(1) To be a participant in the chronic care management program, a client must:
(a) Be a recipient of the supplemental security income (SSI) program or general assistance with expedited medical categorically needy (GAX) program;
(b) Be identified through predictive modeling as being high risk for high medical costs as a result of needing medical treatment for multiple conditions; and
(c) Agree to participate in the program.
(2) A client participating in the chronic care management program must not be:
(a) Receiving medicare benefits;
(b) Residing in an institution, as defined in WAC 388-500-0005
, for more than thirty days;
(c) Eligible for third party coverage that provides care management services or requires administrative controls that would duplicate or interfere with the department's chronic care management program;
(d) Enrolled with a managed care organization (MCO) plan contracted with DSHS;
(e) Currently receiving long term care services; or
(f) Receiving case management services that chronic care management program services would duplicate.
(3) Using data provided by DSHS, the statewide care management (SCM) contractor identifies medical assistance clients who are potential participants for chronic care management program services. A client who meets the participation requirements in this section:
(a) Will be served by the SCM program or a local care management (LCM) program, based on the geographical area of the state the client resides.
(b) Will be contacted by an SCM or LCM care manager for an assessment and enrollment in the program;
(c) Will not be enrolled unless the client specifically agrees to the enrollment;
(d) May request disenrollment at any time. Disenrollment is effective the first day of the following month; and
(e) May request reenrollment at any time. Reenrollment is effective the first day of the following month.
(4) A participating client who subsequently enrolls in a DSHS voluntary managed care program is no longer eligible for chronic care management program services.
(5) A client who meets the eligibility and enrollment criteria for participation in the chronic care management services program:
(a) Is eligible to participate for six months from the date of enrollment provided the client continues to meet eligibility and enrollment criteria; and
(b) May participate for additional six-month participation periods if both the department and the SCM or LCM contractor determine that the participant's self-management skills and health care outcome would benefit.
(6) A client who does not agree with a decision regarding chronic care management program services has a right to a hearing under chapter 388-02
[11-14-075, recodified as § 182-557-0200, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500, 74.09.520, and 2007 c 259, § 4. 07-20-048, § 388-557-0200, filed 9/26/07, effective 11/1/07.]