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.
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.
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).
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.]
