Wash. Admin. Code § 182-557-0200 - Health home program-Eligibility
(1) To be
eligible for the health home program, a client must:
(a) Be a recipient of categorically needy
health care coverage or be eligible for services under an alternative benefits
plan (ABP), as described in WAC 182-501-0060, through:
(i) Fee-for-service, including full dual
eligible clients; or
(ii) An
agency-contracted managed care organization.
(b) Have one or more chronic conditions as
defined in WAC 182-557-0100; and
(c) Have a risk score of 1.5 or greater
measured either with algorithms developed by the department of social and
health services or the agency's clinical eligibility tool located at
https://www.hca.wa.gov/assets/billers-and-providers/Clinical_Eligibility_Tool.xls.
(2) A person is ineligible to
receive health home services when:
(a) The
person is enrolled in a third-party medical insurance plan. For purposes of
this section, a medical insurance plan does not include plans that offer only
dental, vision, pregnancy, or maternity care services.
(b) The person has a risk score of less than
1.0 for six consecutive months and has not received health home
services.
(3) When the
agency determines a client is eligible for health home services, the agency
enrolls the client with a qualified health home in the coverage area where the
client lives.
(a) The client may decline
health home services or change to a different qualified health home or a
different health home care coordinator.
(b) If the client chooses to participate in
the health home program, a health home care coordinator will:
(i) Work with the participant to develop a
health action plan that describes the participant's health goals and includes a
plan for reaching those goals; and
(ii) Provide health home services at a level
appropriate to the participant's needs.
(4) A participant who does not agree with a
decision regarding health home services, including a decision regarding the
client's eligibility to receive health home services, has the right to an
administrative hearing as described in chapter 182-526 WAC.
Notes
Statutory Authority:
RCW
41.05.021 and
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