(1) To participate in the health home program, a beneficiary must:
(a) Be a recipient of categorically needy health care coverage; or
(b) A full dual eligible; and
(i) Have one or more chronic condition(s) as defined in WAC 182-557-0100
and at risk of developing another as determined by a PRISM risk score of 1.5 or greater; and
(ii) Agree to participate in a health home program.
(2) A beneficiary participating in the health home program must not be:
(a) Eligible for third-party coverage that provides comparable care management services or requires administrative controls that would duplicate or interfere with the agency's health home program; or
(b) Receiving services through another health system that health home services would duplicate.
(3) Using data provided by the department of social and health services (DSHS), the agency identifies beneficiaries who are potential participants of health home services.
(a) Beneficiaries who are eligible for health homes will be enrolled with a qualified health home; and
(b) May decline enrollment or change to a different plan if he or she chooses to.
(4) A beneficiary who meets the participation requirements in this section will:
(a) Receive services from a qualified health home that contracts with the agency to provide health home services in the coverage area in which the beneficiary resides;
(b) Work with a care coordinator employed by or contracting with a qualified health home provider to develop a health action plan that details the beneficiary's health goals and a plan for achievement of those goals; and
(c) Receive additional health home services at a level appropriate to the beneficiary's needs.
(5) A participant who does not agree with a decision regarding health home services, including a decision regarding the beneficiary's eligibility to participate in health home services, has the right to an administrative hearing as described in chapter 182-526
[Statutory Authority: RCW 41.05.021
and 2011 c 316. WSR 13-12-002, § 182-557-0200, filed 5/22/13, effective 7/1/13. WSR 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. WSR 07-20-048, § 388-557-0200, filed 9/26/07, effective 11/1/07.]