs to the enrollee;
(f) A managed care enrollee does not need a PCP referral to receive women's health care services, as described in RCW 48.42.100, from any women's health care provider participating with the MCO. Any covered services ordered and/or prescribed by the women's health care provider must meet the MCO's service authorization requirements for the specific service.
(g) For enrollees temporarily outside their MCO services area, the MCO is required to cover enrollees for emergency care and medically necessary covered benefits that cannot wait until the enrollees return to their MCO services area.
(4) Unless the MCO chooses to cover these services, or an appeal, or a hearing decision reverses an MCO or agency denial, the following services are not covered:
(a) For all managed care enrollees:
(i) Services that are not medically necessary as defined in WAC 182-500-0070.
(ii) Services not included in the categorically needy scope of services.
(iii) Services, other than a screening exam as described in WAC 182-538-100(3), received in a hospital emergency department for nonemergency medical conditions.
(b) For MCO enrollees:
(i) Services received from a participating specialist that require prior authorization from the MCO, but were not authorized by the MCO.
(ii) Services received from a nonparticipating provider that require prior authorization from the MCO that were not authorized by the MCO. All nonemergency services covered under the MCO contract and received from nonparticipating providers require prior authorization from the MCO.
(c) For PCCM enrollees, services that require a referral from the PCCM provider as described in the PCCM contract, but were not referred by the PCCM provider.
(5) A provider may bill an enrollee for noncovered services as described in subsection (4) of this section, if the requirements of WAC 182-502-0160 are met.
[Statutory Authority: RCW 41.05.021, 42 C.F.R. 438. WSR 13-02-010, § 182-538-095, filed 12/19/12, effective 2/1/13. WSR 11-14-075, recodified as § 182-538-095, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.09.522. WSR 08-15-110, § 388-538-095, filed 7/18/08, effective 8/18/08. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. WSR 06-24-036, § 388-538-095, filed 11/30/06, effective 1/1/07. Statutory Authority: RCW 74.08.090 and 74.09.522. WSR 06-03-081, § 388-538-095, 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, § 388-538-095, filed 12/8/04, effective 1/8/05. Statutory Authority: RCW 74.08.090, 74.09.522. WSR 03-18-109, § 388-538-095, 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, § 388-538-095, filed 12/14/01, effective 1/14/02. Statutory Authority: RCW 74.08.090. WSR 01-02-076, § 388-538-095, filed 12/29/00, effective 1/29/01. 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, § 388-538-095, 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, § 388-538-095, 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), § 388-538-095, filed 8/29/95, effective 9/1/95. Statutory Authority: RCW 74.08.090. WSR 93-17-039 (Order 3621), § 388-538-095, filed 8/11/93, effective 9/11/93.]