WAC 388-538-130   Exemptions and ending enrollment in managed care.  (1) The department exempts a client from mandatory enrollment in managed care or ends an enrollee's enrollment in managed care as specified in this section.

     (2) A client or enrollee, or the client's or enrollee's representative as defined in RCW 7.70.065, may request the department to exempt or end enrollment in managed care as described in this section.

     (a) If a client requests exemption prior to the enrollment effective date, the client is not enrolled until the department approves or denies the request.

     (b) If an enrollee requests to end enrollment, the enrollee remains enrolled pending the department's final decision, unless staying in managed care would adversely affect the enrollee's health status.

     (c) The client or enrollee receives timely notice by telephone or in writing when the department approves or denies the client's or enrollee's request. The department follows a telephone denial by written notification. The written notice contains all of the following:

     (i) The action the department intends to take;

     (ii) The reason(s) for the intended action;

     (iii) The specific rule or regulation supporting the action;

     (iv) The client's or enrollee's right to request a hearing; and

     (v) A translation into the client's or enrollee's primary language when the client or enrollee has limited English proficiency.

     (3) A managed care organization (MCO) or primary care case management (PCCM) provider may request the department to end enrollment. The request must be in writing and be sufficient to satisfy the department that the enrollee's behavior is inconsistent with the MCO's or PCCM provider's rules and regulations (e.g., intentional misconduct). The department does not approve a request to remove an enrollee from managed care when the request is solely due to an adverse change in the enrollee's health or the cost of meeting the enrollee's healthcare needs. The MCO or PCCM provider's request must include documentation that:

     (a) The provider furnished clinically appropriate evaluation(s) to determine whether there is a treatable problem contributing to the enrollee's behavior;

     (b) Such evaluation either finds no treatable condition to be contributing, or after evaluation and treatment, the enrollee's behavior continues to prevent the provider from safely or prudently providing medical care to the enrollee; and

     (c) The enrollee received written notice of the provider's intent to request the enrollee's removal, unless the department has waived the requirement for provider notice because the enrollee's conduct presents the threat of imminent harm to others. The provider's notice must include:

     (i) The enrollee's right to use the provider's grievance system as described in WAC 388-538-110 and 388-538-111; and

     (ii) The enrollee's right to use the department's hearing process, after the enrollee has exhausted all grievance and appeals available through the provider's grievance system (see WAC 388-538-110 and 388-538-111 for provider grievance systems, and WAC 388-538-112 for the hearing process for enrollees).

     (4) When the department receives a request from an MCO or PCCM provider to remove an enrollee from enrollment in managed care, the department attempts to contact the enrollee for the enrollee's perspective. If the department approves the request, the department sends a notice at least ten days in advance of the effective date that enrollment will end. The notice includes:

     (a) The reason the department approved ending enrollment; and

     (b) Information about the enrollee's hearing rights.

     (5) The department will exempt a client from mandatory enrollment or end an enrollee's enrollment in managed care when any of the following apply:

     (a) The client or enrollee is receiving foster care placement services from the division of children and family services (DCFS);

     (b) The client has or the enrollee becomes eligible for medicare, basic health (BH), CHAMPUS/TRICARE, or any other third-party healthcare coverage comparable to the department's managed care coverage that would require exemption or involuntarily ending enrollment from:

     (i) An MCO, in accordance with the department's managed care contract; or

     (ii) A primary care case management (PCCM) provider, according to the department's PCCM contract.

     (c) The enrollee is no longer eligible for managed care.

     (6) The department will grant a client's request for exemption or an enrollee's request to end enrollment when:

     (a) The client or enrollee is American Indian/Alaska native (AI/AN) as specified in WAC 388-538-060(2);

     (b) The client or enrollee has been identified by the department as a child who meets the definition of "children with special healthcare needs";

     (c) The client or enrollee is homeless or is expected to live in temporary housing for less than one hundred twenty days from the date of the request; or

     (d) The client or enrollee speaks limited English or is hearing impaired and the client or enrollee can communicate with a provider who communicates in the client's or enrollee's language or in American sign language and is not available through the MCO and the MCO does not have a provider available who can communicate in the client's language and an interpreter is not available.

     (7) On a case-by-case basis, the department may grant a client's request for exemption or an enrollee's request to end enrollment when, in the department's judgment, the client or enrollee has a documented and verifiable medical condition, and enrollment in managed care could cause an interruption of treatment that could jeopardize the client's or enrollee's life or health or ability to attain, maintain, or regain maximum function.

     (8) Upon request, the department may exempt the client or end enrollment for the period of time the circumstances or conditions that lead to exemption or ending enrollment are expected to exist. The department may periodically review those circumstances or conditions to determine if they continue to exist. If the department approves the request for a limited time, the client or enrollee is notified in writing or by telephone of the time limitation, the process for renewing the exemption or the ending of enrollment.



[Statutory Authority: RCW 74.08.090 and 74.09.522. 08-15-110, § 388-538-130, filed 7/18/08, effective 8/18/08; 06-03-081, § 388-538-130, filed 1/12/06, effective 2/12/06; 03-18-111, § 388-538-130, filed 9/2/03, effective 10/3/03. Statutory Authority: RCW 74.09.080, 74.08.510, [74.08.]522,74.09.450 , 1115 Waiver, 42 U.S.C. 1396. 02-01-075, § 388-538-130, filed 12/14/01, effective 1/14/02. Statutory Authority: RCW 74.08.090, 74.09.510 and [74.09.]522 and 1115 Federal Waiver, 42 U.S.C. 1396 (a), (e), (p), 42 U.S.C. 1396r-6(b), 42 U.S.C. 1396u-2. 00-04-080, § 388-538-130, filed 2/1/00, effective 3/3/00. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057 and 74.08.090. 98-16-044, § 388-538-130, filed 7/31/98, effective 9/1/98. Statutory Authority: RCW 74.08.090 and 1995 2nd sp.s. c 18. 95-18-046 (Order 3886), § 388-538-130, filed 8/29/95, effective 9/1/95. Statutory Authority: RCW 74.08.090. 93-17-039 (Order 3621), § 388-538-130, filed 8/11/93, effective 9/11/93.]