WAC 388-538-0095 Scope of care for managed care enrollees.

1. Managed care enrollees are eligible for the scope of medical care as described in WAC 388-501-0060  for categorically needy clients. 

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

   2. The managed care organization (MCO) covers the services included in the MCO contract for MCO enrollees. MCOs may, at their discretion, cover additional services not required under the MCO contract. However, the department may not require the MCO to cover any additional services outside the scope of services negotiated in the MCO's contract with the department.

   3. The department covers medically necessary services described in WAC 388-501-0060 and WAC 388-50-0065  that are excluded from coverage in the MCO contract.

   4. The department covers services through the fee-for-service system for enrollees with a primary care case management (PCCM) provider. Except for emergencies, the PCCM provider must either provide the covered services needed by the enrollee or refer the enrollee to other providers who are contracted with the department for covered services. The PCCM provider is responsible for instructing the enrollee regarding how to obtain the services that are referred by the PCCM provider. The services that require PCCM provider referral are described in the PCCM contract. The department informs enrollees about the enrollee's program coverage, limitations to covered services, and how to obtain covered services.

   5. MCO enrollees may obtain certain services from either a MCO provider or from a department-enrolled provider with a current core provider agreement without needing to obtain a referral from the PCP or MCO. These services are described in the managed care contract, and are communicated to enrollees by the department and MCOs as described in (f) of this subsection.

   6. The department sends each client written information about covered services when the client is required to enroll in managed care, and any time there is a change in covered services. This information describes covered services, which services are covered by the department, and which services are covered by MCOs. In addition, the department requires MCOs to provide new enrollees with written information about covered services.

2. For services covered by the department through PCCM contracts for managed care:

   1. The department covers medically necessary services included in the categorically needy scope of care and rendered by providers who have a current core provider agreement with the department to provide the requested service;

   2. The department may require the PCCM provider to obtain authorization from the department for coverage of nonemergency services;

   3. The PCCM provider determines which services are medically necessary;

   4. An enrollee may request a hearing for review of PCCM provider or the department coverage decisions (see WAC 388-538-0110); and

   5. Services referred by the PCCM provider require an authorization number in order to receive payment from the department.

3. For services covered by the department through contracts with MCOs:

   1. The department requires the MCO to subcontract with a sufficient providers to deliver the scope of contracted services in a timely manner. Except for emergency services, MCOs provide covered services to enrollees through their participating providers;

   2. The department requires MCOs to provide new enrollees with written information about how enrollees may obtain covered services;

   3. For nonemergency services, MCOs may require the enrollee to obtain a referral from the primary care provider (PCP), or the provider to obtain authorization from the MCO, according to the requirements of the MCO contract;

   4. MCOs and their providers determine which services are medically necessary given the enrollee's condition, according to the requirements included in the MCO contract;

   5. The department requires the MCO to coordinate benefits with other insurers in a manner that does not reduce benefits to the enrollee or result in costs to the enrollee;

   6. A managed care enrollee does not need a PCP referral to receive women's health care services, as described in RCW 48.42.100 from any women's health care provider participating with the MCO. Any covered services ordered and/or prescribed by the women's health care provider must meet the MCO's service authorization requirements for the specific service.

   7. For enrollees temporarily outside their MCOs service area, the MCO is required to cover enrollees for up to ninety days for emergency care and medically necessary covered benefits that cannot wait until the enrollees return to their service area.

4. Unless the MCO chooses to cover these services, or an appeal, independent review, or a hearing decision reverses an MCO or department denial, the following services are not covered:

   1. For all managed care enrollees:

      1. Services that are not medically necessary;

      2. Services not included in the categorically needy scope of services; and

      3. Services, other than a screening exam as described in WAC 388-538-0100(3), received in a hospital emergency department for nonemergency medical conditions.

   2. For MCO enrollees:

      1. Services received from a participating specialist that require prior authorization from the MCO, but were not authorized by the MCO; and

      2. Services received from a nonparticipating provider that require prior authorization from the MCO that were not authorized by the MCO. All nonemergency services covered under the MCO contract and received from nonparticipating providers require prior authorization from the MCO.

   3. For PCCM enrollees, services that require a referral from the PCCM provider as described in the PCCM contract, but were not referred by the PCCM provider.

5. A provider may bill an enrollee for noncovered services as described in subsection (4) of this section, if the requirements of WAC 388-502-0160  are met. The provider must give the original agreement to the enrollee and file a copy in the enrollee's record.

   1. The agreement must state all of the following:

      1. The specific service to be provided;

      2. That the service is not covered by either the department or the MCO;

      3. An explanation of why the service is not covered by the MCO or the department, such as:

         1. The service is not medically necessary; or

         2. The service is covered only when provided by a participating provider.

      4. The enrollee chooses to receive and pay for the service; and

      5. Why the enrollee is choosing to pay for the service, such as:

         1. The enrollee understands that the service is available at no cost from a provider participating with the MCO, but the enrollee chooses to pay for the service from a provider not participating with the MCO;

         2. The MCO has not authorized emergency department services for nonemergency medical conditions and the enrollee chooses to pay for the emergency department's services rather than wait to receive services at no cost in a participating provider's office; or

         3. The MCO or PCCM has determined that the service is not medically necessary and the enrollee chooses to pay for the service.

   2. For enrollees with limited English proficiency, the agreement must be translated or interpreted into the enrollee's primary language to be valid and enforceable.

   3. The agreement is void and unenforceable, and the enrollee is under no obligation to pay the provider, if the service is covered by the department or the MCO as described in subsection (1) of this section, even if the provider is not paid for the covered service because the provider did not satisfy the payor's billing requirements.