Washington § 74.09.895 - Network adequacy standards for postacute care services.

(1) The legislature finds medicaid enrollees are entitled to timely access to postacute care services when apple health managed care organizations have determined such services are medically necessary for quality of care and health outcomes.

(2) In order to facilitate more access to postacute care services, the authority shall establish and adopt network adequacy standards for postacute care services by no later than January 1, 2028. Network adequacy standards development must include nursing homes licensed under chapter 18.51 RCW and inpatient rehabilitation facilities licensed under chapter 70.41 RCW.

(a) Network adequacy standards for nursing homes must take into consideration the Washington medicaid principle of keeping care local to an enrollee's community and any geographic adequacy threshold should not be broader than the regional service area a managed care organization is contracted to serve. The authority may narrow the geographic standards during development. These standards must also consider:

(i) Provider availability in a regional service area;

(ii) Timeliness of care, which is defined as the reasonable amount of time in which patients can receive access to postacute care based on their medical needs; and

(iii) Any other network adequacy standard required to maintain compliance with federal medicaid regulations.

(b) Network adequacy standards for inpatient rehabilitation facilities must take into consideration the Washington medicaid principle of keep care local to an enrollee's community and the geographic adequacy threshold must not be narrower than the regional service area a managed care organization is contracted to serve and must take into consideration patient referral and practice patterns. The authority may narrow the geographic standards during development. These standards must also consider:

(i) Provider availability in a regional service area;

(ii) Timeliness of care, which is defined as the reasonable amount of time in which patients can receive access to postacute care based on their medical needs; and

(iii) Any other network adequacy standard required to maintain compliance with federal medicaid regulations.

(3) As part of the development of network adequacy standards, the authority shall obtain stakeholder feedback.

(a) Stakeholders must include hospitals, nursing homes, managed care organizations, and any associations representing members of these groups. If the authority chooses to include additional provider types in developing postacute care network standards, it must include representatives from those facility types in the stakeholder feedback process.

(b) Feedback must be obtained at least three times, including:

(i) For initial criteria used to develop standards;

(ii) To review draft standards; and

(iii) To review final standards prior to publication and inclusion in the managed care contract.

(4) Network adequacy standards for postacute care services do not alter the ability of a facility to determine whether the facility can meet the needs of a prospective resident through available staffing and reasonable accommodations.