Proposed

(((23))) (20) The grievance and appeal process found in
WAC 182-538-110 applies to MCS enrollees described in
this section.
(((24))) (21) The hearing process found in chapter 182-
526 WAC ((and WAC 182-538-112)) applies to MCS enrollees
described in this section.
AMENDATORY SECTION (Amending WSR 11-14-075,
filed 6/30/11, effective 7/1/11)
WAC 182-538-065 Medicaid-eligible basic health
(BH) enrollees. (1) Certain children and pregnant women
who have applied for, or are enrolled in, managed care
through basic health (BH) (chapter 70.47 RCW) are eligible
for medicaid under pediatric and maternity expansion provisions
of the Social Security Act. The ((department)) agency
determines medicaid eligibility for children and pregnant
women who enroll through BH.
(2) Eligible children are enrolled in the ((basic health))
BH plus program and eligible pregnant women are enrolled
in the maternity benefits program.
(3) The administrative rules and regulations that apply to
managed care enrollees also apply to medicaid-eligible clients
enrolled through BH plus or the maternity benefits program
as described in this section, except as follows:
(a) ((The process for enrolling in managed care
described in WAC 388-538-060(3) does not apply since
enrollment is through the health care authority, the state
agency that administers BH;
(b))) American Indian((/)) and Alaska native (AI/AN)
clients cannot choose fee-for-service or PCCM as described
in WAC ((388-538-060)) 182-538-060(2). They must enroll
in a ((BH-contracted)) HCA-contracted MCO.
(((c) If a medicaid eligible client applying for BH plus
does not choose an MCO prior to the department's eligibility
determination, the client is transferred from BH plus to the
department for assignment to managed care.
(d))) (b) The ((department)) agency does not consider the
basic health plus and the maternity benefits programs to be
third party.
(4) This section does not apply to the subsidized basic
health program found in chapter 182-24 WAC.
AMENDATORY SECTION (Amending WSR 11-14-075,
filed 6/30/11, effective 7/1/11)
WAC 182-538-067 Managed care provided through
managed care organizations (MCOs). (1) Managed care
organizations (MCOs) may contract with the ((department))
agency to provide prepaid health care services to eligible clients.
The MCOs must meet the qualifications in this section
to be eligible to contract with the ((department)) agency. The
MCO must:
(a) Have a certificate of registration from the office of
the insurance commissioner (OIC) that allows the MCO to
provide the health care services;
(b) Accept the terms and conditions of the ((department's))
agency's managed care contract;
(c) Be able to meet the network and quality standards
established by the ((department)) agency; and
Washington State Register, Issue 12-21 WSR 12-21-112
(d) ((Accept the prepaid rates published by the department.))
At the sole option of the agency, be awarded a contract
through a competitive process or an application process
available to all qualified providers.
(2) The ((department)) agency reserves the right not to
contract with any otherwise qualified MCO.
AMENDATORY SECTION (Amending WSR 11-14-075,
filed 6/30/11, effective 7/1/11)
WAC 182-538-068 Managed care provided through
primary care case management (PCCM). A provider may
contract with the ((department)) agency as a primary care
case management (PCCM) provider to coordinate health care
services to eligible clients under the ((department's)) agency's
managed care program. The PCCM provider or the individual
providers in a PCCM group or clinic must:
(1) Have a core provider agreement with the ((department))
agency;
(2) Be a recognized urban Indian health center or tribal
clinic;
(3) Accept the terms and conditions of the ((department's))
agency's PCCM contract;
(4) Be able to meet the quality standards established by
the ((department)) agency; and
(5) Accept PCCM rates published by the ((department))
agency.
AMENDATORY SECTION (Amending WSR 11-14-075,
filed 6/30/11, effective 7/1/11)
WAC 182-538-070 Managed care payment. (1) The
((department)) agency pays managed care organizations
(MCOs) monthly capitated premiums that:
(a) Have been developed in accordance with generally
accepted actuarial principles and practices;
(b) Are appropriate for the populations to be covered and
the services to be furnished under the MCO contract;
(c) Have been certified by actuaries who meet the qualification
standards established by the American Academy of
Actuaries and follow the practice standards established by the
Actuarial Standards Board;
(d) Are based on historical analysis of financial cost
and/or rate information; and
(e) Are paid based on legislative allocations.
(2) The ((department)) agency pays primary care case
management (PCCM) providers a monthly case management
fee according to contracted terms and conditions.
(3) The ((department)) agency 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 health care services.
(4) The ((department)) agency pays an enhancement rate
to federally qualified health care centers (FQHC) and rural
health clinics (RHC) for each client enrolled with MCOs
through the FQHC or RHC. The enhancement rate from the
((department)) agency is in addition to the negotiated payments
FQHCs and RHCs receive from the MCOs for services
provided to MCO enrollees.
[ 135 ] Proposed