HTML has links - PDF has Authentication

Chapter 182-557 WAC

Last Update: 12/6/17

HEALTH HOMES

WAC Sections

HTMLPDF182-557-0050Health home—General.
HTMLPDF182-557-0100Health home program—Definitions.
HTMLPDF182-557-0200Health home program—Eligibility.
HTMLPDF182-557-0225Health home services—Methodology for calculating a person's risk score.
HTMLPDF182-557-0300Health home services—Confidentiality and data sharing.
HTMLPDF182-557-0350Health home—Grievance and appeals.
HTMLPDF182-557-0400Health home—Payment.


PDF182-557-0050

Health homeGeneral.

(1) The agency's health home program provides patient-centered care to participants who:
(a) Have at least one chronic condition as defined in WAC 182-557-0100; and
(b) Are at risk of a second chronic condition as evidenced by a minimum predictive risk score of 1.5.
(2) The health home program offers six care coordination activities to assist participants in self-managing their conditions and navigating the health care system:
(a) Comprehensive or intensive care management including, but not limited to, assessing participant's readiness for self-management, promoting self-management skills, coordinating interventions tailored to meet the participant's needs, and facilitating improved outcomes and appropriate use of health care services;
(b) Care coordination and health promotion;
(c) Comprehensive transitional care between care settings including, but not limited to, after discharge from an inpatient facility (hospital, rehabilitative, psychiatric, skilled nursing, substance use disorder treatment or residential habilitation setting);
(d) Individual and family support services to provide health promotion, education, training and coordination of covered services for participants and their support network;
(e) Referrals to community and support services; and
(f) Use of health information technology (HIT) to link services between the health home and participants' providers.
(3) The agency's health home program does not:
(a) Change the scope of services for which a participant is eligible under medicare or a Title XIX medicaid program;
(b) Interfere with the relationship between a participant and his or her chosen agency-enrolled provider(s);
(c) Duplicate case management activities the participant is receiving from other providers or programs; or
(d) Substitute for established activities that are available through other programs administered by the agency or other state agencies.
(4) Qualified health home providers must:
(a) Contract with the agency to provide services under this chapter to eligible participants;
(b) Accept the terms and conditions in the agency's contract;
(c) Be able to meet the network and quality standards established by the agency;
(d) Accept the rates established by the agency; and
(e) Comply with all applicable state and federal requirements.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-17-065, § 182-557-0050, filed 8/14/15, effective 9/14/15. Statutory Authority: RCW 41.05.021. WSR 13-21-048, § 182-557-0050, filed 10/11/13, effective 11/11/13. Statutory Authority: RCW 41.05.021 and 2011 c 316. WSR 13-12-002, § 182-557-0050, filed 5/22/13, effective 7/1/13. WSR 11-14-075, recodified as § 182-557-0050, 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, § 388-557-0050, filed 9/26/07, effective 11/1/07.]



PDF182-557-0100

Health home programDefinitions.

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 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.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-24-111, § 182-557-0100, filed 12/6/17, effective 1/6/18; WSR 15-17-065, § 182-557-0100, filed 8/14/15, effective 9/14/15. Statutory Authority: RCW 41.05.021 and 2011 c 316. WSR 13-12-002, § 182-557-0100, filed 5/22/13, effective 7/1/13. WSR 11-14-075, recodified as § 182-557-0100, 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, § 388-557-0100, filed 9/26/07, effective 11/1/07.]



PDF182-557-0200

Health home programEligibility.

(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 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; or
(b) The person has a risk score of less than 1.0 for six consecutive months and has not received health home 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 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.
(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.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-24-111, § 182-557-0200, filed 12/6/17, effective 1/6/18; WSR 15-17-065, § 182-557-0200, filed 8/14/15, effective 9/14/15. 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.]



PDF182-557-0225

Health home servicesMethodology for calculating a person's risk score.

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 3 in subsection (5)(b) of this section); and
(B) Medical Rx (MRx) which assigns NDCs to MRx risk categories (see Table 2 in 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
CARVH
Cardiovascular, very high
CARM
Cardiovascular, medium
CARL
Cardiovascular, low
CAREL
Cardiovascular, extra low
PSYH
Psychiatric, high
PSYM
Psychiatric, medium
PSYML
Psychiatric, medium low
PSYL
Psychiatric, low
SKCM
Skeletal, medium
SKCL
Skeletal, low
SKCVL
Skeletal, very low
CNSH
Central Nervous System, high
CNSM
Central Nervous System, medium
CNSL
Central Nervous System, low
PULVH
Pulmonary, very high
PULH
Pulmonary, high
PULM
Pulmonary, medium
PULL
Pulmonary, low
GIH
Gastro, high
GIM
Gastro, medium
GIL
Gastro, low
DIA1H
Diabetes, type 1 high
DIA1M
Diabetes, type 1 medium
DIA2M
Diabetes, type 2 medium
DIA2L
Diabetes, type 2 low
SKNH
Skin, high
SKNL
Skin, low
SKNVL
Skin, very low
RENEH
Renal, extra high
RENVH
Renal, very high
RENM
Renal, medium
RENL
Renal, low
SUBL
Substance abuse, low
SUBVL
Substance abuse, very low
CANVH
Cancer, very high
CANH
Cancer, high
CANM
Cancer, medium
CANL
Cancer, low
DDM
Developmental Disability, medium
DDL
Developmental Disability, low
GENEL
Genital, extra low
METH
Metabolic, high
METM
Metabolic, medium
METVL
Metabolic, very low
PRGCMP
Pregnancy, complete
PRGINC
Pregnancy, incomplete
EYEL
Eye, low
EYEVL
Eye, very low
CERL
Cerebrovascular, low
AIDSH
AIDS, high
INFH
Infectious, high
HIVM
HIV, medium
INFM
Infectious, medium
INFL
Infectious, low
HEMEH
Hematological, extra high
HEMVH
Hematological, very high
HEMM
Hematological, medium
HEML
Hematological, low
(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
MRx1
Alcoholism
MRx2
Alzheimer's
MRx3
Anti-coagulants
MRx4
Asthma/COPD
MRx5
Attention Deficit
MRx6
Burns
MRx7
Cardiac
MRx8
Cystic Fibrosis
MRx9
Depression/Anxiety
MRx10
Diabetes
MRx11
EENT
MRx12
ESRD/Renal
MRx13
Folate Deficiency
MRx14
CMV Retinitis
MRx15
Gastric Acid Disorder
MRx16
Glaucoma
MRx17
Gout
MRx18
Growth Hormone
MRx19
Hemophilia/von Willebrands
MRx20
Hepatitis
MRx21
Herpes
MRx22
HIV
MRx23
Hyperlipidemia
MRx24
Infections, high
MRx25
Infections, medium
MRx26
Infections, low
MRx27
Inflammatory/Autoimmune
MRx28
Insomnia
MRx29
Iron Deficiency
MRx30
Irrigating Solution
MRx31
Liver Disease
MRx32
Malignancies
MRx33
Multiple Sclerosis/Paralysis
MRx34
Nausea
MRx35
Neurogenic Bladder
MRx36
Osteoporosis/Pagets
MRx37
Pain
MRx38
Parkinsons/Tremor
MRx39
Prenatal Care
MRx40
Psychotic Illness/Bipolar
MRx41
Replacement Solution
MRx42
Seizure Disorders
MRx43
Thyroid Disorder
MRx44
Transplant
MRx45
Tuberculosis
(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
Group Description
Risk Categories (Ordered Highest to Lowest Intensity)
AIDS/HIV and Infection
AIDSH, INFH, HIVM, INFM, INFL
Cancer
CANVH, CANH, CANM, CANL
Cardiovascular
CARVH, CARM, CARL, CAREL
Central Nervous System
CNSH, CNSM, CNSL
Diabetes
DIA1H, DIA1M, DIA2M, DIA2L
Developmental Disability
DDM, DDL
Eye
EYEL, EYEVL
Gastrointestinal
GIH, GIM, GIL
Hematological
HEMEH, HEMVH, HEMM, HEML
Metabolic
METH, METM, METVL
Pregnancy
PRGCMP, PRGINC
Psychiatric
PSYH, PSYM, PSYML, PSYL
Substance Abuse
SUBL, SUBVL
Pulmonary
PULVH, PULH, PULM, PULL
Renal
RENEH, RENVH, RENM, RENL
Skeletal
SKCM, SKCL, SKCVL
Skin
SKNH, SKNL, SKNVL
(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
Age
Gender
 
Age <1
 
 
 
Age 1 to 4
 
 
 
Age 5 to 14
 
Male
 
Age 5 to 14
 
Female
 
Age 15 to 24
 
Male
 
Age 15 to 24
 
Female
 
Age 25 to 44
 
Male
 
Age 25 to 44
 
Female
 
Age 45 to 64
 
Male
 
Age 45 to 64
 
Female
 
Age 65+
 
 
(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
Category Type
Category
Description
Weights for Children
(age <18)
Weights for Adults
(age 18+)
Age/Gender
Age <1
Clients of age less than 1
0.40671
0.00000
 
Age 1 to 4
Clients age 1 to 4
0.40671
0.00000
 
Age 5 to 14, Male
Male clients age 5 to 14
0.28867
0.00000
 
Age 5 to 14, Female
Female clients age 5 to 14
0.29441
0.00000
 
Age 15 to 24, Male
Male clients age 15 to 24
0.22630
-0.01629
 
Age 15 to 24, Female
Female clients age 15 to 24
0.26930
0.03640
 
Age 25 to 44, Male
Male clients age 25 to 44
0.00000
0.04374
 
Age 25 to 44, Female
Female clients age 25 to 44
0.00000
0.06923
 
Age 45 to 64, Male
Male clients age 45 to 64
0.00000
0.13321
 
Age 45 to 64, Female
Female clients age 45 to 64
0.00000
0.06841
 
Age 65+
Clients age 65 and older
0.00000
-0.05623
CDPS
CARVH
Cardiovascular, very high
0.53941
2.86702
 
CARM
Cardiovascular, medium
0.23927
0.73492
 
CARL
Cardiovascular, low
0.18510
0.24620
 
CAREL
Cardiovascular, extra low
0.06589
0.06225
 
PSYH
Psychiatric, high
0.47759
0.27085
 
PSYM
Psychiatric, medium
0.31301
0.00000
 
PSYML
Psychiatric, medium low
0.16307
0.00000
 
PSYL
Psychiatric, low
0.10344
0.00000
 
SKCM
Skeletal, medium
0.23477
0.42212
 
SKCL
Skeletal, low
0.10630
0.15467
 
SKCVL
Skeletal, very low
0.07873
0.06773
 
CNSH
Central Nervous System, high
0.30440
0.78090
 
CNSM
Central Nervous System, medium
0.34386
0.40886
 
CNSL
Central Nervous System, low
0.16334
0.18261
 
PULVH
Pulmonary, very high
1.28955
4.01723
 
PULH
Pulmonary, high
0.67772
0.39309
 
PULM
Pulmonary, medium
0.39768
0.31774
 
PULL
Pulmonary, low
0.14708
0.13017
 
GIH
Gastro, high
0.78046
1.34924
 
GIM
Gastro, medium
0.29755
0.24372
 
GIL
Gastro, low
0.14579
0.05104
 
DIA1H
Diabetes, type 1 high
0.31680
1.04302
 
DIA1M
Diabetes, type 1 medium
0.31680
0.23620
 
DIA2M
Diabetes, type 2 medium
0.16101
0.17581
 
DIA2L
Diabetes, type 2 low
0.16101
0.09635
 
SKNH
Skin, high
0.49898
0.37981
 
SKNL
Skin, low
0.25185
0.45155
 
SKNVL
Skin, very low
0.07523
0.02119
 
RENEH
Renal, extra high
2.43609
3.41999
 
RENVH
Renal, very high
0.93888
0.69251
 
RENM
Renal, medium
0.33261
0.92846
 
RENL
Renal, low
0.17492
0.17220
 
SUBL
Substance Abuse, low
0.27104
0.16104
 
SUBVL
Substance Abuse, very low
0.04493
0.08784
 
CANVH
Cancer, very high
1.31064
2.80074
 
CANH
Cancer, high
0.57909
0.97173
 
CANM
Cancer, medium
0.29642
0.38022
 
CANL
Cancer, low
0.15058
0.22625
 
DDM
Developmental Disability, medium
0.31414
0.27818
 
DDL
Developmental Disability, low
0.11095
0.05913
 
GENEL
Genital, extra low
0.02242
0.01121
 
METH
Metabolic, high
0.51575
0.47226
 
METM
Metabolic, medium
0.33856
0.11310
 
METVL
Metabolic, very low
0.14658
0.18678
 
PRGCMP
Pregnancy, complete
0.00000
0.00000
 
PRGINC
Pregnancy, incomplete
0.17563
0.51636
 
EYEL
Eye, low
0.11538
0.13271
 
EYEVL
Eye, very low
0.04094
0.00000
 
CERL
Cerebrovascular, low
0.10623
0.00000
 
AIDSH
AIDS, high
0.91357
0.47361
 
INFH
Infectious, high
0.91357
0.79689
 
HIVM
HIV, medium
0.60245
0.07937
 
INFM
Infectious, medium
0.41047
0.79689
 
INFL
Infectious, low
0.15311
0.05617
 
HEMEH
Hematological, extra high
2.80021
12.71981
 
HEMVH
Hematological, very high
0.97895
3.08836
 
HEMM
Hematological, medium
0.46032
0.63211
 
HEML
Hematological, low
0.17762
0.25601
MRx
MRx1
Alcoholism
0.11051
0.01924
 
MRx2
Alzheimer's
0.00000
0.08112
 
MRx3
Anti-coagulants
0.31281
0.13523
 
MRx4
Asthma/COPD
0.09825
0.05751
 
MRx5
Attention Deficit
0.00000
0.00779
 
MRx6
Burns
0.13977
0.00000
 
MRx7
Cardiac
0.09177
0.06425
 
MRx8
Cystic Fibrosis
0.48222
0.37265
 
MRx9
Depression/Anxiety
0.07013
0.09436
 
MRx10
Diabetes
0.16852
0.17046
 
MRx11
EENT
0.00000
0.00072
 
MRx12
ESRD/Renal
1.32358
1.20707
 
MRx13
Folate Deficiency
0.17618
0.11899
 
MRx14
CMV Retinitis
0.41138
0.00000
 
MRx15
Gastric Acid Disorder
0.11001
0.15470
 
MRx16
Glaucoma
0.03738
0.12971
 
MRx17
Gout
0.00000
0.00000
 
MRx18
Growth Hormone
0.97620
1.59521
 
MRx19
Hemophilia/von Willebrands
11.68858
89.14461
 
MRx20
Hepatitis
0.16213
0.00000
 
MRx21
Herpes
0.04497
0.01725
 
MRx22
HIV
0.69702
1.01178
 
MRx23
Hyperlipidemia
0.00000
0.03791
 
MRx24
Infections, high
1.23096
1.51663
 
MRx25
Infections, medium
0.07841
0.06192
 
MRx26
Infections, low
0.00000
0.00918
 
MRx27
Inflammatory/Autoimmune
0.09058
0.20046
 
MRx28
Insomnia
0.08510
0.06437
 
MRx29
Iron Deficiency
0.12948
0.15054
 
MRx30
Irrigating Solution
0.64194
0.16387
 
MRx31
Liver Disease
0.34084
0.22681
 
MRx32
Malignancies
0.36730
0.44200
 
MRx33
Multiple Sclerosis/Paralysis
0.03542
0.04353
 
MRx34
Nausea
0.16101
0.17120
 
MRx35
Neurogenic Bladder
0.13864
0.07675
 
MRx36
Osteoporosis/Pagets
0.00000
0.00000
 
MRx37
Pain
0.04154
0.04151
 
MRx38
Parkinsons/Tremor
0.17179
0.06257
 
MRx39
Prenatal Care
0.00000
0.13192
 
MRx40
Psychotic Illness/Bipolar
0.24399
0.20274
 
MRx41
Replacement Solution
0.47152
1.49405
 
MRx42
Seizure Disorders
0.23418
0.19837
 
MRx43
Thyroid Disorder
0.04267
0.06326
 
MRx44
Transplant
0.34858
0.05810
 
MRx45
Tuberculosis
0.22778
0.00000
(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.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-24-111, § 182-557-0225, filed 12/6/17, effective 1/6/18; WSR 15-17-065, § 182-557-0225, filed 8/14/15, effective 9/14/15.]



PDF182-557-0300

Health home servicesConfidentiality and data sharing.

(1) Qualified health homes must comply with the confidentiality and data sharing requirements that apply to participants eligible under medicare and Title XIX medicaid programs and as specified in the health home contract.
(2) The agency and the department of social and health services (DSHS) share health care data with qualified health homes under the provisions of RCW 70.02.050 and the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
(3) The agency requires qualified health homes to monitor and evaluate participant activities and report to the agency as required by the health home contract.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-17-065, § 182-557-0300, filed 8/14/15, effective 9/14/15. Statutory Authority: RCW 41.05.021 and 2011 c 316. WSR 13-12-002, § 182-557-0300, filed 5/22/13, effective 7/1/13. WSR 11-14-075, recodified as § 182-557-0300, 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, § 388-557-0300, filed 9/26/07, effective 11/1/07.]



PDF182-557-0350

Health homeGrievance and appeals.

(1) Qualified health homes must have a grievances and appeals process in place that complies with the requirements of this section and must maintain records of all grievances and appeals.
(a) This section contains information about the grievance system for fee-for-service clients, including full dual eligible clients, for health home services. These participants must follow the process in chapter 182-526 WAC for appeals.
(b) Participants who are enrolled in an agency-contracted managed care organization must follow the process in WAC 182-538-110 to file a grievance or an appeal for health home services.
(2) Grievance process.
(a) Only a participant or the participant's authorized representative may file a grievance with the qualified health home orally or in writing. A health home care coordinator may not file a grievance for the participant unless the participant gives the health home care coordinator written consent to act on the participant's behalf.
(b) The qualified health home must:
(i) Accept, document, record, and process grievances that it receives from the participant, the participant's representative, or the agency;
(ii) Acknowledge receipt of each grievance, either orally or in writing, within two business days of receiving the grievance;
(iii) Assist the participant with all grievance processes;
(iv) Cooperate with any representative authorized in writing by the participant;
(v) Ensure that decision makers on grievances were not involved in the activity or decision being grieved, or any review of that activity or decision by qualified health home staff;
(vi) Consider all information submitted by the participant or the participant's authorized representative;
(vii) Investigate and resolve all grievances;
(viii) Complete the disposition of a grievance and notice to the affected parties as quickly as the participant's health condition requires, but no later than forty-five calendar days from receipt of the grievance;
(ix) Notify the participant, either orally or in writing, of the disposition of grievances within five business days of determination. Notification must be in writing if the grievance is related to a quality of care issue.
(3) Appeal process.
(a) The qualified health home must give the participant written notice of an action.
(b) The written notice must:
(i) State what action the qualified health home intends to take and the effective date of the action;
(ii) Explain the specific facts and reasons for the decision to take the intended action;
(iii) Explain the specific rule or rules that support the decision, or the specific change in federal or state law that requires the action;
(iv) Explain the participant's right to appeal the action according to chapter 182-526 WAC;
(v) State that the participant must request a hearing within ninety calendar days from the date that the notice of action is mailed.
(c) The qualified health home must send the written notice to the participant no later than ten days before the date of action. The written notice may be sent by the qualified health home no later than the date of the action it describes only if:
(i) The qualified health home has factual information confirming the death of a participant; or
(ii) The qualified health home receives a written statement signed by a participant that:
(A) The participant no longer wishes to receive health home services; or
(B) Provides information that requires termination or reduction of health home services and which indicates that the participant understands that supplying the information will result in health home services being ended or reduced.
(d) A health home care coordinator may not file an appeal for the participant.
(e) If the agency receives a request to appeal an action of the qualified health home, the agency will provide the qualified health home notice of the request.
(f) The agency will process the participant's appeal in accordance with chapter 182-526 WAC.
(g) Continued coverage. If a participant appeals an action by a qualified health home, the participant's health home services will continue consistent with WAC 182-504-0130.
(h) Reinstated coverage. If the agency ends or changes the participant's qualified health home coverage without advance notice, the agency will reinstate coverage consistent with WAC 182-504-0135.
(i) If the participant requests a hearing, the qualified health home must provide to the agency and the participant, upon request, and within three working days, all documentation related to the appeal.
(j) The qualified health home is an independent party and is responsible for its own representation in any administrative hearing, subsequent review process, and judicial proceedings.
(k) If a final order, as defined in WAC 182-526-0010, requires a qualified health home to provide the participant health home services that were not provided while the appeal was pending, the qualified health home must authorize or provide the participant those health home services promptly. A qualified health home cannot seek further review of a final order issued in a participant's administrative appeal of an action taken by the qualified health home.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-17-065, § 182-557-0350, filed 8/14/15, effective 9/14/15.]



PDF182-557-0400

Health homePayment.

Only an agency-contracted qualified health home may bill and be paid for providing health home services described in this chapter. Billing requirements and payment methodology are described in the contract between the agency and the qualified health home.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-17-065, § 182-557-0400, filed 8/14/15, effective 9/14/15. Statutory Authority: RCW 41.05.021 and 2011 c 316. WSR 13-12-002, § 182-557-0400, filed 5/22/13, effective 7/1/13. WSR 11-14-075, recodified as § 182-557-0400, 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, § 388-557-0400, filed 9/26/07, effective 11/1/07.]