WAC 388-538-0060 Managed care and choice.

1. A client is required to enroll in managed care when that client meets all of the following conditions: 

   1. Is eligible for one of the medical programs for which clients must enroll in managed care;

   2. Resides in an area, determined by the medical assistance administration (MAA), where clients must enroll in managed care;

   3. Is not exempt from managed care enrollment as determined by MAA, and any related fair hearing has been held and decided; and

   4. Has not had managed care enrollment ended by MAA, consistent with WAC 388-538-0130.

2. American Indian/Alaska Native (AI/AN) clients who meet the provisions of 25 U.S.C. 1603 (c)-(d) for federally-recognized tribal members and their descendants may choose one of the following:

   1. Enrollment with a managed care organization (MCO) available in their area;

   2. Enrollment with an Indian or tribal primary care case management (PCCM) provider available in their area; or

   3. MAA's fee-for-service system.

3. A client may enroll with an MCO or PCCM provider by calling MAA's toll-free enrollment line or by sending a completed enrollment form to MAA.

   1. Except as provided in subsection (2) of this section for clients who are AI/AN, a client required to enroll in managed care must enroll with an MCO or PCCM provider available in the area where the client lives.

   2. All family members must either enroll with the same MCO or enroll with PCCM providers.

   3. Enrollees may request an MCO or PCCM provider change at any time.

   4. When a client requests enrollment with an MCO or PCCM provider, MAA enrolls a client effective the earliest possible date given the requirements of MAA's enrollment system. MAA does not enroll clients retrospectively.

4. MAA assigns a client who does not choose an MCO or PCCM provider as follows:

   1. If the client has family members enrolled with an MCO, the client is enrolled with that MCO;

   2. If the client does not have family members enrolled with an MCO that is currently under contract with DSHS, and the client was previously enrolled with the MCO or PCCM provider,  and DSHS can identify the previous enrollment, the client is reenrolled with the same MCO or PCCM provider;

   3. If a client does not choose an MCO or a PCCM provider, but indicates a preference for a provider to serve as the client's primary case provider (PCP), MAA attempts to contact the client to complete the required choice. If MAA is not able to contact the client in a timely manner, MAA documents the attempted contacts and, using the best information available, assigns the client as follows. If the client's preferred PCP is:

      1. Available with one MCO, MAA assigns the client in the MCO where the client's PCP provider is available. The MCO is responsible for PCP choice and assignment;

      2. Available only as a PCCM provider, MAA assigns the client to the preferred provider as the client's PCCM provider;

      3. Available with multiple MCOs or through an MCO and as a PCCM provider, MAA assigns the client to an MCO as described in (d) of this subsection;

      4. Not available through any MCO or as a PCCM provider, MAA assigns the client to an MCO or PCCM provider as described in (d) of this subsection.

   4. If the client cannot be assigned according to (a), (b), or (c) of this subsection, MAA assigns the client as follows:

      1. If an AI/AN client does not choose an MCO or PCCM provider, MAA assigns the client to a tribal PCCM provider if that client lives in a zip code served by a tribal PCCM provider. If there is no tribal PCCM provider in the client's area, the client continues to be served by MAA's fee-for-service system. A client assigned under this subsection may request to end enrollment at any time.

      2. If a non-AI/AN client does not choose an MCO or PCCM provider, MAA assigns the client to an MCO or PCCM provider available in the area where the client lives. The MCO is responsible for PCP choice and assignment. An MCO must meet the healthy options (HO) contract's access standards unless the MCO has been granted an exemption by MAA.

      3. For clients who are new to medical assistance or who have had a break in eligibility of greater than two months, MAA sends a written notice to each household of one or more clients who are assigned to an MCO or PCCM provider. The assigned client has ten calendar days to contact MAA to change the MCO or PCCM provider assignment before enrollment is effective. The notice includes the name of the MCO or PCCM provider to which each client has been assigned, the effective date of enrollment, the date by which the client must respond in order to change MAA's assignment, and the toll-free telephone number of either:

         1. The MCO for enrollees assigned to an MCO; or

         2. MAA for enrollees assigned to a PCCM provider.

      4. If the client has a break in eligibility of less than two months, the client will be automatically reenrolled with his or her previous MCO or PCCM provider and no notice will be sent.

5. An MCO enrollee's selection of the enrollee's PCP or the enrollee's assignment to a PCP occurs as follows:

   1. MCO enrollees may choose:

      1. A PCP or clinic that is in the enrollee's MCO and accepting new enrollees; or

      2. Different PCPs or clinics participating with the same MCO for different family members.

   2. The MCO assigns a PCP or clinic that meets the access standards set forth in the managed care contact if the enrollee does not choose a PCP or clinic;

   3. MCO enrollees may change PCPs or clinics in an MCO for any reason, with the change becoming effective no later than the beginning of the month following the enrollee's request; or

   4. In accordance with this subsection, MCO enrollees may file a grievance with the MCO and may change plans if the MCO denies an enrollee's request to change PCPs or clinics.