Proposed

WSR 12-21-112 Washington State Register, Issue 12-21
(c)-(d) for federally recognized tribal members and their
descendants may choose one of the following:
(a) Enrollment with a managed care organization (MCO)
available in their area;
(b) Enrollment with an Indian or tribal primary care case
management (PCCM) provider available in their area; or
(c) The ((department's)) agency's fee-for-service system.
(((3))) (4) To enroll with an MCO or PCCM provider, a
client may:
(a) Call the ((department's)) agency's toll-free enrollment
line at 800-562-3022;
(b) Mail a postage-paid completed managed care enrollment
form (((healthy options sign-up)) enrollment form,
((DSHS 13-664)) HCA 13-862) to the ((department's))
agency's unit responsible for managed care enrollment; or
(c) Fax the managed care enrollment form (((healthy
options sign-up)) enrollment form, ((DSHS 13-664)) HCA
13-862) to the ((department)) agency at ((360-725-2144)) the
number located on the enrollment form.
(((4))) (5) A client must enroll with an MCO provider
available in the area where the client resides.
(((5))) (6) All family members of an enrollee placed in
the patient review and coordination (PRC) program under
WAC ((388-501-0135)) 182-501-0135 must enroll with the
same MCO but may enroll in a different MCO than the family
member placed in the PRC program.
(((6))) (7) When a client requests enrollment with an
MCO or PCCM provider, the ((department)) agency enrolls a
client effective the earliest possible date given the requirements
of the ((department's)) agency's enrollment system.
The ((department)) agency does not enroll clients retrospectively.
(((7))) (8) The ((department)) agency assigns a client
who does not choose an MCO or PCCM provider as follows:
(a) If the client has a family member or family members
enrolled with an MCO, the client is enrolled with that MCO;
(b) If the client does not have a family member or family
members enrolled with an MCO that is currently under contract
with the ((department)) agency, and the client was previously
enrolled with the MCO or PCCM provider, and the
((department)) agency can identify the previous enrollment,
the client is reenrolled with the same MCO or PCCM provider;
(c) If the client cannot be assigned according to (a) or (b)
of this subsection, the ((department)) agency assigns the client
as follows:
(i) If an AI((/)) or AN client does not choose an MCO or
PCCM provider, the ((department)) agency assigns the client
to a tribal PCCM provider if that client resides in a zip code
served by a tribal PCCM provider. If there is no tribal PCCM
provider in the client's area, the client continues to be served
by the ((department's)) agency's fee-for-service system. A
client assigned under this subsection may request to end
enrollment at any time.
(ii) If a ((non-AI/AN)) client who is not AI or AN does
not choose an MCO provider, the ((department)) agency
assigns the client to an MCO available in the area where the
client resides. The MCO is responsible for primary care provider
(PCP) choice and assignment.
Proposed [ 132 ]
(iii) For clients who are new recipients or who have had
a break in eligibility of greater than two months, the ((department))
agency sends a written notice to each household of
one or more clients who are assigned to an MCO or PCCM
provider. The assigned client has ten calendar days to contact
the ((department)) agency to change the MCO or PCCM provider
assignment before enrollment is effective. The notice
includes the name of the MCO or PCCM provider to which
each client has been assigned, the effective date of enrollment,
the date by which the client must respond in order to
change the assignment, and the toll-free telephone number of
either:
(A) The MCO (for enrollees assigned to an MCO); or
(B) The ((department)) agency (for enrollees assigned to
a PCCM provider).
(iv) If the client has a break in eligibility of less than two
months, the client will be automatically reenrolled with his or
her previous MCO or PCCM provider and no notice will be
sent.
(((8))) (9) The ((department)) agency:
(a) Helps facilitate the choice of a PCP by providing
information regarding available providers contracted with the
MCOs in the client's service area; and
(b) Upon request, will assist clients in identifying an
MCO with which their provider participates.
(((9))) (10) An MCO enrollee's selection of a PCP or
assignment to a PCP occurs as follows:
(a) An MCO enrollee may choose:
(i) A PCP or clinic that is in the enrollee's MCO and
accepting new enrollees; or
(ii) A different PCP or clinic participating with the
enrollee's MCO for different family members.
(b) The MCO assigns a PCP or clinic that meets the
access standards set forth in the relevant managed care contract
if the enrollee does not choose a PCP or clinic.
(c) An MCO enrollee may change PCPs or clinics in an
MCO for any reason, with the change becoming effective no
later than the beginning of the month following the enrollee's
request.
(d) An MCO enrollee may file a grievance with the
MCO if the MCO does not approve an enrollee's request to
change PCPs or clinics.
(e) MCO enrollees required to participate in the ((department's))
agency's PRC program may be limited in their right
to change PCPs (see WAC 388-501-0135).
AMENDATORY SECTION (Amending WSR 11-14-075,
filed 6/30/11, effective 7/1/11)
WAC 182-538-061 Voluntary enrollment into managed
care—Washington medicaid integration partnership
(WMIP). (1) The purpose of this section is to describe
the managed care requirements for clients eligible for the
Washington Medicaid Integration Partnership (WMIP).
(2) Unless otherwise stated in this section, all of the provisions
of chapter ((388-538)) 182-538 WAC apply to clients
enrolled in WMIP.
(3) The following sections of chapter ((388-538)) 182-
538 WAC do not apply to WMIP enrollees: