WAC 388-538-0063 Mandatory enrollment in managed care for GAU clients.

1. The purpose of this section is to describe the managed care requirement for general assistance unemployable (GAU) clients mandated by the Laws of 2003, chapter 25, section 209 (15). 

2. The only sections of chapter 388-538 WAC that apply to GAU clients described in this section are incorporated by reference into this section.

3. To receive department-paid medical care, GAU clients must enroll in a managed care plan as required by WAC 388-505-0110(7) when they reside in a county designated as a mandatory managed care plan county.

4. GAU clients are exempt from mandatory enrollment in managed care if they:

   1. Are American Indian or Alaska Native (AI/AN); and

   2. Meet the provisions of 25 U.S.C. 1603 (c) - (d) for federally recognized tribal members and their descendants.

5. In addition to subsection (4), the department will exempt a GAU client from mandatory enrollment in managed care or end an enrollee's enrollment in managed care in accordance with WAC 388-538-130(3) and 388-538-130(4).

6. On a case-by-case basis, the department may grant a GAU client’s request for exemption from managed care or a GAU enrollee’s request to end enrollment when, in the department’s judgment:

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

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

7. The department enrolls GAU clients in managed care effective on the earliest possible date, given the requirements of the enrollment system. The department does not enroll clients in managed care on a retroactive basis.

8. Managed care organizations (MCOs) that contract with the department to provide services for GAU clients must meet the qualifications and requirements in WAC 388-538-067 and 388-538-095(3)(a), (b), (c) and (d).

9. The department pays MCOs capitated premiums for GAU enrollees based on legislative allocations for the GAU program.

10. GAU enrollees are eligible for the scope of care as described in WAC 388-501-0060   for medical care services (MSC). Other scope of care provisions that apply:

    1. A client is entitled to timely access to medically necessary services as defined in WAC 388-500-0005;

    2. MCOs cover the services included in the managed care contract for GAU enrollees. MCOs may, at their discretion, cover services not required under the MCO’s contract for GAU enrollees;

    3. The department pays providers on a fee-for-service basis for the medically necessary, covered medical care services not covered under the MCO’s contract for GAU enrollees; and

    4. A GAU enrollee may obtain emergency services in accordance with WAC 388-538-100.

11. The department does not pay providers on a fee-for-service basis for services covered under the MCO’s contract for GAU 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 health care services that are:

    1. Provided by an MCO-contracted provider; or

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

12. The following services are not covered for GAU enrollees unless the MCO chooses to cover these services at no additional cost to the department:

    1. Services that are not medically necessary;

    2. Services not included in the medical care services scope of care;

    3. Services, other than a screening exam as described in WAC 388-538-100(3), received in a hospital emergency department for nonemergency medical conditions; and

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

13. A provider may bill a GAU enrollee for noncovered services described in subsection (12), if the requirements of WAC 388-502-0160 and 388-538-095(5) are met.

14. The grievance and appeal process found in WAC 388-538-110 applies to GAU enrollees described in this section.

15. The hearing process found in chapter 388-02 WAC and WAC 388-538-112 applies to GAU enrollees described in this section.