Chapter 182-557 WAC
Last Update: 8/24/22HEALTH HOMES
WAC Sections
| HTMLPDF | 182-557-0050 | Health home—General. |
| HTMLPDF | 182-557-0100 | Health home program—Definitions. |
| HTMLPDF | 182-557-0200 | Health home program—Eligibility. |
| HTMLPDF | 182-557-0225 | Health home services—Methodology for calculating a person's risk score. |
| HTMLPDF | 182-557-0300 | Health home services—Confidentiality and data sharing. |
| HTMLPDF | 182-557-0350 | Health home—Grievance and appeals. |
| HTMLPDF | 182-557-0400 | Health home—Payment. |
| HTMLPDF | 182-557-0500 | Involuntary disenrollment from a health home. |
PDF182-557-0050
Health home—General.
(1) The agency's health home program provides patient-centered care to participants who:
(a) Have at least one chronic condition as defined in WAC 182-557-0100; and
(b) Are at risk of a second chronic condition as evidenced by a minimum predictive risk score of 1.5.
(2) The health home program offers six care coordination activities to assist participants in self-managing their conditions and navigating the health care system:
(a) Comprehensive or intensive care management including, but not limited to, assessing participant's readiness for self-management, promoting self-management skills, coordinating interventions tailored to meet the participant's needs, and facilitating improved outcomes and appropriate use of health care services;
(b) Care coordination and health promotion;
(c) Comprehensive transitional care between care settings including, but not limited to, after discharge from an inpatient facility (hospital, rehabilitative, psychiatric, skilled nursing, substance use disorder treatment or residential habilitation setting);
(d) Individual and family support services to provide health promotion, education, training and coordination of covered services for participants and their support network;
(e) Referrals to community and support services; and
(f) Use of health information technology (HIT) to link services between the health home and participants' providers.
(3) The agency's health home program does not:
(a) Change the scope of services for which a participant is eligible under medicare or a Title XIX medicaid program;
(b) Interfere with the relationship between a participant and his or her chosen agency-enrolled provider(s);
(c) Duplicate case management activities the participant is receiving from other providers or programs; or
(d) Substitute for established activities that are available through other programs administered by the agency or other state agencies.
(4) Qualified health home providers must:
(a) Contract with the agency to provide services under this chapter to eligible participants;
(b) Accept the terms and conditions in the agency's contract;
(c) Be able to meet the network and quality standards established by the agency;
(d) Accept the rates established by the agency; and
(e) Comply with all applicable state and federal requirements.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-17-065, § 182-557-0050, filed 8/14/15, effective 9/14/15. Statutory Authority: RCW 41.05.021. WSR 13-21-048, § 182-557-0050, filed 10/11/13, effective 11/11/13. Statutory Authority: RCW 41.05.021 and 2011 c 316. WSR 13-12-002, § 182-557-0050, filed 5/22/13, effective 7/1/13. WSR 11-14-075, recodified as § 182-557-0050, 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, § 388-557-0050, filed 9/26/07, effective 11/1/07.]
PDF182-557-0100
Health home program—Definitions.
The following terms and definitions and those found in chapter 182-500 WAC apply to this chapter:
Action - For the purposes of this chapter, means one or more of the following:
(a) The denial of eligibility for health home services.
(b) The denial or limited authorization by the qualified health home of a requested health home service, including a type or level of health home service.
(c) The reduction, suspension, or termination by the qualified health home of a previously authorized health home service.
(d) The failure of a qualified health home to provide authorized health home services or provide health home services as quickly as the participant's condition requires.
Agency - See WAC 182-500-0010.
Chronic condition - Means mental health conditions, substance use disorders, asthma, diabetes, heart disease, cancer, cerebrovascular disease, coronary artery disease, dementia or Alzheimer's disease, intellectual disability, HIV/AIDS, renal failure, chronic respiratory conditions, neurological disease, gastrointestinal, hematological, and musculoskeletal conditions.
Client - For the purposes of this chapter, means a person who is eligible to receive health home services under this chapter.
Clinical eligibility tool - Means an electronic spreadsheet that determines a client's risk score using the client's age, gender, diagnoses, and medications.
Coverage area - Means a geographical area composed of one or more counties within Washington state. The map of the coverage areas and the list of the qualified health homes is located at https://www.hca.wa.gov/billers-providers/programs-and-services/health-homes.
Fee-for-service (FFS) - See WAC 182-500-0035.
Full dual eligible - For the purpose of this chapter, means a fee-for-service client who receives qualified medicare beneficiary coverage or specified low-income medicare beneficiary coverage and categorically needy health care coverage.
Grievance - Means an expression of a participant's dissatisfaction about any matter other than an action. Possible subjects for grievances include the quality of health home services provided when an employee of a qualified health home provider is rude to the participant or shares confidential information about the participant without their permission.
Health action plan - Means a plan that lists the participant's goals to improve and self-manage their health conditions and steps needed to reach those goals.
Health home care coordinator - Means staff employed by or subcontracted by the qualified health home to provide one or more of the six defined health home care coordination benefits listed in WAC 182-557-0050.
Health home services - Means services described in WAC 182-557-0050 (2)(a) through (f).
Medicaid - See WAC 182-500-0070.
Participant - Means a client who has agreed to receive health home services under the requirements of this chapter.
Qualified health home - Means an organization that contracts with the agency to provide health home services to participants in one or more coverage areas and meets the requirements in WAC 182-557-0050(4).
Risk score - Means a measure of the expected costs of the health care a client is likely to incur in the next twelve months that the agency calculates using an algorithm developed by the department of social and health services (DSHS) or the clinical eligibility tool.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-24-111, § 182-557-0100, filed 12/6/17, effective 1/6/18; WSR 15-17-065, § 182-557-0100, filed 8/14/15, effective 9/14/15. Statutory Authority: RCW 41.05.021 and 2011 c 316. WSR 13-12-002, § 182-557-0100, filed 5/22/13, effective 7/1/13. WSR 11-14-075, recodified as § 182-557-0100, 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, § 388-557-0100, filed 9/26/07, effective 11/1/07.]
PDF182-557-0200
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 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 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.]
PDF182-557-0225
Health home services—Methodology for calculating a person's risk score.
The agency uses eight steps to calculate a person's risk score.
(1) Step 1. Collect paid claims and health plan encounter data. The agency obtains a set of paid fee-for-service claims and managed care encounters for a client.
(a) For clients age 17 and younger, the agency uses all paid claims and encounters within the last 24 months.
(b) For clients age 18 and older, the agency uses all paid claims and encounters within the last 15 months.
(i) The claims and encounters include the international classification of diseases (ICD) diagnosis codes and national drug codes (NDC) submitted by health care providers. These are used in steps 2 and 3 to create a set of risk categories.
(ii) The agency uses two algorithms developed by the University of San Diego:
(A) Chronic illness and disability payment system (CDPS) which assigns ICD diagnosis codes to CDPS risk categories (see Table 3 in subsection (5)(b) of this section); and
(B) Medical Rx (MRx) which assigns NDCs to MRx risk categories (see Table 2 in subsection (3)(b) of this section).
(2) Step 2. Group ICD diagnosis codes into chronic illness and disability payment system risk categories.
(a) To group ICD diagnosis codes into the CDPS risk categories (see Table 1 in (b) of this subsection), the agency uses an ICD diagnosis code to CDPS risk categories crosswalk in subsection (1)(b)(ii)(A) of this section. Each of the ICD diagnosis codes listed is assigned to one risk category. If an ICD diagnosis code is not listed in the crosswalk it does not map to a risk category that is used in the calculation of the risk score.
(b) Table 1. Titles of Chronic Illness and Disability Payment System Risk Categories
CARVH | Cardiovascular, very high |
CARM | Cardiovascular, medium |
CARL | Cardiovascular, low |
CAREL | Cardiovascular, extra low |
PSYH | Psychiatric, high |
PSYM | Psychiatric, medium |
PSYML | Psychiatric, medium low |
PSYL | Psychiatric, low |
SKCM | Skeletal, medium |
SKCL | Skeletal, low |
SKCVL | Skeletal, very low |
CNSH | Central Nervous System, high |
CNSM | Central Nervous System, medium |
CNSL | Central Nervous System, low |
PULVH | Pulmonary, very high |
PULH | Pulmonary, high |
PULM | Pulmonary, medium |
PULL | Pulmonary, low |
GIH | Gastro, high |
GIM | Gastro, medium |
GIL | Gastro, low |
DIA1H | Diabetes, type 1 high |
DIA1M | Diabetes, type 1 medium |
DIA2M | Diabetes, type 2 medium |
DIA2L | Diabetes, type 2 low |
SKNH | Skin, high |
SKNL | Skin, low |
SKNVL | Skin, very low |
RENEH | Renal, extra high |
RENVH | Renal, very high |
RENM | Renal, medium |
RENL | Renal, low |
SUBL | Substance abuse, low |
SUBVL | Substance abuse, very low |
CANVH | Cancer, very high |
CANH | Cancer, high |
CANM | Cancer, medium |
CANL | Cancer, low |
DDM | Developmental Disability, medium |
DDL | Developmental Disability, low |
GENEL | Genital, extra low |
METH | Metabolic, high |
METM | Metabolic, medium |
METVL | Metabolic, very low |
PRGCMP | Pregnancy, complete |
PRGINC | Pregnancy, incomplete |
EYEL | Eye, low |
EYEVL | Eye, very low |
CERL | Cerebrovascular, low |
AIDSH | AIDS, high |
INFH | Infectious, high |
HIVM | HIV, medium |
INFM | Infectious, medium |
INFL | Infectious, low |
HEMEH | Hematological, extra high |
HEMVH | Hematological, very high |
HEMM | Hematological, medium |
HEML | Hematological, low |
(3) Step 3. Group national drug codes (NDCs) into MRx risk categories.
(a) To group the NDC codes into MRx risk categories (see Table 2 in (b) of this subsection), the agency uses a NDC code to MRx risk categories crosswalk in subsection (1)(b)(ii)(B) of this section.
(b) Table 2. Titles of Medicaid Rx Risk Categories
MRx1 | Alcoholism |
MRx2 | Alzheimer's |
MRx3 | Anti-coagulants |
MRx4 | Asthma/COPD |
MRx5 | Attention Deficit |
MRx6 | Burns |
MRx7 | Cardiac |
MRx8 | Cystic Fibrosis |
MRx9 | Depression/Anxiety |
MRx10 | Diabetes |
MRx11 | EENT |
MRx12 | ESRD/Renal |
MRx13 | Folate Deficiency |
MRx14 | CMV Retinitis |
MRx15 | Gastric Acid Disorder |
MRx16 | Glaucoma |
MRx17 | Gout |
MRx18 | Growth Hormone |
MRx19 | Hemophilia/von Willebrands |
MRx20 | Hepatitis |
MRx21 | Herpes |
MRx22 | HIV |
MRx23 | Hyperlipidemia |
MRx24 | Infections, high |
MRx25 | Infections, medium |
MRx26 | Infections, low |
MRx27 | Inflammatory/Autoimmune |
MRx28 | Insomnia |
MRx29 | Iron Deficiency |
MRx30 | Irrigating Solution |
MRx31 | Liver Disease |
MRx32 | Malignancies |
MRx33 | Multiple Sclerosis/Paralysis |
MRx34 | Nausea |
MRx35 | Neurogenic Bladder |
MRx36 | Osteoporosis/Pagets |
MRx37 | Pain |
MRx38 | Parkinsons/Tremor |
MRx39 | Prenatal Care |
MRx40 | Psychotic Illness/Bipolar |
MRx41 | Replacement Solution |
MRx42 | Seizure Disorders |
MRx43 | Thyroid Disorder |
MRx44 | Transplant |
MRx45 | Tuberculosis |
(4) Step 4. Remove duplicate risk categories. After mapping all diagnosis and drug codes to the risk categories, the agency eliminates duplicates of each client's risk categories so that there is only one occurrence of any risk category for each client.
(5) Step 5. Select the highest CDPS risk category within a disease group.
(a) The agency organizes CPDS risk categories into risk category groups of different intensity levels. The high risk category in each group is used in the calculation of the risk score. The lower level risk categories are eliminated from further calculations.
(b) Table 3. Chronic Disease Payment System Risk Category Groups
Group Description | Risk Categories (Ordered Highest to Lowest Intensity) |
AIDS/HIV and Infection | AIDSH, INFH, HIVM, INFM, INFL |
Cancer | CANVH, CANH, CANM, CANL |
Cardiovascular | CARVH, CARM, CARL, CAREL |
Central Nervous System | CNSH, CNSM, CNSL |
Diabetes | DIA1H, DIA1M, DIA2M, DIA2L |
Developmental Disability | DDM, DDL |
Eye | EYEL, EYEVL |
Gastrointestinal | GIH, GIM, GIL |
Hematological | HEMEH, HEMVH, HEMM, HEML |
Metabolic | METH, METM, METVL |
Pregnancy | PRGCMP, PRGINC |
Psychiatric | PSYH, PSYM, PSYML, PSYL |
Substance Abuse | SUBL, SUBVL |
Pulmonary | PULVH, PULH, PULM, PULL |
Renal | RENEH, RENVH, RENM, RENL |
Skeletal | SKCM, SKCL, SKCVL |
Skin | SKNH, SKNL, SKNVL |
(6) Step 6. Determine age/gender category.
(a) For each client, the agency selects the appropriate age/gender category. The 11 categories are listed in Table 4 in (b) of this subsection. The categories for ages below five and above 65 are gender neutral.
(b) Table 4. Age/Gender Categories
Age | Gender | ||
Age <1 | |||
Age 1 to 4 | |||
Age 5 to 14 | Male | ||
Age 5 to 14 | Female | ||
Age 15 to 24 | Male | ||
Age 15 to 24 | Female | ||
Age 25 to 44 | Male | ||
Age 25 to 44 | Female | ||
Age 45 to 64 | Male | ||
Age 45 to 64 | Female | ||
Age 65+ | |||
(7) Step 7. Apply risk weights.
(a) The agency assigns each risk category and age/gender category a weight. The weight comes from either the model for clients who are age 17 and younger or from the model for clients age 18 and older.
(b) In each model there are three types of weights.
(i) Age/gender – Weights that correspond to the age/gender category of a client.
(ii) CDPS – Weights that correspond to 58 of the CDPS risk categories.
(iii) MRx – Weights that correspond to 45 of the MRx risk categories.
(c) Table 5. Risk Score Weights
Category Type | Category | Description | Weights for Children (age <18) | Weights for Adults (age 18+) |
Age/Gender | Age <1 | Clients of age less than 1 | 0.91261 | 0.00000 |
Age 1 to 4 | Clients age 1 to 4 | 0.31764 | 0.00000 | |
Age 5 to 14, Male | Male clients age 5 to 14 | 0.25834 | 0.00000 | |
Age 5 to 14, Female | Female clients age 5 to 14 | 0.26338 | 0.00000 | |
Age 15 to 24, Male | Male clients age 15 to 24 | 0.25662 | -0.01629 | |
Age 15 to 24, Female | Female clients age 15 to 24 | 0.29685 | 0.03640 | |
Age 25 to 44, Male | Male clients age 25 to 44 | 0.00000 | 0.04374 | |
Age 25 to 44, Female | Female clients age 25 to 44 | 0.00000 | 0.06923 | |
Age 45 to 64, Male | Male clients age 45 to 64 | 0.00000 | 0.13321 | |
Age 45 to 64, Female | Female clients age 45 to 64 | 0.00000 | 0.06841 | |
Age 65+ | Clients age 65 and older | 0.00000 | -0.05623 | |
CDPS | CARVH | Cardiovascular, very high | 0.84325 | 2.86702 |
CARM | Cardiovascular, medium | 0.33428 | 0.73492 | |
CARL | Cardiovascular, low | 0.12835 | 0.24620 | |
CAREL | Cardiovascular, extra low | 0.04307 | 0.06225 | |
PSYH | Psychiatric, high | 0.40351 | 0.27085 | |
PSYM | Psychiatric, medium | 0.23892 | 0.00000 | |
PSYML | Psychiatric, medium low | 0.13796 | 0.00000 | |
PSYL | Psychiatric, low | 0.07675 | 0.00000 | |
SKCM | Skeletal, medium | 0.21071 | 0.42212 | |
SKCL | Skeletal, low | 0.08343 | 0.15467 | |
SKCVL | Skeletal, very low | 0.06244 | 0.06773 | |
CNSH | Central Nervous System, high | 0.80483 | 0.78090 | |
CNSM | Central Nervous System, medium | 0.31945 | 0.40886 | |
CNSL | Central Nervous System, low | 0.15106 | 0.18261 | |
PULVH | Pulmonary, very high | 1.14056 | 4.01723 | |
PULH | Pulmonary, high | 0.34356 | 0.39309 | |
PULM | Pulmonary, medium | 0.35587 | 0.31774 | |
PULL | Pulmonary, low | 0.11315 | 0.13017 | |
GIH | Gastro, high | 0.65934 | 1.34924 | |
GIM | Gastro, medium | 0.24699 | 0.24372 | |
GIL | Gastro, low | 0.09767 | 0.05104 | |
DIA1H | Diabetes, type 1 high | 0.27018 | 1.04302 | |
DIA1M | Diabetes, type 1 medium | 0.27018 | 0.23620 | |
DIA2M | Diabetes, type 2 medium | 0.13647 | 0.17581 | |
DIA2L | Diabetes, type 2 low | 0.13647 | 0.09635 | |
SKNH | Skin, high | 0.56322 | 0.37981 | |
SKNL | Skin, low | 0.23664 | 0.45155 | |
SKNVL | Skin, very low | 0.05697 | 0.02119 | |
RENEH | Renal, extra high | 1.80489 | 3.41999 | |
RENVH | Renal, very high | 0.59311 | 0.69251 | |
RENM | Renal, medium | 0.28630 | 0.92846 | |
RENL | Renal, low | 0.21048 | 0.17220 | |
SUBL | Substance Abuse, low | 0.15170 | 0.16104 | |
SUBVL | Substance Abuse, very low | 0.01794 | 0.08784 | |
CANVH | Cancer, very high | 1.19700 | 2.80074 | |
CANH | Cancer, high | 0.51985 | 0.97173 | |
CANM | Cancer, medium | 0.22164 | 0.38022 | |
CANL | Cancer, low | 0.10350 | 0.22625 | |
DDM | Developmental Disability, medium | 0.50073 | 0.27818 | |
DDL | Developmental Disability, low | 0.19696 | 0.05913 | |
GENEL | Genital, extra low | 0.00790 | 0.01121 | |
METH | Metabolic, high | 0.47167 | 0.47226 | |
METM | Metabolic, medium | 0.26297 | 0.11310 | |
METVL | Metabolic, very low | 0.11546 | 0.18678 | |
PRGCMP | Pregnancy, complete | 0.00244 | 0.00000 | |
PRGINC | Pregnancy, incomplete | 0.12631 | 0.51636 | |
EYEL | Eye, low | 0.09919 | 0.13271 | |
EYEVL | Eye, very low | 0.02835 | 0.00000 | |
CERL | Cerebrovascular, low | 0.14294 | 0.00000 | |
AIDSH | AIDS, high | 0.70597 | 0.47361 | |
INFH | Infectious, high | 0.70597 | 0.79689 | |
HIVM | HIV, medium | 0.26129 | 0.07937 | |
INFM | Infectious, medium | 0.26129 | 0.79689 | |
INFL | Infectious, low | 0.07784 | 0.05617 | |
HEMEH | Hematological, extra high | 5.37808 | 12.71981 | |
HEMVH | Hematological, very high | 0.72873 | 3.08836 | |
HEMM | Hematological, medium | 0.37824 | 0.63211 | |
HEML | Hematological, low | 0.18676 | 0.25601 | |
MRx | MRx1 | Alcoholism | 0.05982 | 0.01924 |
MRx2 | Alzheimer's | 0.00000 | 0.08112 | |
MRx3 | Anti-coagulants | 0.34428 | 0.13523 | |
MRx4 | Asthma/COPD | 0.08758 | 0.05751 | |
MRx5 | Attention Deficit | 0.00000 | 0.00779 | |
MRx6 | Burns | 0.16633 | 0.00000 | |
MRx7 | Cardiac | 0.0906 | 0.06425 | |
MRx8 | Cystic Fibrosis | 0.50399 | 0.37265 | |
MRx9 | Depression/Anxiety | 0.06743 | 0.09436 | |
MRx10 | Diabetes | 0.1519 | 0.17046 | |
MRx11 | EENT | 0.00000 | 0.00072 | |
MRx12 | ESRD/Renal | 1.24598 | 1.20707 | |
MRx13 | Folate Deficiency | 0.17973 | 0.11899 | |
MRx14 | CMV Retinitis | 0.37762 | 0.00000 | |
MRx15 | Gastric Acid Disorder | 0.10082 | 0.15470 | |
MRx16 | Glaucoma | 0.04221 | 0.12971 | |
MRx17 | Gout | 0.00000 | 0.00000 | |
MRx18 | Growth Hormone | 0.9741 | 1.59521 | |
MRx19 | Hemophilia/von Willebrands | 13.56192 | 89.14461 | |
MRx20 | Hepatitis | 0.03018 | 0.00000 | |
MRx21 | Herpes | 0.0348 | 0.01725 | |
MRx22 | HIV | 0.65537 | 1.01178 | |
MRx23 | Hyperlipidemia | 0.00000 | 0.03791 | |
MRx24 | Infections, high | 1.38405 | 1.51663 | |
MRx25 | Infections, medium | 0.07462 | 0.06192 | |
MRx26 | Infections, low | 0.00000 | 0.00918 | |
MRx27 | Inflammatory/Autoimmune | 0.08075 | 0.20046 | |
MRx28 | Insomnia | 0.07093 | 0.06437 | |
MRx29 | Iron Deficiency | 0.13306 | 0.15054 | |
MRx30 | Irrigating Solution | 0.87573 | 0.16387 | |
MRx31 | Liver Disease | 0.45314 | 0.22681 | |
MRx32 | Malignancies | 0.36859 | 0.44200 | |
MRx33 | Multiple Sclerosis/Paralysis | 0.0345 | 0.04353 | |
MRx34 | Nausea | 0.18219 | 0.17120 | |
MRx35 | Neurogenic Bladder | 0.15282 | 0.07675 | |
MRx36 | Osteoporosis/Pagets | 0.00000 | 0.00000 | |
MRx37 | Pain | 0.0295 | 0.04151 | |
MRx38 | Parkinsons/Tremor | 0.17163 | 0.06257 | |
MRx39 | Prenatal Care | 0.00000 | 0.13192 | |
MRx40 | Psychotic Illness/Bipolar | 0.22819 | 0.20274 | |
MRx41 | Replacement Solution | 0.58622 | 1.49405 | |
MRx42 | Seizure Disorders | 0.23997 | 0.19837 | |
MRx43 | Thyroid Disorder | 0.03948 | 0.06326 | |
MRx44 | Transplant | 0.37388 | 0.05810 | |
MRx45 | Tuberculosis | 0.20006 | 0.00000 |
(8) Step 8. Sum risk weights to obtain the risk score.
After obtaining the weights that correspond to a client's age/gender category and set of risk categories, the agency takes a sum of the values of all of the weights. This sum is the risk score for a client.
PDF182-557-0300
Health home services—Confidentiality and data sharing.
(1) Qualified health homes must comply with the confidentiality and data sharing requirements that apply to participants eligible under medicare and Title XIX medicaid programs and as specified in the health home contract.
(2) The agency and the department of social and health services (DSHS) share health care data with qualified health homes under the provisions of RCW 70.02.050 and the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
(3) The agency requires qualified health homes to monitor and evaluate participant activities and report to the agency as required by the health home contract.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-17-065, § 182-557-0300, filed 8/14/15, effective 9/14/15. Statutory Authority: RCW 41.05.021 and 2011 c 316. WSR 13-12-002, § 182-557-0300, filed 5/22/13, effective 7/1/13. WSR 11-14-075, recodified as § 182-557-0300, 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, § 388-557-0300, filed 9/26/07, effective 11/1/07.]
PDF182-557-0350
Health home—Grievance and appeals.
(1) Qualified health homes must have a grievances and appeals process in place that complies with the requirements of this section and must maintain records of all grievances and appeals.
(a) This section contains information about the grievance system for fee-for-service clients, including full dual eligible clients, for health home services. These participants must follow the process in chapter 182-526 WAC for appeals.
(b) Participants who are enrolled in an agency-contracted managed care organization must follow the process in WAC 182-538-110 to file a grievance or an appeal for health home services.
(2) Grievance process.
(a) Only a participant or the participant's authorized representative may file a grievance with the qualified health home orally or in writing. A health home care coordinator may not file a grievance for the participant unless the participant gives the health home care coordinator written consent to act on the participant's behalf.
(b) The qualified health home must:
(i) Accept, document, record, and process grievances that it receives from the participant, the participant's representative, or the agency;
(ii) Acknowledge receipt of each grievance, either orally or in writing, within two business days of receiving the grievance;
(iii) Assist the participant with all grievance processes;
(iv) Cooperate with any representative authorized in writing by the participant;
(v) Ensure that decision makers on grievances were not involved in the activity or decision being grieved, or any review of that activity or decision by qualified health home staff;
(vi) Consider all information submitted by the participant or the participant's authorized representative;
(vii) Investigate and resolve all grievances;
(viii) Complete the disposition of a grievance and notice to the affected parties as quickly as the participant's health condition requires, but no later than forty-five calendar days from receipt of the grievance;
(ix) Notify the participant, either orally or in writing, of the disposition of grievances within five business days of determination. Notification must be in writing if the grievance is related to a quality of care issue.
(3) Appeal process.
(a) The qualified health home must give the participant written notice of an action.
(b) The written notice must:
(i) State what action the qualified health home intends to take and the effective date of the action;
(ii) Explain the specific facts and reasons for the decision to take the intended action;
(iii) Explain the specific rule or rules that support the decision, or the specific change in federal or state law that requires the action;
(iv) Explain the participant's right to appeal the action according to chapter 182-526 WAC;
(v) State that the participant must request a hearing within ninety calendar days from the date that the notice of action is mailed.
(c) The qualified health home must send the written notice to the participant no later than ten days before the date of action. The written notice may be sent by the qualified health home no later than the date of the action it describes only if:
(i) The qualified health home has factual information confirming the death of a participant; or
(ii) The qualified health home receives a written statement signed by a participant that:
(A) The participant no longer wishes to receive health home services; or
(B) Provides information that requires termination or reduction of health home services and which indicates that the participant understands that supplying the information will result in health home services being ended or reduced.
(d) A health home care coordinator may not file an appeal for the participant.
(e) If the agency receives a request to appeal an action of the qualified health home, the agency will provide the qualified health home notice of the request.
(f) The agency will process the participant's appeal in accordance with chapter 182-526 WAC.
(g) Continued coverage. If a participant appeals an action by a qualified health home, the participant's health home services will continue consistent with WAC 182-504-0130.
(h) Reinstated coverage. If the agency ends or changes the participant's qualified health home coverage without advance notice, the agency will reinstate coverage consistent with WAC 182-504-0135.
(i) If the participant requests a hearing, the qualified health home must provide to the agency and the participant, upon request, and within three working days, all documentation related to the appeal.
(j) The qualified health home is an independent party and is responsible for its own representation in any administrative hearing, subsequent review process, and judicial proceedings.
(k) If a final order, as defined in WAC 182-526-0010, requires a qualified health home to provide the participant health home services that were not provided while the appeal was pending, the qualified health home must authorize or provide the participant those health home services promptly. A qualified health home cannot seek further review of a final order issued in a participant's administrative appeal of an action taken by the qualified health home.
PDF182-557-0400
Health home—Payment.
Only an agency-contracted qualified health home may bill and be paid for providing health home services described in this chapter. Billing requirements and payment methodology are described in the contract between the agency and the qualified health home.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-17-065, § 182-557-0400, filed 8/14/15, effective 9/14/15. Statutory Authority: RCW 41.05.021 and 2011 c 316. WSR 13-12-002, § 182-557-0400, filed 5/22/13, effective 7/1/13. WSR 11-14-075, recodified as § 182-557-0400, 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, § 388-557-0400, filed 9/26/07, effective 11/1/07.]
PDF182-557-0500
Involuntary disenrollment from a health home.
(1) Involuntary disenrollment for health and safety concerns. If a qualified health home or care coordinator believes there are unresolved health or safety concerns with a health home client, the medicaid agency reviews the health home's written request for involuntary disenrollment of the client from the health home program.
(a) Concerns about health and safety include, but are not limited to:
(i) Inappropriate or threatening behavior, such as inappropriate sexual or physical behavior;
(ii) Illegal or criminal activity;
(iii) Harassment; or
(iv) Environmental hazards, such as methamphetamine laboratories, dangerous animals, poor sanitation, or an unsafe home structure.
(b) The agency does not approve requests to end enrollment that are solely due to uncooperative or disruptive behavior resulting from a client's special needs, disability, or behavioral health condition, except when continued enrollment in the health home seriously impairs the health home's ability to furnish services to the client or other clients.
(c) Health homes requesting disenrollment must provide a client's assessment with any reasonable modifications attempted or made of policies, practices, procedures, or the provision of auxiliary aids or services, based on available evidence, in light of a client's special needs, disability, or behavioral health condition.
(d) A client's involuntary disenrollment is for one year, beginning on the first day of the month following the date on the notice of involuntary disenrollment.
(2) Disenrollment request. The agency grants a request from a qualified health home to involuntarily disenroll a client when the request is submitted to the agency in writing and includes documentation for the agency to determine that the criteria under subsection (1) of this section is met.
(3) Client notification and appeal rights. The agency notifies the qualified health home of the agency's decision within ten business days. If the request is approved, the agency sends a written notice of involuntary disenrollment to the client. The notice includes:
(a) The client's administrative hearing rights as described in chapter 182-526 WAC;
(b) The specific factual basis for disenrolling the client;
(c) The applicable provision under subsection (1) of this section, and any other applicable rule on which the disenrollment is based; and
(d) Any other information required by WAC 182-518-0005.
(4) Reenrollment. The agency may reenroll a client with a qualified health home within one year if:
(a) All of the concerns that led to the involuntary disenrollment are resolved; and
(b) The client continues to meet the health home eligibility criteria in this chapter.