WAC 182-538-0063

Effective October 14, 2012

WAC 182-538-0063 Managed care for medical care services clients.

1.  The agency provides coverage of certain medical and mental health benefits through a voluntary managed care program to clients who receive medical services under the medical care services (MCS) program in WAC 182-508-0005.

 

2.  The sections of chapter 182-538 WAC that apply to MCS clients described in this section are incorporated by reference into this section.

 

3.   The agency ends an MCS enrollee's enrollment in managed care upon request by the enrollee, either in writing or by telephone.

 

4.  The agency enrolls MCS clients in managed care effective on the earliest possible date, given the requirements of the enrollment system. The agency does not enroll clients in managed care on a retroactive basis. Upon notification of enrollment in managed care, new enrollees may choose to opt out or end enrollment in mangaed care.

 

5.  Managed care organizations (MCOs) that contract with the agency to provide services to MCS clients must meet the qualifications and requirements in WAC 182-538-067 and 182-538-095 (3)(a), (b), (c),and (d).

 

6.  The agency pays MCOs capitated premiums for MCS enrollees based on legislative allocations for the MCS program.

 

7.  MCS enrollees are eligible for the scope of care as described in WAC 182-501-0060 for medical care services (MCS) programs.

a.  An MCS enrollee is entitled to timely access to medically necessary services as defined in WAC 182-500-0070;

b.  MCOs cover the services included in the managed care contract for MCS enrollees. MCOs may, at their discretion, cover services not required under the MCO's contract for MCS enrollees;

c.  The agency pays providers on a fee-for-service basis for the medically necessary, covered medical care services not covered under the MCO's contract for MCS enrollees;

d.  An MCS enrollee may obtain:

i.  Emergency services in accordance with WAC 182-538-100; and

ii. Mental health services in accordance with this section.

 

8.  The agency does not pay providers on a fee-for-service basis for services covered under the MCO's contract for MCS enrollees, even if the MCO has not paid for the service, regardless of the reason. The MCO is solely responsible for payment of MCO-contracted healthcare services that are:

a.  Provided by an MCO-contracted provider; or

b.  Authorized by the MCO and provided by nonparticipating providers.

 

9.  The following services are not covered for MCS enrollees unless the MCO chooses to cover these services at no additional cost to the agency:

a.  Services that are not medically necessary;

b.  Services not included in the medical care services scope of care, unless otherwise specified in this section;

c.  Services, other than a screening exam as described in WAC 182-538-100(3), received in a hospital emergency department for nonemergency medical conditions; and

d.  Services received from a nonparticipating provider requiring prior authorization from the MCO that were not authorized by the MCO.

 

10.  A provider may bill an MCS enrollee for noncovered services described in subsection (9) of this section, if the requirements of WAC 182-502-0160 and 182-538-095 (5) are met.

 

11.  Mental health services and care coordination are available to MCS enrollees on a limited basis, subject to available funding from the legislature and an appropriate delivery system.

 

12.  A care coordinator (a person employed by the MCO or one of the MCO's subcontractors) provides care coordination to an MCS enrollee in order to improve access to mental health services. Care coordination may include brief, evidenced-based mental health services.

 

13.  To ensure an MCS enrollee receives appropriate mental health services and care coordination, the agency requires the enrollee to complete at least one of the following assessments:

a.  A physical evaluation;

b.  A psychological evaluation;

c.  A mental health assessment completed through the client's local community mental health agency (CMHA) and/or other mental health agencies;

d.  A brief evaluation completed through the appropriate care coordinator located at a participating community health center (CHC);

e.  An evaluation by the client's primary care provider (PCP); or

f.  An evaluation completed by medical staff during an emergency room visit.

 

14.  An MCS enrollee who is screened positive for a mental health condition after completing one or more of the assessments described in subsection (13) of this section may receive one of the following levels of care:

a.  Level 1. Care provided by a care coordinator when it is determined that the MCS enrollee does not require Level 2 services. The care coordinator will provide the following, as determined appropriate and available:

i.  Evidenced-based behavioral health services and care coordination to facilitate receipt of other needed services.

ii.  Coordination with the PCP to provide medication management.

iii.  Referrals to other services as needed.

iv.  Coordination with consulting psychiatrist as necessary.

b.  Level 2. Care provided by a contracted provider when it is determined that the MCS enrollee requires services beyond Level 1 services. A care coordinator refers the MCS enrollee to the appropriate provider for services:

i.  A regional support network (RSN) contracted provider; or

ii.  A contractor-designated entity.

 

15.  Billing and reporting requirements and payment amounts for mental health services and care coordination provided to MCS enrollees are described in the contract between the MCOand the agency.

 

16.  The total amount the agency pays in any biennium for services provided pursuant to this section cannot exceed the amount appropriated by the legislature for that biennium. The agency has the authority to take whatever actions necessary to ensure the agency stays within the appropriation.

 

17.  Nothing in this section shall be construed as creating a legal entitlement to any MCS client for the receipt of any medical or mental health service by or through the agency.

 

18.  An MCO may refer enrollees to the agency's patient review and coordination (PRC) program according to WAC 182-501-0135.

 

19.  The grievance and appeal process found in WAC 182-538-110 applies to MCS enrollees described inthis section.

 

20.  The hearing process found in chapter 182-526 WAC applies to MCS enrollees described in this section.

 

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.