- There were a total of 1,182,587 beneficiaries enrolled in the state’s Medicaid program as of July 2011. Of these, 1,041,904 were enrolled in Washington’s Apple Health managed care program through one of eight commercial managed care organizations (MCOs).
- The Apple Health MCOs provide physical health services, while Medicaid dental services are offered on a fee-for-service basis.
- The state delivers behavioral health services through two Prepaid Inpatient Health Plans (PIHP): the Integrated Mental Health Services PIHP is statewide and has 881,740 mental health only enrollees, while the other PIHP operates in a single county and has 122,907 mental health and substance use disorder enrollees. Washington’s Integrated Mental Health Services PIHP delivers mental health services through a system of 13 Regional Support Networks.
Medical necessity is defined in the Washington Administrative Code (WAC 182-500-0070) as:
“a term for describing requested service which is reasonably calculated to prevent, diagnose, correct, cure, alleviate or prevent worsening of conditions in the client that endanger life, or cause suffering or pain, or result in an illness or infirmity, or threaten to cause or aggravate a handicap, or cause physical deformity or malfunction. There is no other equally effective, more conservative or substantially less costly course of treatment available or suitable for the client requesting the service. For the purposes of this section, ‘course of treatment’ may include mere observation or, where appropriate, no medical treatment at all.”
|Initiatives to Improve Access
Washington’s administrative code (WAC 182-534-0200) provides for enhanced payments for EPSDT screens provided to children in out-of-home placements.
|Reporting & Data Collection||
Washington collects a variety of NCQA HEDIS measures from Medicaid managed care plans, including measures pertaining to children. This includes measures of childhood and adolescent immunization status, well-child visits, and child access to primary care providers.
Managed care organizations in Washington are required to implement a performance improvement plan if NCQA HEDIS measures of well care visits for children and adolescents fall below set benchmarks.
Publicly funded behavioral health services in Washington, including services for children and adolescents, are delivered through Regional Support Networks (RSNs). The RSNs contract with community mental health agencies to deliver behavioral services to Medicaid-enrolled children.
Medicaid managed care contracts require managed care organizations (MCOs) to contract with RSNs, and to collaborate with other MCOs to define screening tools to assess development and behavioral health conditions in children. MCOs and RSNs must have in place operational agreements to coordinate physical and behavioral health service delivery. In addition to establishing protocols for care transitions between MCOs and RSNs, these agreements must contain provisions for the exchange of health information regarding Medicaid beneficiaries’ diagnoses, treatment plans, medications, lab tests, and treating providers.
|Support to Providers and Families|
Care coordination services are provided by Medicaid managed care organizations (MCOs), which must develop formal Care Coordination Plans for enrollees with special health care needs. MCOs are charged with ensuring continuity of care across care settings for enrollees with chronic conditions. The Regional Support Networks that manage mental health services for Medicaid beneficiaries also each have a Children’s Care Coordinator on staff.
Washington has two Medicaid health homes state plan amendments coordinating care and providing care management for Medicaid beneficiaries with chronic conditions, including mental health conditions. The state’s health homes embed care coordinators in community-based settings and are responsible not only for coordinating medical care but also for referring beneficiaries to community-based and social service supports.
||Washington’s Medicaid program reimburses dentists, physicians, physician assistant, advanced registered nurse practitioners for fluoride varnish applications.|