WAC 388-538-0130 Exemptions and enrollment in managed care.

1. The medical assistance administration (MAA) exempts a client from mandatory enrollment in managed care or ends an enrollee's enrollment in managed care as specified in this section. Only MAA has authority to exempt a client from enrollment in, or remove an enrollee from, managed care.

2. A client or enrollee, or the client's or enrollee's representative as defined in RCW 7.70.065, may request MAA to exempt or end enrollment in managed care as described in this section.

   1. If a client requests exemption prior to the enrollment effective date, the client is not enrolled until MAA approves or denies the request.

   2. If an enrollee requests to end enrollment, the enrollee remains enrolled pending MAA's final decision, unless staying in managed care would adversely affect the enrollee's health status.

   3. The client or enrollee receives timely notice by telephone or in writing when MAA approves or denies the client's or enrollee's request. MAA follows a telephone denial by written notification. The written notice contains all of the following:

      1. The action MAA intends to take;

      2. The reason(s) for the intended action;

      3. The specific rule or regulation supporting the action;

      4. The client's or enrollee's right to request a fair hearing; and

      5. A translation into the client's or enrollee's primary language when the client or enrollee has limited English proficiency.

3. A managed care organization (MCO) or primary care case management (PCCM) provider may request MAA to end enrollment. The request must be in writing and be sufficient to satisfy MAA that the enrollee's behavior is inconsistent with the MCO's or PCCM provider's rules and regulations (e.g. intentional misconduct). MAA does not approve a request to remove an enrollee from managed care when the request is solely due to an adverse change in the enrollee's health or the cost of meeting the enrollee's health care needs. The MCO or PCCM provider's request must include documentation that:

   1. The provider furnished clinically appropriate evaluation(s) to determine whether there is a treatable problem contributing to the enrollee's behavior;

   2. Such evaluation either finds no treatable condition to be contributing, or after evaluation and treatment, the enrollee's behavior continues to prevent the provider from safely or prudently providing medical care to the enrollee; and

   3. The enrollee received written notice of the provider's intent to request the enrollee's removal, unless MAA has waived the requirement for provider notice because the enrollee's conduct presents the threat of imminent harm to others. The provider's notice must include:

      1. The enrollee's right to use the provider's grievance system as described in WAC 388-538-110 and WAC 388-538-111; and

      2. The enrollee's right to use the department's fair hearing process, after the enrollee has exhausted all grievance and appeals available through the provider's grievance system (see WAC 388-538-110 and WAC 388-538-111 for provider grievance systems, and WAC 388-538-112 for the fair hearing process for enrollees).

4. When MAA receives a request from an MCO or PCCM provider to remove an enrollee from enrollment in managed care, MAA attempts to contact the enrollee for the enrollee's perspective. If MAA approves the request, MAA sends a notice at least ten days in advance of the effective date that enrollment will end. The notice includes:

   1. The reason MAA approved ending enrollment; and

   2. Information about the enrollee's fair hearing rights.

5. MAA will exempt a client from mandatory enrollment or end an enrollee's enrollment in managed care when any of the following apply:

   1. The client or enrollee is receiving foster care placement services from the division of children and family services (DCFS);

   2. The client has or the enrollee becomes eligible for Medicare, basic health (BH), CHAMPUS/TRICARE, or any other accessible third-party health care coverage that would require exemption or involuntary disenrollment from:

      1. An MCO, in accordance with MAA's healthy options (HO) contract; or

      2. A primary care case management (PCCM) provider, in accordance with MAA's PCCM contract.

6. MAA will grant a client's request for exemption or an enrollee's request to end enrollment when:

   1. The client or enrollee is American Indian/Alaska native (AI/AN) as specified in WAC 388-538-060(2);

   2. The client or enrollee has been identified by MAA as a child who meets the definition of "children with special health care needs";

   3. The client or enrollee is homeless or is expected to live in temporary housing for less than one hundred twenty days from the date of the request; or

   4. The client or enrollee speaks limited English or is hearing impaired and the client or enrollee can communicate with a provider who communicates in the client's or enrollee's language or in American sign language and is not available through the MCO and the MCO does not have a provider available who can communicate in the client's language.

7. On a case-by-case basis, MAA may grant a client's request for exemption or an enrollee's request to end enrollment when, in MAA's judgment, the client or enrollee has a documented and verifiable medical condition, and 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.

8. Upon request, MAA may exempt the client or end enrollment for the period of time the circumstances or conditions that lead to exemption or ending enrollment are expected to exist. MAA may periodically review those circumstances or conditions to determine if they continue to exist. If MAA approves the request for a limited time, the client or enrollee is notified in writing or by telephone of the time limitation, the process for renewing the exemption or the ending of enrollment.

9. An MCO may refer enrollees to MAA's patients requiring regulation (PRR) program in accordance with WAC 388-501-0135.