Section 182-557-0200. Health home program—Eligibility.  


Latest version.
  • (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 condition 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 on the agency's web site at http://www.hca.wa.gov/Pages/health_homes.aspx; and
    (d) Agree to participate in a health home program.
    (2) A person is ineligible to receive health home services when the person has third-party coverage that provides comparable health care services.
    (3) Using information provided by the department of social and health services (DSHS), the agency identifies clients who are eligible for health home services.
    (4) 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 accepts enrollment 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.
    (5) 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 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.]
RCW 41.05.021 and 41.05.160. 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.

Rules

182-557-0100,182-526,