WAC 182-557-0200
WAC 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 or be eligible for services under an alternative benefits plan (ABP), as described in WAC 182-501-0060 , 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 is enrolled in a third-party medical insurance plan. For purposes of this section, a medical insurance plan does not include plans that offer only dental, vision, pregnancy, or maternity care services.
(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.