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182-557-0100  <<  182-557-0200 >>   182-557-0225

PDFWAC 182-557-0200

Health home programEligibility.

(1) To be eligible for the health home program, a client must:
(a) Be a recipient of categorically needy health care coverage 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
(2) A person is ineligible to receive health home services when:
(a) The person has third-party coverage that provides comparable health care services; or
(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.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-24-111, § 182-557-0200, filed 12/6/17, effective 1/6/18; WSR 15-17-065, § 182-557-0200, filed 8/14/15, effective 9/14/15. Statutory Authority: RCW 41.05.021 and 2011 c 316. WSR 13-12-002, § 182-557-0200, filed 5/22/13, effective 7/1/13. WSR 11-14-075, recodified as § 182-557-0200, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500, 74.09.520, and 2007 c 259, § 4. WSR 07-20-048, § 388-557-0200, filed 9/26/07, effective 11/1/07.]
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