Exemptions and ending enrollment in managed care.
(1) The agency exempts a client from enrollment or end enrollment from mandatory managed care when any of the following apply:
(a) The client has or the enrollee becomes eligible for medicare, TRICARE, or any other third-party health care coverage comparable to the agency's managed care coverage;
(b) The client or enrollee is not eligible for managed care enrollment, for Washington apple health programs, or both; or
(c) A request for exemption or to end enrollment is received and approved by the agency as described in this section.
(i) If a client requests exemption within the notice period stated in WAC 182-538-060
, the client is not enrolled until the agency approves or denies the request.
(ii) If an enrollee request to end enrollment is received after the enrollment effective date, the enrollee remains enrolled pending the agency's decision, unless continued enrollment creates loss of access to providers of medically necessary care.
(2)(a) The following people may request that the agency exempt or end enrollment in managed care as described in this section:
(i) A client or enrollee;
(ii) A client or enrollee's authorized representative under WAC 182-503-0130
(iii) A client or enrollee's representative as defined in RCW 7.70.065
(b) The agency grants a request to exempt or end enrollment in managed care when the client or enrollee:
(i) Is American Indian or Alaska native;
(ii) Lives in an area or is enrolled in a Washington apple health program in which participation in managed care is voluntary; or
(iii) Requires care that meets the criteria in subsection (3) of this section for case-by-case clinical exemptions or ending of enrollment.
(3) Case-by-case clinical exemption for ending of enrollment.
(a) The following criteria must be met:
(i) The care must be medically necessary;
(ii) That medically necessary care is covered under the agency's managed care contracts;
(iii) The client is receiving the medically necessary care from an established provider or providers who is not available through any contracted MCO; and
(iv) It is medically necessary to continue that care from the established provider or providers.
(b) When the agency approves a request for exemption or ending enrollment, the agency will notify the client or enrollee of its decision by telephone or in writing. If the agency approves the request for a limited time, the client or enrollee is notified of the time limitation and the process for renewing the exemption or the ending of enrollment.
(c) When the agency denies a request for exemption or ending enrollment, the agency will notify the client or enrollee of its decision by telephone or in writing and confirms a telephone notification in writing. When a client or enrollee is limited-English proficient, the written notice must be available in the client's or enrollee's primary language under 42 C.F.R. 438.10. The written notice must contain all the following information:
(i) The agency's decision;
(ii) The reason for the decision;
(iii) The specific rule or regulation supporting the decision; and
(iv) The right to request an agency administrative hearing.
(4)(a) If a client or enrollee does not agree with the agency's decision regarding a request for exemption or to end enrollment, the client or enrollee may file a request for an agency administrative hearing based on RCW 74.09.741
, the rules in this chapter, and the agency hearing rules in chapter 182-526
(b) A client seeking to remain unenrolled who appeals an agency denial retains that status pending the appeal if the appeal is filed within the time frames required in WAC 182-504-0130
(5) The agency will grant a request from an MCO to remove an enrollee from enrollment on a case-by-case basis when the request is submitted to the agency in writing and includes sufficient documentation for the agency to determine that the criteria for ending enrollment in this subsection is met.
(a) All of the following criteria must be met to end enrollment:
(i) The enrollee puts the safety or property of the contractor or the contractor's staff, providers, patients, or visitors at risk and the enrollee's conduct presents the threat of imminent harm to others, except for enrollees described in (c) of this subsection;
(ii) A clinically appropriate evaluation was conducted 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;
(iii) The enrollee's health care needs have been coordinated as contractually required and the safety concerns cannot be addressed; and
(iv) The enrollee has received written notice from the MCO of its intent to request the enrollee's termination of enrollment, unless the requirement for notification has been waived by the agency because the enrollee's conduct presents the threat of imminent harm to others. The MCO's notice to the enrollee includes the enrollee's right to use the MCO's grievance process to review the request to end the enrollee's enrollment.
(b) The agency will not approve a request to end enrollment when the request is solely due to any of the following:
(i) An adverse change in the enrollee's health status;
(ii) The cost of meeting the enrollee's health care needs or because of the enrollee's utilization of services;
(iii) The enrollee's diminished mental capacity; or
(iv) Uncooperative or disruptive behavior resulting from the enrollee's special needs or behavioral health condition, except when continued enrollment in the MCO or PCCM seriously impairs the entity's ability to furnish services to either this particular enrollee or other enrollees.
(c) When the agency receives a request from an MCO to remove an enrollee from enrollment in managed care, the agency reviews each request on a case-by-case basis. The agency will respond to the MCO in writing with the decision. If the agency grants the request to end enrollment:
(i) The MCO will notify the enrollee in writing of the decision. The notice must include:
(A) The enrollee's right to use the MCO's grievance system as described in WAC 182-538-110
(B) The enrollee's right to use the agency's hearing process (see WAC 182-526-0200
for the hearing process for enrollees).
(ii) The agency will send a written notice to the enrollee at least ten calendar days in advance of the effective date that enrollment will end. The notice to the enrollee includes the information in subsection (3)(c) of this section.
(d) The MCO will continue to provide services to the enrollee until the date the individual is no longer enrolled.
(6) The agency may exempt the client for the period of time the circumstances or conditions described in this section are expected to exist. The agency may periodically review those circumstances or conditions to determine if they continue to exist. Any authorized exemption or ending of enrollment will continue only until the client can be enrolled in managed care.
[Statutory Authority: RCW 41.05.021
. WSR 15-24-098, § 182-538-130, filed 12/1/15, effective 1/1/16. 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.]