HEALTH CARE AUTHORITY

The following terms and definitions and those found in chapter 182-500 WAC apply to this chapter:

Action - For the purposes of this chapter, means one or more of the following:

(a) The denial of eligibility for health home services.

(b) The denial or limited authorization by the qualified health home of a requested health home service, including a type or level of health home service.

(c) The reduction, suspension, or termination by the qualified health home of a previously authorized health home service.

(d) The failure of a qualified health home to provide authorized health home services or provide health home services as quickly as the participant's condition requires.

Agency - See WAC 182-500-0010.

Chronic condition - Means mental health conditions, substance use disorders, asthma, diabetes, heart disease, cancer, cerebrovascular disease, coronary artery disease, dementia or Alzheimer's disease, intellectual disability, HIV/AIDS, renal failure, chronic respiratory conditions, neurological disease, gastrointestinal, hematological, and musculoskeletal conditions.

Client - For the purposes of this chapter, means a person who is eligible to receive health home services under this chapter.

Clinical eligibility tool - Means an electronic spreadsheet that determines a client's risk score using the client's age, gender, diagnoses, and medications.

Coverage area - Means a geographical area composed of one or more counties within Washington state. The map of the coverage areas and the list of the qualified health homes is ((available on the agency's web site at: http://www.hca.wa.gov/medicaid/health_homes/Pages/index.aspx)) located at https://www.hca.wa.gov/billers-providers/programs-and-services/health-homes.

Fee-for-service (FFS) - See WAC 182-500-0035.

Full dual eligible - For the purpose of this chapter, means a fee-for-service client who receives qualified medicare beneficiary coverage or specified low-income medicare beneficiary coverage and categorically needy health care coverage.

Grievance - Means an expression of a participant's dissatisfaction about any matter other than an action. Possible subjects for grievances include the quality of health home services provided when an employee of a qualified health home provider is rude to the participant or shares confidential information about the participant without their permission.

Health action plan - Means a plan that lists the participant's goals to improve and self-manage their health conditions and steps needed to reach those goals.

Health home care coordinator - Means staff employed by or subcontracted by the qualified health home to provide one or more of the six defined health home care coordination benefits listed in WAC 182-557-0050.

Health home services - Means services described in WAC 182-557-0050 (2)(a) through (f).

Medicaid - See WAC 182-500-0070.

Participant - Means a client who has agreed to receive health home services under the requirements of this chapter.

Qualified health home - Means an organization that contracts with the agency to provide health home services to participants in one or more coverage areas and meets the requirements in WAC 182-557-0050(4).

Risk score - Means a measure of the expected costs of the health care a client is likely to incur in the next twelve months that the agency calculates using an algorithm developed by the department of social and health services (DSHS) or the clinical eligibility tool.

(1) To be eligible for the health home program, a client must:

(a) Be a recipient of categorically needy health care coverage through:

(i) Fee-for-service, including full dual eligible clients; or

(ii) An agency-contracted managed care organization.

(b) Have one or more chronic conditions as defined in WAC 182-557-0100; and

(c) Have a risk score of 1.5 or greater measured either with algorithms developed by the department of social and health services or the agency's clinical eligibility tool located ((on the agency's web site at http://www.hca.wa.gov/Pages/health_homes.aspx; and

(d) Agree to participate in a health home program)) at https://www.hca.wa.gov/assets/billers-and-providers/Clinical_Eligibility_Tool.xls.

(2) A person is ineligible to receive health home services when:

(a) The person has third-party coverage that provides comparable health care services((.

(3) When the agency determines a client is eligible for health home services, the agency enrolls the client with a qualified health home in the coverage area where the client lives.

(a) The client may decline health home services or change to a different qualified health home or a different health home care coordinator.

(b) If the client ((accepts enrollment)) chooses to participate in the health home program, a health home care coordinator will:

(i) Work with the participant to develop a health action plan that describes the participant's health goals and includes a plan for reaching those goals; and

(ii) Provide health home services at a level appropriate to the participant's needs.

(((5))) (4) A participant who does not agree with a decision regarding health home services, including a decision regarding the client's eligibility to receive health home services, has the right to an administrative hearing as described in chapter 182-526 WAC.

The agency uses eight steps to calculate a person's risk score.

(1) Step 1. Collect paid claims and health plan encounter data. The agency obtains a set of paid fee-for-service claims and managed care encounters for a client.

(a) For clients age seventeen and younger, the agency uses all paid claims and encounters within the last twenty-four months.

(b) For clients age eighteen and older, the agency uses all paid claims and encounters within the last fifteen months.

(i) The claims and encounters include the international classification of diseases (ICD) diagnosis codes and national drug codes (NDC) submitted by health care providers. These are used in steps 2 and 3 to create a set of risk categories.

(ii) The agency uses two algorithms developed by the University of San Diego:

(A) Chronic illness and disability payment system (CDPS) which assigns ICD diagnosis codes to CDPS risk categories (see Table ((6)) 3 in ((Steps to Calculate a Medical Expenditure Risk Score located at http://www.hca.wa.gov/medicaid/health_homes/Documents/calculate_medical_expenditure_risk.pdf)) subsection (5)(b) of this section); and

(B) Medical Rx (MRx) which assigns NDCs to MRx risk categories (see Table ((7)) 2 in ((Steps to Calculate a Medical Expenditure Risk Score located at http://www.hca.wa.gov/medicaid/health_homes/Documents/calculate_medical_expenditure_risk.pdf)) subsection (3)(b) of this section).

(2) Step 2. Group ICD diagnosis codes into chronic illness and disability payment system risk categories.

(a) To group ICD diagnosis codes into the CDPS risk categories (see Table 1 in (b) of this subsection), the agency uses an ICD diagnosis code to CDPS risk categories crosswalk in subsection (1)(b)(ii)(A) of this section. Each of the ICD diagnosis codes listed is assigned to one risk category. If an ICD diagnosis code is not listed in the crosswalk it does not map to a risk category that is used in the calculation of the risk score.

(b) Table 1. Titles of Chronic Illness and Disability Payment System Risk Categories

(3) Step 3. Group national drug codes (NDCs) into MRx risk categories.

(a) To group the NDC codes into MRx risk categories (see Table 2 in (b) of this subsection), the agency uses a NDC code to MRx risk categories crosswalk in subsection (1)(b)(ii)(B) of this section.

(b) Table 2. Titles of Medicaid Rx Risk Categories

(4) Step 4. Remove duplicate risk categories. After mapping all diagnosis and drug codes to the risk categories, the agency eliminates duplicates of each client's risk categories so that there is only one occurrence of any risk category for each client.

(5) Step 5. Select the highest CDPS risk category within a disease group.

(a) The agency organizes CPDS risk categories into risk category groups of different intensity levels. The high risk category in each group is used in the calculation of the risk score. The lower level risk categories are eliminated from further calculations.

(b) Table 3. Chronic Disease Payment System Risk Category Groups

(6) Step 6. Determine age/gender category.

(a) For each client, the agency selects the appropriate age/gender category. The eleven categories are listed in Table 4 in (b) of this subsection. The categories for ages below five and above sixty-five are gender neutral.

(b) Table 4. Age/Gender Categories

(7) Step 7. Apply risk weights.

(a) The agency assigns each risk category and age/gender category a weight. The weight comes from either the model for clients who are age seventeen and younger or from the model for clients age eighteen and older.

(b) In each model there are three types of weights.

(i) Age/gender – Weights that correspond to the age/gender category of a client.

(ii) CDPS – Weights that correspond to fifty-eight of the CDPS risk categories.

(iii) MRx – Weights that correspond to forty-five of the MRx risk categories.

(c) Table 5. Risk Score Weights

(8) Step 8. Sum risk weights to obtain the risk score.

After obtaining the weights that correspond to a client's age/gender category and set of risk categories, the agency takes a sum of the values of all of the weights. This sum is the risk score for a client.