WAC 388-538-0061 Managed care provided through the Washington Medicaid Integration Partnership (WMIP) or Medicare/Medicaid Integration Program (MMIP).

1. The purpose of this section is to describe the managed care requirements for clients eligible for either the Washington Medicaid Integration Partnership (WMIP) or the Medicare/Medicaid Integration Program (MMIP). 

2. Unless otherwise stated in this section, all of the provisions of chapter 388-538 WAC apply to clients enrolled in WMIP and MMIP.

3. The following sections of chapter 388-538 WAC do not apply to WMIP enrollees or MMIP enrollees:

   1. WAC 388-538-0060. However, WAC 388-538-0060(5), describing enrollees' ability to choose their PCP, does apply to WMIP enrollees and MMIP enrollees;

   2. WAC 388-538-0063;

   3. WAC 388-538-0065;

   4. WAC 388-538-0068; and

   5. WAC 388-538-0130. However, WAC 388-538-0130  (3) and (4), describing the process used when MAA receives a request from an MCO to remove an enrollee from enrollment in managed care, do apply to WMIP enrollees and MMIP enrollees. Also, WAC 388-538-0130 (9), describing the MCO's ability to refer enrollees to MAA's "Patient Review and Restriction" program, does apply to WMIP enrollees and MMIP enrollees.

4. The process for enrollment of WMIP and MMIP clients is as follows:

   1. Enrollment in WMIP and MMIP is voluntary, subject to program limitations in subsection (b) and (c) of this section.

   2. For WMIP, MAA automatically enrolls clients, with the exception of American Indian/Alaska natives and clients eligible for both Medicare and Medicaid, when they:

      1. Are aged, blind, or disabled;

      2. Are twenty-one years of age or older; and

      3. Receive categorically needy medical assistance.

   3. For MMIP, clients may enroll when they:

      1. Are sixty-five years of age or older; and

      2. Receive Medicare and/or Medicaid.

   4. American Indian/Alaska native (AI/AN) clients and clients who are eligible for Medicare and Medicaid who meet the eligibility criteria in (b) or (c) of this subsection may voluntarily enroll or end enrollment in WMIP or MMIP at any time.

   5. MAA will not enroll a client in WMIP or MMIP, or will end an enrollee's enrollment in WMIP or MMIP when the client has, or becomes eligible for, CHAMPUS/TRICARE or any other third-party health care coverage that would require exemption or involuntary disenrollment from managed care.

   6. A client or enrollee in WMIP or MMIP or the client's or enrollee's representative may end enrollment from the MCO at any time without cause. The client may then reenroll at any time with the MCO. MAA ends enrollment for clients prospectively to the first of the month following request to end enrollment, except as provided in subsection (g) of this section.

   7. Clients may request that MAA retroactively end enrollment from WMIP and MMIP. On a case-by-case basis, MAA may retroactively end enrollment from WMIP and MMIP when, in MAA's judgment:

      1. The client or enrollee has a documented and verifiable medical condition; and

      2. Enrollment in managed care could cause an interruption of on-going treatment that could jeopardize the client's or enrollee's life or health or ability to attain, maintain, or regain maximum function.

5. In addition to the scope of medical care described in WAC 388-538-0095, WMIP and MMIP are designed to include the following services:

   1. For WMIP enrollees - mental health, chemical dependency treatment, and long-term care services; and

   2. For MMIP enrollees - long-term care services.

6. MAA sends each client written information about covered services when the client is eligible to enroll in WMIP or MMIP, and any time there is a change in covered services. In addition, MAA requires MCOs to provide new enrollees with written information about covered services. This notice informs the client about the right to disenroll and how to do so.