WAC 388-538-061   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 WAC apply to clients enrolled in WMIP.

     (3) The following sections of chapter 388-538 WAC do not apply to WMIP enrollees:

     (a) WAC 388-538-060. However, WAC 388-538-060(9), describing enrollees' ability to choose their PCP, does apply to WMIP enrollees;

     (b) WAC 388-538-063;

     (c) WAC 388-538-065;

     (d) WAC 388-538-068; and

     (e) WAC 388-538-130. However, WAC 388-538-130 (3) and (4), describing the process used when the department receives a request from an MCO to remove an enrollee from enrollment in managed care, do apply to WMIP enrollees. Also, WAC 388-538-130(9), describing the MCO's ability to refer enrollees to the department's "Patient Review and Coordination" program, does apply to WMIP enrollees.

     (4) The process for enrollment of WMIP clients is as follows:

     (a) Enrollment in WMIP is voluntary, subject to program limitations in (b) and (d) of this subsection.

     (b) For WMIP, the department automatically enrolls clients, with the exception of American Indian/Alaska natives and clients eligible for both medicare and medicaid, when they:

     (i) Are aged, blind, or disabled;

     (ii) Are twenty-one years of age or older; and

     (iii) Receive categorically needy medical assistance.

     (c) American Indian/Alaska native (AI/AN) clients and clients who are eligible for both medicare and medicaid who meet the eligibility criteria in (b) of this subsection may voluntarily enroll or end enrollment in WMIP at any time.

     (d) The department will not enroll a client in WMIP, or will end an enrollee's enrollment in WMIP when the client has, or becomes eligible for, CHAMPUS/TRICARE or any other third-party healthcare coverage that would:

     (i) Require the department to either exempt the client from enrollment in managed care; or

     (ii) End the enrollee's enrollment in managed care.

     (e) A client or enrollee in WMIP, or the client's or enrollee's representative, may end enrollment from the MCO at any time without cause. The client may then reenroll at any time with the MCO. The department ends enrollment for clients prospectively to the first day of the month following the request to end enrollment, except as provided in (f) of this subsection.

     (f) A client or enrollee may request that the department retroactively end enrollment from WMIP. On a case-by-case basis, the department may retroactively end enrollment from WMIP when, in the department's judgment:

     (i) The client or enrollee has a documented and verifiable medical condition; and

     (ii) Enrollment in managed care could cause an interruption of on-going treatment that could jeopardize the client's or enrollee's life or health or ability to attain, maintain, or regain maximum function.

     (5) In addition to the scope of medical care services described in WAC 388-538-095, WMIP includes mental health, chemical dependency treatment, and long-term care services.

     (6) The department sends each client written information about covered services when the client is eligible to enroll in WMIP, and any time there is a change in covered services. In addition, the department requires MCOs to provide new enrollees with written information about covered services. This notice informs the client about the right to end enrollment and how to do so.



[Statutory Authority: RCW 74.08.090 and 74.09.522. 08-15-110, § 388-538-061, filed 7/18/08, effective 8/18/08; 06-03-081, § 388-538-061, filed 1/12/06, effective 2/12/06. Statutory Authority: RCW 74.08.090, 74.09.522, 2003 E1 c 25 § 201(4), 2004 c 276 § 201(4), 42 USC 1396N (section 1915 (b) and (c) of the Social Security Act of 1924). 05-01-066, § 388-538-061, filed 12/8/04, effective 1/8/05.]