PERMANENT RULES
(Basic Health Plan)
Date of Adoption: March 18, 1999.
Purpose: Executive Order 97-02 requires that rules be reviewed for clarity. This revises rules for appealing a basic health or MHCS decision, to make them more understandable for basic health enrollees and to include additional detail.
Citation of Existing Rules Affected by this Order: Amending WAC 182-25-100, 182-25-105, and 182-25-110.
Statutory Authority for Adoption: RCW 70.47.050.
Adopted under notice filed as WSR 98-22-070 on November 3, 1998.
Changes Other than Editing from Proposed to Adopted Version: WAC 182-25-110(5) was revised for clarity and to add a timeline, in response to stakeholder input. Minor revisions to WAC 182-25-105 (4), (7)(a) and (10), for clarification, also in response to stakeholder input.
Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.
Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.
Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 3, Repealed 0.
Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 3, Repealed 0.
Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 3, Repealed 0. Effective Date of Rule: Thirty-one days after filing.
March 17, 1999
Bob Blacksmith
for Elin S. Meyer
Rules Coordinator
OTS-2635.4
AMENDATORY SECTION(Amending WSR 98-07-002, filed 3/5/98, effective 4/5/98)
WAC 182-25-100
((Appeals and mediation of grievances.)) Where to find
instructions for filing an appeal.
(((1) HCA decisions regarding basic health plan eligibility,
premium, enrollment, suspension, disenrollment or change of MHCS may be appealed pursuant
to WAC 182-25-105.
(2) The HCA will not hear appeals of decisions regarding children covered under BHP plus. Those decisions must be appealed through the department of social and health services, according to the provisions of chapters 388-08 and 388-526 WAC, as amended.
(3) Decisions made by a MHCS, such as coverage disputes or benefits interpretation may be appealed pursuant to WAC 182-25-110.)) (1) WAC 182-25-105 and 182-25-110 cover appeals submitted by or on behalf of basic health plan enrollees or applicants. To appeal a decision regarding a child enrolled in BHP plus or a woman receiving maternity benefits through medical assistance, subscribers must contact the Washington state department of social and health services (DSHS) to request a fair hearing under chapters 388-08 and 388-526 WAC.
(2) WAC 182-25-105 covers appeals of decisions made by the health care authority, such as decisions regarding basic health plan eligibility, premium, premium adjustments or penalties, enrollment, suspension, disenrollment, or a member's selection of managed health care system (MHCS). Decisions which affect an entire group (for example, the disenrollment of an employer group) should be appealed for the entire group by the employer, home care agency, or financial sponsor, using these same rules.
(3) WAC 182-25-110 covers appeals of decisions made by the enrollee's managed health care system (MHCS), such as decisions regarding coverage disputes or benefits interpretation. The term MHCS, which is defined in WAC 182-25-010(22), refers to the health plan or carrier that provides BHP coverage.
[Statutory Authority: RCW 70.47.050. 98-07-002, § 182-25-100, filed 3/5/98, effective 4/5/98; 96-15-024, § 182-25-100, filed 7/9/96, effective 8/9/96.]
(((1) If a subscriber or applicant wishes to appeal a HCA
decision regarding BHP eligibility, premium, enrollment, suspension, disenrollment or change of
MHCS, he/she must send a letter of appeal, signed by the appealing party, to the HCA appeals
committee no more than thirty days after the date the HCA's decision was sent to the subscriber
or applicant. The letter should include the name, address and BHP account number of the
enrollee and subscriber or the applicant and a statement of:
(a) The decision being appealed;
(b) Why the enrollee considers the decision to be incorrect; and
(c) The facts upon which the appeal is based, including any supporting documents.
(2) When the letter of appeal is received, the HCA appeals coordinator will contact the subscriber to explain his/her appeal rights and the appeal procedure used by the HCA appeals committee to conduct a brief adjudicative proceeding pursuant to RCW 34.05.482 through 34.05.494, as amended. Generally, the appeal will be limited to a review of submitted documents, but may also include a telephone or in-person conference. The HCA appeals committee will send its written initial decision to the subscriber or applicant within sixty days of receipt of the subscriber's or applicant's letter of appeal. The written initial decision will include reasons for the decision and information and instructions on further appeal rights. The appeals committee may also elect to convert the brief adjudicative proceeding to a formal adjudicative proceeding when it is more appropriate to resolve issues affecting the participants, and refer the appeal to the hearing officer.
(3) If the HCA appeals committee decision results in disenrollment, the enrollee may request a review hearing by the office of administrative hearings, pursuant to chapter 34.12 RCW and RCW 34.05.488 through 34.05.494, as amended. An enrollee or applicant may request review of all other initial decisions of the HCA appeals committee by a HCA hearings officer, pursuant to RCW 34.05.488 through 34.05.494, as amended. A request for review of the initial decision must be made in writing within twenty-one days after service of the written statement as required by RCW 34.05.485(3), as amended. Otherwise, the HCA appeals committee decision will be the final agency decision.
(4) An enrollee who has appealed a disenrollment decision will remain disenrolled pending the appeal decision, with the exception of enrollees who have filed a timely appeal of a disenrollment decision that was due to an issue of eligibility. In appeals of a disenrollment for ineligibility, the disenrollment will not become effective pending the appeal decision, provided:
(a) The enrollee otherwise remains eligible and continues to make all premium payments when due; and
(b) The enrollee has not demonstrated a risk to the safety or property of MHCS or health care authority staff, providers, patients or visitors.)) (1) Under this section, enrollees or applicants may file appeals of health care authority decisions regarding eligibility, premiums, premium adjustments or penalties, enrollment, suspension, disenrollment, or a member's selection of managed health care system (MHCS).
(2) To appeal a health care authority (HCA) decision, enrollees or applicants must send a letter of appeal to the HCA appeals committee. The letter of appeal must be signed by the appealing party and received by the HCA within thirty calendar days of the date of the decision. The letter of appeal must include:
(a) The name, mailing address, and BHP account number of the subscriber or applicant;
(b) The name and address of the enrollee or applicant affected by the decision, if that person is not the subscriber on the account;
(c) A copy of the HCA notice of the decision that is being appealed or, if the notice is not available, a statement of the decision being appealed; and
(d) A statement explaining why the appealing party believes the decision was incorrect, outlining the facts surrounding the decision and including supporting documentation.
(3) Upon receiving the letter of appeal, the HCA will send notification to the appealing party, confirming that the appeal has been received and indicating when a decision can be expected.
(4) The HCA will conduct appeals according to RCW 34.05.485. The HCA appeals committee or a hearings officer designated by the HCA will review and decide the appeal based on submitted documents unless the HCA and the appealing party agree to hold a hearing in person or by telephone.
(5) The HCA will send the appealing party written notification of the appeals committee's or hearings officer's initial decision within sixty days of receiving the letter of appeal. The notification will include the reasons for their initial decision, and instructions on further appeal rights.
(6) The initial decision of the appeals committee or hearings officer becomes the final decision unless the HCA receives a request for a review hearing from the appealing party within thirty days of the date of the decision. The appealing party may request review of the initial decision either verbally or in writing. The person requesting review must reference the initial decision and provide any additional written information that the appealing party would like considered in the review.
(a) If the appealing party requests a review of the appeals committee's or hearings officer's initial decision regarding a disenrollment, the office of administrative hearings will review the decision through a hearing conducted under chapter 34.12 RCW and RCW 34.05.488 through 34.05.494.
(b) If the appealing party requests a review of any decision of the appeals committee or hearings officer other than a disenrollment decision, a hearings officer designated by the HCA will review the decision through a hearing conducted under RCW 34.05.488 through 34.05.494.
(7) In a review under subsection (6)(a) or (b) of this section:
(a) The hearings officer will review and decide the appeal based on submitted documents unless the HCA and the appealing party agree to hold a hearing in person or by telephone.
(b) The review officer will make any inquiries necessary to determine whether the proceeding must become a formal adjudicative proceeding under the provisions of chapter 34.05 RCW.
(8) If an enrollee submits a timely appeal of a disenrollment decision that was based on eligibility issues and not related to premium payments, the enrollee will remain enrolled during the appeal process, provided the enrollee:
(a) Otherwise remains eligible;
(b) Continues to make all premium payments when due; and
(c) Has not demonstrated a danger or threat to the safety or property of the MHCS or health care authority or their staff, providers, patients or visitors.
(9) An enrollee who has appealed a disenrollment decision related to nonpayment of premium or any issue other than eligibility will remain disenrolled during the appeal process.
(10) If the appealing party disagrees with a review decision under subsection (6) of this section, the appealing party may request judicial review of the decision, as provided for in RCW 34.05.542. Request for judicial review must be filed with the court within thirty days of service of the final agency decision.
[Statutory Authority: RCW 70.47.050. 98-07-002, § 182-25-105, filed 3/5/98, effective 4/5/98; 96-15-024, § 182-25-105, filed 7/9/96, effective 8/9/96.]
(((1) Disputes arising between enrollees and the managed
health care system in which they are enrolled, such as coverage disputes or benefits
interpretation, are considered to be contractual disputes between those parties. Every MHCS is
required to maintain a grievance/appeals process for enrollees, providing for resolution by
MHCS personnel with authority to require corrective action, including but not limited to review
by appropriate medical personnel of complaints regarding quality of care or access to urgently
needed services. The MHCS will make available information on its grievance/appeals process
through its customer service department.
(2) The enrollee must exhaust the grievance/appeals process through the MHCS.
(a) If an issue is not resolved through that process within a reasonable time, or if the MHCS has not replied in writing to the enrollee within thirty days of receiving his/her written grievance/appeal, the enrollee may send a letter of appeal to the HCA appeals committee, requesting the HCA to inquire as to the status of the grievance/appeal. The HCA may initiate informal dispute resolution aimed at achieving a resolution satisfactory to the MHCS and the enrollee. In the event informal dispute resolution is unable to resolve the issue, the grievance/appeal will be reviewed by the HCA appeals committee.
(b) If the MHCS decision is not satisfactory to the enrollee, and the enrollee has not previously requested HCA assistance with the issue, the enrollee may send a letter of appeal to the HCA appeals committee. The letter of appeal must be received by the HCA no more than thirty days after the MHCS written notice of the decision is sent.
(3) When the letter of appeal is received, the HCA appeals coordinator will contact the subscriber to explain his/her appeal rights and the appeal procedure used by the HCA appeals committee to conduct a brief adjudicative proceeding pursuant to RCW 34.05.482 through 34.05.494, as amended. Generally, the appeal will be limited to a review of submitted documents, but may also include a telephone or in-person conference. The HCA appeals committee will send its written initial decision to both parties in the appeal, including the reasons for the decision, within sixty days of scheduling the appeal and, if the decision supports the MHCS position, will advise the enrollee of further appeal rights. The appeals committee may also elect to convert the brief adjudicative proceeding to a formal adjudicative proceeding when it is more appropriate to resolve issues affecting the participants, and refer the appeal to the hearing officer. A HCA appeals committee decision which differs from the MHCS decision shall prevail and the MHCS shall perform in accordance to the HCA appeals committee decision.
(4)(a) If the HCA appeals committee agrees with the MHCS decision, the enrollee may request review of the HCA appeals committee decision by the HCA hearings officer. This request for review of the decision must be received no more than twenty-one days after the date of the HCA appeals committee decision.
(b) If the decision of the HCA appeals committee disagrees with the MHCS decision, the MHCS may request a dispute hearing with the HCA administrator, according to the terms of the contract between the MHCS and the HCA.)) (1) Enrollees who are appealing a MHCS decision, including decisions related to coverage disputes, denial of claims, or benefits interpretation, must first appeal the decision through their MHCS's grievance/appeals process. Under this section, the HCA may review MHCS decisions that have been the subject of a MHCS grievance/appeal process.
(2) Each MHCS must maintain a grievance/appeals process for enrollees and must provide enrollees with instructions for filing a grievance or appeal. This grievance/appeals process must comply with HCA contract requirements for timeliness in responding to complaints, including procedures for an expedited review if the enrollee is urgently in need of medical care. In addition, the MHCS grievance/appeal process must include review of MHCS decisions by:
(a) MHCS personnel who have the authority to require corrective action; and
(b) Appropriate medical personnel, if the appeal includes complaints regarding quality of care or access to urgently needed services.
(3) An enrollee who has appealed a MHCS decision may ask the HCA to initiate informal dispute resolution in either of the following circumstances:
(a) The appeal has not been resolved within the timelines established by the MHCS grievance/appeal process or agreed to by the MHCS and the appealing party; or
(b) The enrollee has not received a response from the MHCS within thirty days of initiating the appeal. The response from the MHCS may be a decision or, if a delay of the appeal decision is necessary, it may be notification of a delay. If the decision has been delayed, the notice must include the reason for the delay and the date the enrollee can expect a decision from the MHCS. The HCA has the authority to determine if the delay is reasonable.
(i) If the HCA determines the delay to be unreasonable, the HCA will initiate informal dispute resolution.
(ii) If the HCA determines the delay to be reasonable, the HCA will not initiate informal dispute resolution unless the MHCS fails to issue a decision by the date indicated in the delay notice.
(4) Enrollees requesting informal dispute resolution must submit a written request to the HCA, which includes:
(a) The name, mailing address, and BHP account number of the subscriber;
(b) The name and address of the enrollee affected by the decision, if that person is not the subscriber on the account;
(c) A statement of the dispute and efforts to resolve it; and
(d) A statement, with facts and documentation, in support of the appealing party's opinion.
(5) When the HCA receives the request for informal dispute resolution, the HCA will notify the MHCS and will attempt to resolve the dispute. The HCA will notify the enrollee of the outcome of the informal dispute resolution or of the reason for a delay, within thirty days of receiving the request. If the issue has not been resolved to the satisfaction of the enrollee, the appealing party may ask the HCA appeals committee to review the MHCS decision. The request may be written or oral and must be received within thirty days of the date the HCA notifies the appealing party of the outcome of the informal dispute resolution. The appealing party may submit additional documentation with the request.
(6) Enrollees may appeal a final MHCS decision by sending a letter of appeal to the HCA appeals committee, asking for review of the final MHCS decision. The letter of appeal must be signed by the appealing party and received by the HCA within thirty days of the date of the final MHCS decision, and must include the information listed in subsection (4) of this section.
(7) The HCA will follow the procedures in WAC 182-25-105 (3) through (7) when conducting reviews of MHCS decisions. The MHCS must be given the opportunity to submit written comments or participate in any proceeding before the appeals committee or in any subsequent administrative review.
[Statutory Authority: RCW 70.47.050. 96-15-024, § 182-25-110, filed 7/9/96, effective 8/9/96.]