(1) DSHS enrolls a medicaid recipient in a mental health prepaid inpatient health plan when the person resides in the contracted service area of the prepaid inpatient health plan. The assigned prepaid inpatient health plan is responsible to provide outpatient medically necessary state medicaid plan approved services to medicaid service recipients in the contracted service area and to assure inpatient medically necessary state medicaid plan approved services are received;
(2) An enrolled medicaid service recipient who requests or receives medically necessary nonemergency community mental health rehabilitation services may request and receive such service from the assigned mental health prepaid inpatient health plan through authorized providers only;
(3) An enrolled medicaid service recipient is automatically transferred from the assigned prepaid inpatient health plan when the recipient moves from the contracted service area of one mental health prepaid inpatient health plan to the contracted service area of another;
(4) Services to medicaid recipients may be provided through alternative means if currently contracted authorized providers are not able to provide those services when:
(a) The services are state medicaid plan approved services and are medically necessary for the medicaid service recipient; and
(b) Services are or should be available to other medicaid service recipients in the local mental health prepaid inpatient health plan; and
(c) The medicaid service recipient has made reasonable attempts to utilize services through authorized providers; or
(d) The medicaid service recipient has received a choice of providers and has made an informed decision to request medically necessary services through a provider outside the prepaid inpatient health plan provider network that has cultural or linguistic expertise or both needed to meet medical necessity that are not sufficient within the provider network; or
(e) The medicaid service recipient has utilized the prepaid inpatient health plan grievance or appeal process and the state administrative hearing process, and a decision has been made in favor of the medicaid service recipient that medicaid plan approved services continue to be medically necessary.
[Statutory Authority: RCW 71.24.035. 05-17-154, § 388-865-0335, filed 8/22/05, effective 9/22/05. Statutory Authority: RCW 71.05.560, 71.24.035 (5)(c), 71.34.800,9.41.047 , 43.20B.020, and 43.20B.335. 01-12-047, § 388-865-0335, filed 5/31/01, effective 7/1/01.]