WAC 388-538-0070 Managed care payment.

1. The medical assistance administration (MAA) pays managed care organizations (MCOs) monthly capitated premiums that: 

   1. Have been determined using generally accepted actuarial methods;

   2. Are based on historical analysis of financial cost and/or rate information; and

   3. Are paid based on legislative allocations.

2. MAA pays primary care case management (PCCM) providers a monthly case management fee according to contracted terms and conditions.

3. MAA does not pay providers on a fee-for-service basis for services that are the MCO's responsibility, even if the MCO has not paid for the service for any reason. The MCO is solely responsible for payment of MCO-contracted health care services:

   1. Provided by an MCO-contracted provider; or

   2. That are authorized by the MCO and provided by nonparticipating providers.

4. MAA pays an additional monthly amount, known as an enhancement rate, to federally qualified health care centers (FQHC) and rural health clinics (RHC) for each client enrolled with MCOs through the FQHC or RHC. MCOs may contract with FQHCs and RHCs to provide services.  FQHCs and RHCs receive an enhancement rate from MAA on a per member, per month basis in addition to the negotiated payments they receive from the MCOs for services provided to MCO enrollees.