WAC 182-538-0070

Effective July 1, 2011

WAC 182-538-0070 Managed care payment.

  1. The department pays managed care organizations (MCOs) monthly capitated premiums that: 

    1. Have been developed in accordance with generally accepted actuarial principles and practices;

    2. Are appropriate for the populations to be covered and the services to be furnished under the MCO contract;

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

    4. 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. The department does not pay providers under the fee-for-service system for a service that is 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 healthcare services.

  4. The department pays an enhancement rate to federally qualified healthcare centers (FQHC) and rural health clinics (RHC) for each client enrolled with MCOs through the FQHC or RHC. The enhancement rate from the department is in addition to the negotiated payments FQHCs and RHCs receive from the MCOs for services provided to MCO enrollees. 

  5. The department pays MCOs a delivery case rate, separate from the capitation payment, when an enrollee delivers a child(ren) and the MCO pays for any part of labor and delivery.

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.