Chapter 182-565 WAC

(1) The Washington state health-related social needs (HRSN) program allows qualifying Washington apple health clients to receive limited, evidence-based, nonmedical services to address a client's unmet, adverse social conditions that contribute to poor health.

(2) Subject to available funds, allowable expenditures are covered up to the medicaid agency's financial limit.

(3) Housing transition navigation services are designed to remove barriers to affordable housing. Services include transition costs and housing deposits to assist with identifying, coordinating, securing, or funding one-time services and modifications necessary to help a client establish a basic household.

(4) The agency may contract with third parties to administer funds for the HRSN program.

(5) This subchapter applies to the portion of HRSN services administered by the medicaid agency.

The following definitions and those found in chapter 182-500 WAC apply to this chapter:

(1) "Activities of daily living" has the same meaning as defined in 24 C.F.R. § 700.105 and WAC 388-106-0010.

(2) "Adverse benefit determination" means one or more of the following:

(a) The denial or limited authorization of a requested health-related social needs service, including determinations based on the type of service, requirements for medical necessity, appropriateness, setting, or effectiveness of a service;

(b) The reduction, suspension, or termination of a previously authorized service;

(c) The denial, in whole or in part, of payment for a service;

(d) The failure to provide services in a timely manner, as defined by the state; or

(e) The failure of the third-party administrator (TPA) to act within the time frames provided in WAC 182-565-0170 for standard resolution of grievances and appeals.

(3) "At risk of homelessness" has the same meaning as defined in 24 C.F.R. § 91.5.

(4) "Behavioral health need" means:

(a) A mental health need, where there is a need for improvement, stabilization, or prevention of deterioration of functioning (including ability to live independently without support) resulting from the presence of a mental illness; or

(b) A substance use need, where an assessment using the American Society of Addiction Medicine (ASAM) criteria indicates that the person meets at least ASAM level 1.0, indicating the need for outpatient substance use disorder treatment.

(5) "Complex physical need" means a long continuing or indefinite physical condition requiring improvement, stabilization, or prevention of deterioration of functioning (including the ability to live independently without support).

(6) "Demonstration period" means the period starting July 1, 2023, and ending on June 30, 2028.

(7) "Homeless" has the same meaning as defined in 24 C.F.R. § 91.5.

(8) "Rent" means an eligible client's monthly housing payment and includes past due or forward rent payments as allowed under the health-related social needs program.

(1) To be eligible for housing transition navigation services, a person must be:

(a) Enrolled in foundational community supports as described in WAC 182-559-100;

(b) Determined by the third-party administrator as having met at least one of the following health needs-based criteria upon program enrollment:

(i) A behavioral health need;

(ii) A need for hands-on assistance with one or more activities of daily living;

(iii) A need for assistance with three or more activities of daily living; or

(iv) A complex physical health need; and

(c) Homeless or at risk of homelessness, with the exception of the annual income requirement in 24 C.F.R. § 91.5 (1)(i).

(2) To be eligible for the pantry stocking service, a person must:

(a) Meet the requirements in subsection (1) of this section; and

(b) Be experiencing low food security or very low food security, as those terms are defined by the United States Department of Agriculture.

(1) The services described in WAC 182-565-0140 are short term and limited to a maximum of six months.

(2) The medicaid agency authorizes payment for approved housing transition navigation services for as long as it has funding through the health-related social needs program.

(3) Housing transition navigation services are subject to available funds for each service category in WAC 182-565-0100.

(4) Payments made for services described in WAC 182-565-0100(1) must not exceed six months in total during the demonstration period, to include both retrospective and prospective payments.

Subject to the limitations in WAC 182-565-0130, the medicaid agency pays for short-term housing transition and moving costs necessary to establish a client's basic household, to include:

(1) Security deposits;

(2) Application fees;

(3) Background checks;

(4) The first month's rent as required by the landlord for occupancy;

(5) Utility set-up fees, deposits, first month payments and up to six months of arrears, if necessary, to set up services in a new residence;

(6) Relocation expenses;

(7) A 30-day supply of groceries once per calendar year at the time of move in.

(a) The grocery supply must not exceed 200 percent of the U.S. Department of Agriculture (USDA) SNAP allowance for one month.

(b) This service must be provided in conjunction with the dietary guidelines for Americans and related resources; and

(8) Basic household goods and furniture.

A service provider must be contracted with the foundational community supports (FCS) third-party administrator(s) specifically for FCS services, including payment of transition assistance funds, and meet the requirements of WAC 182-559-200. Other contracted models may be considered within other contracting structures as negotiated by the medicaid agency.

(1) Nothing in this chapter is intended to provide a legal right to any person to any service referenced in this chapter.

(2) The services provided under this chapter are strictly limited to the authority granted to the medicaid agency under the medicaid transformation project and available funds, as determined solely by the agency.

(3) The services described in this chapter must be approved under the explicit authority of the medicaid transformation project.

(4) Nothing in this section limits a person's right to request an administrative hearing under applicable law.

(1) General requirements. This section contains information about the third-party administrator (TPA) grievance and appeal process and the medicaid agency's administrative hearing process for clients relating to housing transition navigation services.

(a) The TPA must have a grievance and appeal process and access to an agency administrative hearing to allow clients to file grievances and seek review of a TPA adverse benefit determination as defined in WAC 182-565-0110.

(b) The agency's administrative hearing rules in chapter 182-526 WAC apply to agency administrative hearings requested by a client to review the resolution of a client's appeal of a TPA adverse benefit determination.

(c) The TPA's policies and procedures regarding the grievance process must be approved by the agency.

(d) The TPA must maintain records of grievances and appeals.

(2) TPA grievance and appeal process. The TPA grievance and appeal process must include:

(a) A grievance process for addressing complaints about any matter that is not an adverse benefit determination;

(b) A TPA appeals process to address a client's request for review of a TPA adverse benefit determination;

(c) Access to the agency's administrative hearing process for review of a TPA's resolution of an appeal; and

(d) Allowing the client and the client's authorized representative to file grievances and appeals orally or in writing. The TPA cannot require clients to provide written follow up for a grievance or an appeal that the TPA received orally.

(3) Notice requirements.

(a) The TPA must send written notice when it:

(i) Approves the client's health-related social needs services (HRSN) eligibility and authorizes the delivery of services; or

(ii) Denies the client's HRSN eligibility.

(b) The TPA must follow the notice and timeline requirements under chapter 182-518 WAC for these notices.

(4) The TPA grievance process.

(a) A client or client's authorized representative may file a grievance with the TPA. A provider may not file a grievance on behalf of a client without the client's written consent.

(b) Clients do not have a right to an agency administrative hearing regarding the resolution of a grievance.

(c) The TPA must acknowledge receipt of each grievance either orally or in writing within two business days.

(d) The TPA must notify clients of the resolution of grievances within five business days of determination.

(5) The TPA appeals process.

(a) A client, the client's authorized representative, or a provider acting on behalf of the client with the client's written consent may appeal a TPA adverse benefit determination.

(b) The TPA must treat oral inquiries about appealing an adverse benefit determination as an appeal to establish the earliest possible filing date for the appeal. The TPA must confirm the oral appeal in writing.

(c) The TPA must acknowledge in writing the receipt of each appeal to both the client and the requesting provider within five calendar days of receiving the appeal request. The appeal acknowledgment letter sent by the TPA serves as written confirmation of an appeal filed orally by a client.

(d) The client must file an appeal of a TPA action within 60 calendar days of the date on the TPA's notice of adverse benefit determination.

(e) The TPA must continue services pending the results of an appeal or subsequent agency administrative hearing.

(f) The TPA internal appeal process must:

(i) Provide the client a reasonable opportunity to present evidence and allegations of fact or law, both in person and in writing;

(ii) Provide the client and the client's representative the client's case file, other documents and records, and any new or additional evidence considered, relied upon, or generated by the TPA (or at the direction of the TPA) in connection with the action. This information must be provided free of charge in advance of the resolution time frame for appeals as specified in this section; and

(iii) Include as parties to the appeal:

(A) The client and the client's authorized representative; and

(B) The legal representative of the deceased client's estate.

(g) The TPA must ensure that the people making decisions on appeals were not involved in any previous level of review or decision making.

(h) Time frames for resolution of appeals. The TPA:

(i) Must resolve each appeal and provide notice as expeditiously as the client's health condition requires and no longer than three calendar days after the day the TPA receives the appeal.

(ii) May extend the time frame by an additional 14 calendar days if it is necessary in order to complete the appeal.

(i) Notice of resolution of appeal. The notice of the resolution of the appeal must:

(i) Be in writing and be sent to the client and the requesting provider;

(ii) Include the results of the resolution of the appeal process and the date it was completed; and

(iii) Include information on the client's right to request an agency administrative hearing and how to do so as provided in the agency hearing rules under WAC 182-526-0095, if the appeal is not resolved wholly in favor of the client.

(j) Deemed completion of the TPA appeal process. If the TPA fails to adhere to the notice and timing requirements for appeals, the client is deemed to have completed the TPA's appeals process and may request an agency administrative hearing under WAC 182-526-0095.

(6) Agency administrative hearing.

(a) Only a client or the client's authorized representative may request an agency administrative hearing. A provider may not request a hearing on behalf of a client.

(b) If the client does not agree with the TPA's resolution of an appeal at the completion of the TPA appeal process, the client may file a request for an agency administrative hearing based on the rules in this section and the agency hearing rules in chapter 182-526 WAC. The client must request an agency administrative hearing within 90 calendar days of the notice of resolution of appeal.

(c) The TPA is an independent party and responsible for its own representation in any administrative hearing, appeal to the board of appeals, and any subsequent judicial proceedings.

(7) Effect of reversed resolutions of appeals. If the TPA or a final order as defined in chapter 182-526 WAC reverses a decision to deny or limit services, the TPA must authorize or provide the disputed services promptly and as expeditiously as the client's circumstances require.

(8) Funding unavailable. When available resources are exhausted, any appeals process or agency administrative hearing process related to a request to authorize a service will be terminated, since services cannot be authorized without funding regardless of medical necessity.

(1) Rent and temporary housing payments provide stable independent living situations for clients in housing transitions who are homeless or at risk of homelessness. The payments may cover rent for up to six months per demonstration period.

(2) Subject to available funds, allowable expenditures are covered up to the medicaid agency's financial limit.

(3) The agency may contract with third parties to administer funds for the HRSN program.

(4) This subchapter applies to the portion of health-related social needs services administered by the medicaid agency.

The definitions in WAC 182-565-0110 and those found in chapter 182-500 WAC apply to this chapter.

To be eligible for rental services, a person must meet the requirements identified in WAC 182-565-0120.

(1) The services described in WAC 182-565-0240 are short term and limited to a maximum of six months.

(2) The medicaid agency reimburses rental payments only for residences that meet housing habitability standards for safety, sanitation, and habitability.

(3) Rental services are subject to available funds for each service category in WAC 182-565-0240.

(4) Payments made for services described in WAC 182-565-0240 must not exceed six months in total during the demonstration period, to include both retrospective and prospective payments.

Subject to the limitations in WAC 182-565-0230, the medicaid agency may pay for past-due or future rent payments.

(1) The rental payments identified in WAC 182-565-0240 must be used only for independent living situations, such as in-home and interim housing settings that meet the housing habitability standards found on the agency's website.

(2) The medicaid agency does not reimburse for facilities:

(a) That have been temporarily converted to shelters (e.g., gymnasiums or convention centers); or

(b) Without private sleeping spaces available to residents 24 hours a day.

Rental service providers must meet the requirements in WAC 182-565-0150.

Rental services are subject to the limitation of scope of benefits described in WAC 182-565-0160.

Grievances and appeals related to rental services follow the process described in WAC 182-565-0170.

Medical respite programs offer a lower-intensity care setting for patients who are homeless or at risk of homelessness and who would otherwise require a hospital stay or lack a safe option for discharge and recovery. Medical respite programs must meet the minimum operating standards and meet the required medical respite standards of the facility through the national institute for medical respite care (NIMRC), offer required services, meet local codes and ordinances for licensing, safety, and occupancy.

The following definitions and those found in chapter 182-500 WAC apply to this chapter:

"Behavioral health need" - See WAC 182-565-0110.

"Demonstration period" - See WAC 182-565-0110.

"Facility" - The physical location where the medical respite program provides medical respite care services to clients.

"Homelessness" or "at risk of homelessness" - See WAC 182-565-0110.

"Medical respite care services" - Temporary, short-term room and board, health care services and supports.

"Medical respite program (a.k.a., recuperative care)" - A not-for-profit organization that serves clients whose medical and behavioral health need medical respite care services.

"Rolling 12-month period" - Calculation of eligibility based on the 12 months immediately preceding any new request for services. The rolling 12-month period moves forward with each new episode of care ensuring a consistent limit on total days used, capped at 180 days within that rolling year.

(1) A person must have or be eligible for apple health coverage before entering a medical respite program. If a person does not have coverage and wants to participate in the medical respite program, the program can help them register for coverage.

(2) To receive medical respite care services, a client must have a qualifying acute medical condition that requires treatment and/or care, does not require a hospital inpatient stay, and is too ill or frail to recover from a physical illness or injury while living on the street and is at risk of being homeless or experiencing homelessness.

A client is eligible for admission to a medical respite program when the client:

(1) Is experiencing homelessness or is at risk of becoming homeless;

(2) Is experiencing medical and behavioral health needs and meets one of the following:

(a) Has recently been discharged from a hospital setting including emergency room visits; or

(b) Is referred from a medical clinic (e.g., a primary care clinic, federally qualified health center, urgent care facility, mobile medical clinic, street medicine) and both of the following are true:

(i) The client has an acute medical condition that can be safely managed in a sheltered outpatient setting; and

(ii) Medical respite care is appropriate to provide the conditions to support recovery from the acute medical condition;

(3) Can perform activities of daily living (ADLs) with minimal or no assistance; and

(4) Has signed an admission agreement.

(1) The medical respite program will discharge the client when the client meets one of the following:

(a) No longer benefits from medical respite care services;

(b) Reaches the 90-day utilization limit for their current admission or the six-month utilization limit during the rolling 12-month period; or

(c) An appropriate alternative service becomes available.

(2) The six-month utilization period limit is shared amongst other housing support services including, but not limited to, housing transition navigation services, and rent/temporary housing.

(3) The medical respite program must begin discharge planning upon the client's admission and maintain discharge planning throughout the client's stay at the facility.

(4) To discharge a client, the program must provide a referral tailored to client needs, to include:

(a) Potential housing options;

(b) Referrals to appropriate health care providers;

(c) Supportive services; and

(d) Provide advance and written notice of discharge to the client, and as applicable, the client's health care provider, managed care organization, and caregivers.

(5) Upon admission and discharge, the program must provide an admission or discharge summary to the client, the health care provider, the managed care organization if applicable, and other persons or entities requested by the client. The admission or discharge summary must include the following:

(a) Written medication list and medication refill information;

(b) Admitting primary diagnosis following discharge from the hospital or referral from a medical clinic;

(c) Estimated or documented length of stay in the medical respite program;

(d) Ongoing medical needs or conditions;

(e) Instructions for accessing relevant resources within the community including shelters or other housing options;

(f) A list of follow-up appointments and contact information for treating providers;

(g) Special medical instructions (e.g., weight-bearing limitations, dietary precautions, allergies, wound orders);

(h) Pain management plan; and

(i) A point of contact for the client.

(6) The medical respite program must ensure adequate protocols are in place for the transfer of client information and access to electronic records to appropriate providers and, if applicable, the client's managed care organization.

(1) Medical respite programs must provide or arrange for the provision of the following services:

(a) Room and board which must include, at a minimum:

(i) A dedicated bed that is available to the client 24 hours a day, seven days a week;

(ii) Three meals a day in accordance with medical respite standards;

(iii) Laundry services;

(iv) Secured storage for personal belongings and medications;

(v) Compliance with standards set by NIMRC; and

(vi) Compliance with local codes and ordinances for licensing, safety, and occupancy.

(b) The medical respite provider must notify the agency if they no longer meet the requirements to provide medical respite care.

(2) The agency may conduct a post pay review to ensure medical respite care requirements are met. If requirements are not met at the time services are provided, the agency may recoup payment.

The medical respite program must provide coordination such that the client can access the following services:

(1) Clinical assessments;

(2) Behavioral health screenings for psychosocial needs;

(3) Medical case management;

(4) Case management support in accessing benefits and housing;

(5) Twenty-four hour wellness checks;

(6) Medical oversight to include:

(a) Medication monitoring; and

(b) Ongoing assessments to determine effectiveness of care plan and/or treatments;

(7) Minor clinical interventions (e.g., wound care, infection control, nonpharmacological pain management);

(8) Arrangement for transportation for the client to and from appointments that are not covered by nonemergency transportation as defined in WAC 182-546-5500; and

(9) Access to equipment for telehealth services and communication related to medical needs or care.

Medical respite care services are short-term. For medical respite care, short-term is defined as up to 90 days per instance, and up to six months cumulative utilization per rolling 12-month period with the limitation that the six-month utilization limit is shared amongst other housing support services. The other housing support services that share the six-month utilization limit with medical respite care include, but are not limited to, housing transition navigation services and rent/temporary housing. See WAC 182-565-0340.

A medical respite program may provide medical respite care services when the medical respite program:

(1) Is enrolled as a Washington apple health medicaid provider for claims to be paid and be able to provide documentation of proof of service;

(2) Meets the standards for medical respite care programs set by NIMRC;

(3) Completes all necessary agency forms and attestation and receives agency approval; and

(4) Meets local codes and ordinances for licensing, safety, and occupancy.

Grievance and appeals related to medical respite care services follow the process described in chapter 182-526 WAC.

(1) Washington state has nine accountable communities of health (ACHs), as defined in RCW 82.04.43395, each of which operates a regional community care hub. In addition, the federally recognized tribes in Washington operate a statewide native hub to support the delivery of whole-person care coordination.

(2) An eligible person may access any community care hub in the state of Washington. The community care hubs also work closely with managed care organizations, providers, and community partners to identify and engage apple health clients who are likely to have multiple health and social needs.

(3) Community care hubs provide case management, outreach, and education services to qualifying Washington apple health clients across Washington state.

(4) Subject to available funds, allowable expenditures are covered up to the medicaid agency's financial limit, as determined by the agency.

(5) This subchapter applies to the portion of health-related social needs (HRSN) services the agency administers through community care hubs.

"Clinical-risk factor" means physiological conditions that increase the likelihood of poor health outcomes.

"Community care hub (CCH)" means one of the nine regional centers managed and operated by one of the nine accountable communities of health (ACH). Each CCH organizes and supports a regional network of community-based organizations providing community-based care coordination and services to address health-related social (HRSN) needs. The medicaid agency contracts with the ACHs to provide the HRSN screening and referral service.

"Health-related social needs (HRSN)" means unmet, adverse social conditions (e.g., housing instability, homelessness, nutrition insecurity) that contribute to a person's poor health and result from underlying social determinants of health (conditions in which people are born, grow, work, and age).

"Social risk factor" means a social condition that negatively impacts a person's health and contributes to poor health outcomes and health inequities.

To be eligible to receive covered services through community care hubs, a person must be enrolled in Washington apple health and:

(1) Meet one or more of the following social risk factors:

(a) Be homeless or at risk of homelessness, as defined by 24 C.F.R. § 91.5, except for the annual income requirement in 24 C.F.R. § 91.5 (1)(i);

(b) Meet the U.S. Department of Agriculture's (USDA) definition of low food security or very low food security;

(c) Be experiencing poverty or near poverty, as defined by income below 200 percent of the federal poverty level (FPL); or

(d) Screen positive for a health-related social need; and

(2) Have at least one of the following clinical risk factors:

(a) Complex behavioral health needs;

(b) Developmental disability needs;

(c) Assessed as having a complex physical health need;

(d) Experienced interpersonal violence;

(e) Repeated emergency department use and crisis encounters;

(f) Be pregnant or up to 12 months postpartum; or

(g) Be a child age six or younger who currently has at least one of the following conditions:

(i) Malnutrition, risk of developmental or growth delay, or impairment because of insufficient nutrition as a clinical risk factor for case management related to nutrition services only;

(ii) Child maltreatment, as defined by the Centers for Disease Control and Prevention. (See https://www.cdc.gov/violence-prevention/?CDC_AAref_Val=https://www.cdc.gov/violenceprevention/pdf/%2520CM_Surveillancea.pdf);

(iii) Is a child with a special health care need (CYSHCN) as defined by the Health Resources and Services Administration. (See https://mchb.hrsa.gov/programs-impact/focus-areas/children-youth-special-health-care-needs-cyshcn);

(iv) Low birth weight;

(v) A mental health condition; or

(vi) Health conditions, including behavioral health and developmental syndromes, stemming from trauma, child abuse, and neglect; or

(h) Be an adult age 65 or older who currently has at least one of the following:

(i) Two or more chronic conditions as defined in RCW 74.09.010;

(ii) Social isolation, which may place the person at risk for early death, neurocognitive disorders, sleep disruption, cardiovascular disease, or elder abuse;

(iii) Malnutrition as a clinical risk factor for case management related to nutrition services only;

(iv) Health conditions, including behavioral health and developmental syndromes, stemming from trauma, child abuse, and neglect; or

(v) Requires assistance with activities of daily living as defined in WAC 182-565-0110 or instrumental activities of daily living as defined in WAC 388-106-0010; or

(i) Be eligible under one of the following programs:

(i) Medicaid personal care (MPC) as described in WAC 388-106-0210;

(ii) Nursing facility care services as described in WAC 388-106-0355; or

(iii) Long-term care services as described in WAC 388-106-0045.

Community care hubs provide the following covered services:

(1) Screen clients for health needs and health-related social needs (HRSN);

(2) Check clients' eligibility to receive the case management, outreach, and education service;

(3) Refer clients to providers, community partners, or organizations that will address their HRSNs;

(4) Follow up to ensure clients' connection to services and completion of interventions;

(5) Track client outcomes;

(6) Provide technical assistance and capacity support to community partners or community-based organizations (CBOs); and

(7) Provide navigation assistance for benefit applications or referrals to HRSN services or other federal, state, and local community programs.