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Care Delivery - managed care
December 15, 2014
Purpose: To explain managed care and provide a link to the various services.
WAC 182-538-060 Managed care choice and assignment.
Effective October 25, 2020
- The medicaid agency requires a client to enroll in integrated managed care (IMC) when that client:
- Is eligible for one of the Washington apple health programs for which enrollment is mandatory;
- Resides in an area where enrollment is mandatory; and
- Is not exempt from IMC enrollment and the agency has not ended the client's managed care enrollment, consistent with WAC 182-538-130.
- American Indian and Alaska native (AI/AN) clients and their descendants may choose one of the following:
- Enrollment with a managed care organization (MCO) available in their regional service area;
- Enrollment with a PCCM provider through a tribal clinic or urban Indian center available in their area; or
- The agency's fee-for-service system for physical health or behavioral health or both.
- To enroll with an MCO or PCCM provider, a client may:
- An enrollee in IMC must enroll with an MCO available in the regional service area where the enrollee resides.
- All family members will be enrolled with the same MCO, except family members of an enrollee placed in the patient review and coordination (PRC) program under WAC 182-501-0135 need not enroll in the same MCO as the family member placed in the PRC program.
- An enrollee may be placed into the PRC program by the MCO or the agency. An enrollee placed in the PRC program must follow the enrollment requirements of the program as stated in WAC 182-501-0135.
- When a client requests enrollment with an MCO or PCCM provider, the agency enrolls a client effective the earliest possible date given the requirements of the agency's enrollment system.
- The agency assigns a client who does not choose an MCO or PCCM provider as follows:
- If the client was enrolled with an MCO or PCCM provider within the previous six months, the client is reenrolled with the same MCO or PCCM provider;
- If (a) of this subsection does not apply and the client has a family member enrolled with an MCO, the client is enrolled with that MCO;
- The client is reenrolled within the previous six months with their prior MCO plan if:
- The agency identifies the prior MCO and the program is available; and
- The client does not have a family member enrolled with an agency-contracted MCO or PCCM provider.
- 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; or
- If the client cannot be assigned according to (a), (b), (c), or (d) of this subsection, the agency:
- Assigns the client according to agency policy, or this rule, or both;
- Does not assign clients to any MCO that has a total statewide market share of forty percent or more of clients who are enrolled in apple health IMC. On a quarterly basis, the agency reviews enrollment data to determine each MCO's statewide market share in apple health IMC;
- Applies performance measures associated with increasing or reducing assignment consistent with this rule and agency policy or its contracts with MCOs.
- If the client cannot be assigned according to (a) or (b) of this subsection, the agency assigns the client as follows:
- If a client who is not AI/AN does not choose an MCO, the 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.
- For clients who are newly eligible or who have had a break in eligibility of more than six months, the agency sends a written notice to each household of one or more clients who are assigned to an MCO. The assigned client has ten calendar days to contact the agency to change the MCO assignment before enrollment is effective. The notice includes:
- The agency's toll-free number;
- The toll-free number and name of the MCO to which each client has been assigned;
- The effective date of enrollment; and
- The date by which the client must respond in order to change the assignment.
- An MCO enrollee's selection of a PCP or assignment to a PCP occurs as follows:
- An MCO enrollee may choose:
- A PCP or clinic that is in the enrollee's MCO and accepting new enrollees; or
- A different PCP or clinic participating with the enrollee's MCO for different family members.
- 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.
- 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.
- 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.
- MCO enrollees required to participate in the agency's PRC program may be limited in their right to change PCPs (see WAC 182-501-0135).
- An MCO enrollee may choose: