(1) The medicaid
agency pays apple health managed care organizations (MCOs) monthly capitated
premiums that:
(a) Have been developed using
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 analysis of
historical cost, rate information, or both; and
(e) Are paid based on legislative
allocations.
(2) The MCO
is solely responsible for payment of MCO-contracted health care services. The
agency will not pay for a service that is the MCO's responsibility, even if the
MCO has not paid the provider for the service.
(3) Home health services delivered through
MCOs involving an in-home visit by a provider require the provider to comply
with electronic visit verification requirements. See WAC
182-551-2220.
(4) The agency pays MCOs a service-based
enhancement rate for wraparound with intensive services (WISe) administered by
a certified WISe provider who holds a current behavioral health agency license
issued by the department of health under chapter
246-341 WAC.
(5) For crisis services, the MCO must
determine whether the person receiving the services is eligible for Washington
apple health or if the person has other insurance coverage.
(6) The agency may require corrective action
for:
(a) Substandard rates of clinical
performance measures;
(b)
Deficiencies found in audits and on-site visits; or
(c) Findings of noncompliance with any
contractual, state, or federal requirements.
(7) The agency may:
(a) Impose sanctions for an MCO's
noncompliance with any contractual, state, or federal requirements including,
but not limited to, intermediate sanctions as described in
42 C.F.R. Sec.
438.700 and
42 C.F.R. Sec.
438.702; and
(b) Apply a monthly penalty assessment
associated with poor performance on selected behavioral health performance
measures.
(8) As
authorized by 42 C.F.R. Sec.
438.702(b), if an MCO fails
to meet any material obligation under the MCO contract including, but not
limited to, the items listed in
42 C.F.R. Sec.
438.700 (b), (c), or (d),
the agency may impose the maximum allowable sanction on a per-occurrence,
per-day basis until the agency determines the MCO has:
(a) Corrected the violation; and
(b) Remedied any harm caused by the
noncompliance.
Notes
Wash. Admin.
Code §
182-538-070
Amended by
WSR
15-24-098, Filed 12/1/2015, effective
1/1/2016
Amended by
WSR
18-08-035, Filed 3/27/2018, effective
4/27/2018
Amended by
WSR
19-24-063, Filed 11/27/2019, effective
1/1/2020
Amended by
WSR
23-03-063, Filed 1/12/2023, effective
2/12/2023
Amended by
WSR
23-24-026, Filed 11/29/2023, effective
1/1/2024
Amended by
WSR
24-08-060, Filed 3/29/2024, effective
4/29/2024
Statutory Authority:
RCW
41.05.021, 42 C.F.R. 438. 13-02-010,
§182-538-070, filed 12/19/12, effective 2/1/13. 11-14-075, recodified as
§182-538-070, filed 6/30/11, effective 7/1/11. Statutory Authority:
RCW
74.08.090 and
74.09.522. 08-15-110, §
388-538-070, filed 7/18/08, effective 8/18/08; 06-03-081, § 388-538-070, filed
1/12/06, effective 2/12/06. Statutory Authority:
RCW
74.08.090,
74.09.522, 2003 E 1 c 25§ 201(4),
2004 c 276 § 201(4), 42
U.S.C. 1396 N (section 1915(b) and (c) of the
Social Security Act of 1924). 05-01-066, § 388-538-070, filed 12/8/04,
effective 1/8/05. Statutory Authority:
RCW
74.08.090,
74.09.522. 03-18-109, §
388-538-070, 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, § 388-538-070, 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, § 388-538-070, filed
2/1/00, effective 3/3/00. Statutory Authority:
RCW
74.08.090. 96-24-073, § 388-538-070, filed
12/2/96, effective 1/2/97. Statutory Authority:
RCW
74.08.090 and 1995 2nd sp.s. c 18. 95-18-046
(Order 3886), § 388-538-070, filed 8/29/95 effective 9/1/95. Statutory
Authority:
RCW
74.08.090. 93-17-039 (Order 3621), §
388-538-070, filed 8/11/93, effective
9/11/93.
