Section 182-557-0200 - Health home program-Eligibility(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 conditions 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 at https://www.hca.wa.gov/assets/billers-and-providers/Clinical Eligibility_Tool.xls.(2) A person is ineligible to receive health home services when: (a) The person has third-party coverage that provides comparable health care services; or(b) The person has a risk score of less than 1.0 for six consecutive months and has not received health home services.(3) 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 chooses to participate 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.(4) 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.Wash. Admin. Code § 182-557-0200
Amended by WSR 15-17-065, Filed 8/14/2015, effective 9/14/2015Amended by WSR 17-24-111, Filed 12/6/2017, effective 1/6/2018Statutory Authority: RCW 41.05.021 and 2011 c 316 . 13-12-002, §182-557-0200, filed 5/22/13, effective 7/1/13. 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. 07-20-048, § 388-557-0200, filed 9/26/07, effective 11/1/07.