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Exemptions and ending enrollment in managed care.
(1) The agency exempts a client from mandatory enrollment in managed care or ends an enrollee's enrollment in managed care as specified in this section.
(2) A client or enrollee, or the client's or enrollee's representative as defined in RCW 7.70.065
, may request that the agency exempt or end enrollment in managed care as described in this section.
(a) If a client requests exemption prior to the enrollment effective date, the client is not enrolled until the agency approves or denies the request.
(b) If an enrollee requests to end enrollment, the enrollee remains enrolled pending the agency's final decision, unless staying in managed care would adversely affect the enrollee's health status.
(c) The client or enrollee receives timely notice by telephone or in writing when the agency approves or denies the client's or enrollee's request. The agency follows a telephone denial by written notification. The written notice contains all of the following:
(i) The action the agency intends to take;
(ii) The reason(s) for the intended action;
(iii) The specific rule or regulation supporting the action;
(iv) The client's or enrollee's right to request a hearing; and
(v) A translation into the client's or enrollee's primary language when the client or enrollee has limited English proficiency.
(3) A managed care organization (MCO) or primary care case management (PCCM) provider may request that the agency end enrollment. The request must be in writing and be sufficient to satisfy the agency that the enrollee's behavior is inconsistent with the MCO's or PCCM provider's rules and regulations (e.g., intentional misconduct). The agency does not approve a request to remove an enrollee from managed care when the request is solely due to an adverse change in the enrollee's health or the cost of meeting the enrollee's health care needs. The MCO or PCCM provider's request must include documentation that:
(a) The enrollee purposely put the safety and property of the contractor or the contractor's staff, providers, patients, or visitors at risk;
(b) The enrollee refused to follow procedures or treatment recommended by the enrollee's provider and determined by the contractor's medical director to be essential to the enrollee's health and safety and the enrollee has been told by the provider and/or the contractor's medical director that no other treatment is available;
(c) The enrollee engaged in intentional misconduct, including refusing to provide information to the contractor about third-party insurance coverage; or
(d) The MCO conducted a clinically appropriate evaluation to determine whether there was a treatable problem contributing to the enrollee's behavior and there was not a treatable problem or the enrollee refused to participate in treatment.
(e) The enrollee received written notice of the provider's intent to request the enrollee's removal, unless the agency has waived the requirement for provider notice because the enrollee's conduct presents the threat of imminent harm to others. The provider's notice must include:
(i) The enrollee's right to use the provider's grievance system as described in WAC 182-538-110
(ii) The enrollee's right to use the agency's hearing process, after the enrollee has exhausted all grievance and appeals available through the provider's grievance system (see WAC 182-538-110
for provider grievance systems, and WAC 182-526-0200
for the hearing process for enrollees).
(4) When the agency receives a request from an MCO or PCCM provider to remove an enrollee from enrollment in managed care, the agency attempts to contact the enrollee for the enrollee's perspective. If the agency approves the request, the agency sends a notice at least ten calendar days in advance of the effective date that enrollment will end. The notice includes:
(a) The reason the agency approved ending enrollment; and
(b) Information about the enrollee's hearing rights.
(5) The agency will exempt a client from mandatory enrollment or end an enrollee's enrollment in managed care when any of the following apply:
(a) The client has or the enrollee becomes eligible for medicare, CHAMPUS/TRICARE, or any other third-party health care coverage comparable to the agency's managed care coverage that would require exemption or involuntarily ending enrollment from:
(i) An MCO, in accordance with the agency's managed care contract; or
(ii) A primary care case management (PCCM) provider, according to the agency's PCCM contract.
(b) The enrollee is no longer eligible for managed care.
(6) The agency will grant a client's request for exemption or an enrollee's request to end enrollment when:
(a) The client or enrollee is American Indian or Alaska native (AI/AN) as specified in WAC 182-538-060
(b) The client or enrollee is homeless or is expected to live in temporary housing for less than one hundred twenty days from the date of the request.
(7) On a case-by-case basis, the agency will grant a client's request for exemption or an enrollee's request to end enrollment when, in the agency's judgment, the client or enrollee has a documented treatment plan for medically necessary care by a provider who is not available through any contracted MCO and enrollment would likely disrupt that treatment in such a way as to cause an interruption of treatment that could jeopardize the client's or enrollee's life or health or ability to attain, maintain, or regain maximum function.
(8) Upon request, the agency may exempt the client or end enrollment for the period of time the circumstances or conditions described in subsection (7) of this section are expected to exist. The agency may periodically review those circumstances or conditions to determine if they continue to exist. If the agency approves the request for a limited time, the client or enrollee is notified in writing or by telephone of the time limitation, the process for renewing the exemption or the ending of enrollment.
[Statutory Authority: RCW 41.05.021
, 42 C.F.R. 438. WSR 13-02-010, § 182-538-130, filed 12/19/12, effective 2/1/13. WSR 11-14-075, recodified as § 182-538-130, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090
. WSR 08-15-110, § 388-538-130, filed 7/18/08, effective 8/18/08; WSR 06-03-081, § 388-538-130, filed 1/12/06, effective 2/12/06; WSR 03-18-111, § 388-538-130, filed 9/2/03, effective 10/3/03. Statutory Authority: RCW 74.09.080
, [74.08.]522, 74.09.450
, 1115 Waiver, 42 U.S.C. 1396. WSR 02-01-075, § 388-538-130, filed 12/14/01, effective 1/14/02. Statutory Authority: RCW 74.08.090
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, § 388-538-130, filed 2/1/00, effective 3/3/00. Statutory Authority: RCW 74.04.050
. WSR 98-16-044, § 388-538-130, 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), § 388-538-130, filed 8/29/95, effective 9/1/95. Statutory Authority: RCW 74.08.090
. WSR 93-17-039 (Order 3621), § 388-538-130, filed 8/11/93, effective 9/11/93.]