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Washington Administrative Code (Last Updated: November 23, 2016) |
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Title 182. Health Care Authority |
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Chapter 182-538A. Washington apple health fully integrated managed care (FIMC). |
Section 182-538A-070. Payments to managed care organizations (MCOs) in fully integrated managed care (FIMC) regional service areas.
Latest version.
- (1) In addition to the rules in this section, see WAC 182-538-070 regarding payments to managed care organizations (MCOs) in fully integrated managed care (FIMC) regional service areas.(2) The agency pays MCOs a service-based enhancement rate for wraparound with intensive services (WISe) administered by a certified WISe provider who holds a current behavioral health agency license issued by the division of behavioral health and recovery (DBHR) under chapter 388-877 WAC.(3) For crisis services, the MCO must determine whether the individual receiving the services is eligible for Washington apple health or if the individual has other insurance coverage.(4) The MCO pays a reimbursement for each state hospital patient day of care that exceeds the MCO daily allocation of state hospital beds based on a quarterly calculation of the bed usage.(a) The agency bills the MCO quarterly for state hospital patient days of care exceeding the MCO daily allocation of state hospital beds and the established rate of reimbursement.(b) An MCO using fewer patient days of care than its quarterly allocation of state hospital beds receives a portion of the reimbursement collected proportional to its share of the total number of patient days of care that were not used at the appropriate state hospital.(5) The agency may:(a) Impose intermediate sanctions under 42 C.F.R. 438.700 and corrective action for substandard rates of clinical performance measures and for deficiencies found in audits and on-site visits;(b) Require corrective action for findings for noncompliance with any contractual, state, or federal requirements;(c) Impose sanctions for noncompliance with any contractual, state, or federal requirements not corrected; and(d) Apply a monthly penalty assessment associated with poor performance on selected behavioral health performance measures.
Rules
182-538-070,388-877,