State Programs Eligibility

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PCP Assignment Procedures

PCP changes need to be made by the enrollee or, if the provider is calling, verified with the enrollee prior to making the change. Enrollees will be assigned only to open providers or clinics unless a closed practice is willing to accept the enrollee.

For more details regarding PCP changes, please refer to the PCP Assignment policy and Process Eligibility PCP Enrollment Request procedure on our web site.

PCP changes may be faxed via the Clinic Selection Form to 206-521-8834.

Involuntary Disenrollment for Healthy Options, State Children’s Health Insurance Program, and Basic Health

A client may be involuntarily disenrolled from Healthy Options, Basic Health, or State Children’s Health Insurance Program products under the following conditions:

  • The client loses eligibility for a medical eligibility category that allows or requires enrollment; or
  • A plan requests disenrollment of a client whose behavior is:
    • Inconsistent with the plan’s rules and regulations, such as intentional misconduct; or
    • Such that it becomes medically infeasible to safely or prudently provide medical care.

Disenrollment Policy

The Member Reassignment and Involuntary Disenrollment Policy addresses instances where Community Health Plan enrollees may, due to inappropriate behavior, be reassigned involuntarily to another provider or clinic or disenrolled from Community Health Plan. In the majority of cases, it is the intent of Community Health Plan either to educate the enrollee, or if necessary, to reassign the enrollee to a different site or center, as the appropriate response to enrollee misconduct. Whenever possible, enrollees will be given an opportunity to change or improve inappropriate behavior. However, if an enrollee’s behavior is such that the Plan determines it is no longer safe or prudent to offer medical care to the enrollee at any Plan facility, the Plan may, at its discretion, seek enrollee disenrollment from the appropriate state agency.

This policy applies to enrollees who:

  • have behavior that is grossly inconsistent with clinic rules and standards;
  • refuse to follow a recommended diagnostic treatment plan;
  • are intentionally and continually noncompliant or abusive; or
  • consistently engage in drug-seeking behavior.

Each case will be reviewed independently according to the procedures below.

Community Health Plan will not at any time request from the State of Washington disenrollment of a client solely due to an adverse change in the client’s health or due to the cost of meeting the client’s health care needs.

In the event that any Plan-contracted provider is no longer able or willing to continue to provide care for an enrollee, Community Health Plan will arrange for and secure alternative care until such time as another permanent provider can be located by enrollee reassignment, or until the state approves the disenrollment of the enrollee. This care will be covered by Community Health Plan under Plan benefits as outlined in the applicable program contracts (such as Healthy Options, CHIP, Basic Health, and Medicare) at the time of service.

Enrollees who are to be reassigned involuntarily to another Plan provider will be notified in writing thirty (30) days in advance. This written notice will inform the enrollee of the right to appeal this reassignment, except in cases when the enrollee’s conduct presents the threat of immediate harm to others.

Enrollees who appeal any decision to reassign or disenroll will be provided all necessary covered health care arranged through the PCP with the assistance of the appropriate Plan staff until a decision is rendered by Community Health Plan or the appropriate state agency.

Disenrollment Procedure

Requests to reassign or disenroll an enrollee must be processed by using the following Community Health Plan procedure.

Providers at Community Health Plan clinic sites will, in accordance with their internal policies and procedures, document and address instances of enrollee noncompliance or misbehavior. This documentation may include reports of misbehavior from specialty providers. Clinics may request that the Plan reassign or disenroll an enrollee if the enrollee’s behavior repeatedly falls under one or all of the following descriptions:

  • Enrollee exhibits repeated abusive behaviors toward staff or visitors. This behavior may include yelling; the use of profanity or name-calling; any inappropriate or unwelcome touching; or any threatening words or actions.
  • Enrollee refuses to follow the outlined diagnostic treatment plan or continually engages in drug-seeking behavior.
  • Enrollee repeatedly refuses to follow the procedures of the clinic or enrollee handbook by continually missing appointments, by inappropriately using the emergency room, or by self-referring to specialists without consulting with the primary care physician.

To initiate a reassignment or disenrollment, the following steps must be followed:

  1. When a primary care physician or clinic manager wishes to reassign an enrollee, the appropriate staff member will send a warning letter to the enrollee. This letter will clearly document instances of misbehavior and outline steps of a written plan that the enrollee must follow if he or she wishes to continue to receive health care at the site. Warning letters will be copied to the center’s Managed Care Coordinator and the Community Health Plan Provider Relations Coordinator (PRC). The enrollee will be provided written copies of a center’s or clinics written procedures relating to patient behavior.
  2. If the enrollee repeats the behavior in question or chooses not to follow the steps outlined, clinic staff, with the approval of the clinic Medical Director, will consult with the assigned PRC at Community Health Plan to request that the enrollee be reassigned or, in the most serious cases, disenrolled from the Plan. Plan staff and clinic or center representatives will determine the feasibility of reassigning the enrollee within the Community Health Plan network.
  3. If reassignment is not an option due to the enrollee's location or circumstance, the staff involved will establish a plan for resolution and follow-up that includes enrollee education.
  4. If, after reviewing the case, there is agreement that the enrollee should be reassigned to another site or center, the PRC will inform the enrollee in writing of the decision. This letter will provide thirty (30) days notice and will inform the enrollee of his or her right to appeal the decision and the right to a fair hearing under Washington Administrative Code. Also, the letter will outline the enrollee's options for receiving future health care under the Plan. The PRC will work with clinic staff and/or a Community Health Plan Case Manager and/or Program Manager to arrange for the enrollee's future care. At no time will an enrollee be transferred to another clinic or site without the prior agreement of that clinic.
  5. If, after reviewing the case, the clinic provider or staff member and the Plan Program Manager determine that the enrollee's behavior is serious enough to warrant disenrollment:
    1. The Program Manager will notify the enrollee in writing of Community Health Plan’s intent to request an involuntary disenrollment from Community Health Plan, including the right to appeal.
    2. The Program Manager will work with the Provider Relations Coordinator to gather all necessary documentation from the primary care clinic.
    3. All information provided by the primary care clinic will be forwarded to Community Health Plan Medical Director for review.
    4. If the Medical Director feels the involuntary disenrollment request is valid (meets WAC requirements) and the necessary documentation has been provided, he or she will submit the documentation along with a letter requesting the disenrollment to the DSHS Exception Case Management (ECM) Section.
    5. DSHS will make a determination within 30 days of receiving Community Health Plan’s request. If approved, DSHS will notify Community Health Plan and the enrollee with a minimum of 10 days notice of termination.
    6. The enrollee will stay enrolled with Community Health Plan until a decision is made by ECM.

Clinic staff are responsible for:

  • Documenting client misbehavior.
  • Creating a written action plan for improvement if applicable.
  • Providing enrollees with written notice about action the clinic plans to take.
  • Providing enrollees with written procedures relating to enrollee responsibility.
  • Reporting to law enforcement agencies any criminal behavior.

The Community Health Plan staff is responsible for reviewing documentation and consulting with clinic staff to determine alternatives for providing care for the enrollee. If this is not possible, the Community Health Plan Program Manager serves as liaison to the state when requesting disenrollment.