Proposed

WSR 12-21-112 Washington State Register, Issue 12-21
DirectionsNMap.pdf or directions can be obtained by calling
(360) 725-1000), on November 27, 2012, at 10:00 a.m.
Date of Intended Adoption: Not sooner than November
28, 2012.
Submit Written Comments to: HCA Rules Coordinator,
P.O. Box 45504, Olympia, WA 98504-5504, delivery 626 8th
Avenue, Olympia, WA 98504, e-mail arc@hca.wa.gov, fax
(360) 586-9727, by 5:00 p.m. on November 27, 2012.
Assistance for Persons with Disabilities: Contact Kelly
Richters by November 19, 2012, TTY (800) 848-5429 or
(360) 725-1307 or e-mail kelly.richters@hca.wa.gov.
Purpose of the Proposal and Its Anticipated Effects,
Including Any Changes in Existing Rules: The healthy
options and the former general assistance-unemployable
managed care plans have both changed since the WAC was
last updated due to federal regulation changes and legislative
updates; the WAC must be updated to ensure compliance
with new laws and federal regulation. During the course of
this review, the agency may identify additional changes that
are required in order to improve clarity or update policy.
Reasons Supporting Proposal: See Purpose above.
Statutory Authority for Adoption: RCW 41.05.021, 42
C.F.R. 438.
Statute Being Implemented: RCW 41.05.021.
Rule is not necessitated by federal law, federal or state
court decision.
Name of Proponent: HCA, governmental.
Name of Agency Personnel Responsible for Drafting:
Wendy L. Boedigheimer, HCA, Legal and Administrative
Services, (360) 725-1306; Implementation and Enforcement:
Alison Robbins, HCA, Health Services, Quality and Care
Management, (360) 725-1634.
No small business economic impact statement has been
prepared under chapter 19.85 RCW. The HCA analyzed the
proposed rule amendments and determined that there are no
new costs associated with these changes and they do not
impose disproportionate costs on small businesses.
A cost-benefit analysis is not required under RCW
34.05.328. RCW 34.05.328 does not apply to HCA rules
unless requested by the joint administrative rules [review]
committee or applied voluntarily.
October 23, 2012
Kevin M. Sullivan
Rules Coordinator
AMENDATORY SECTION (Amending WSR 11-14-075,
filed 6/30/11, effective 7/1/11)
WAC 182-538-050 Definitions. The following definitions
and abbreviations and those found in chapter 182-500
WAC ((388-500-0005)), Medical definitions, apply to this
chapter. References to managed care in this chapter do not
apply to mental health managed care administered under
chapter 388-865 WAC.
"Action" means one or more of the following:
(1) The denial or limited authorization of a requested service,
including the type or level of service;
(2) The reduction, suspension, or termination of a previously
authorized service;
Proposed [ 130 ]
(3) The denial, in whole or in part, of payment for a service;
(4) The failure to provide services in a timely manner, as
defined by the state; or
(5) The failure of a managed care organization (MCO) to
act within the time frames provided in 42 C.F.R. 438.408(b).
"Agency" - See WAC 182-500-0010.
"Ancillary health services" means health care services
that are auxiliary, accessory, or secondary to a primary health
care service.
"Appeal" means a request by an enrollee or provider
with written permission of an enrollee for reconsideration of
an action.
"Assign" or "assignment" means the ((department))
agency selects an MCO or primary care case management
(PCCM) provider to serve a client who has not selected an
MCO or PCCM provider.
"Auto enrollment" means the ((department)) agency
has automatically enrolled a client into an MCO in the client's
area of residence.
"Basic health" or "BH" means the health care program
authorized by chapter 70.47 RCW and administered by the
((health care authority (HCA))) agency.
"Basic health plus"((—)) - Refer to WAC ((388-538-
065)) 182-538-065.
"Children with special health care needs" means children
younger than age nineteen who are identified by the
((department)) agency as having special health care needs.
This includes:
(1) Children designated as having special health care
needs by the department of health (DOH) and receiving services
under the Title V program;
(2) Children eligible for supplemental security income
under Title XVI of the Social Security Act (SSA); and
(3) Children who are in foster care or who are served
under subsidized adoption.
"Client" means, for the purposes of this chapter, an
individual eligible for any medical assistance program,
including managed care programs, but who is not enrolled
with an MCO or PCCM provider. In this chapter, "client"
refers to a person before he or she is enrolled in managed
care, while "enrollee" refers to an individual eligible for any
medical assistance program who is enrolled in managed care.
(("Department" means the department of social and
health services (DSHS).))
"Disenrollment"((—)) - See "end enrollment."
"Emergency medical condition" means a condition
meeting the definition in 42 C.F.R. 438.114(a).
"Emergency services" means services defined in 42
C.F.R. 438.114(a).
"End enrollment" means ending the enrollment of an
enrollee for one of the reasons outlined in WAC ((388-538-
130)) 182-538-130.
"Enrollee" means an individual eligible for any medical
assistance program enrolled in managed care with an MCO
or PCCM provider that has a contract with the state.
"Enrollee's representative" means an individual with a
legal right or written authorization from the enrollee to act on
behalf of the enrollee in making decisions.