General Assistance Unemployable (GA-U) Update
November 2009
As of November 1, 2009, most GA-U clients across Washington State became managed care enrollees with Community Health Plan (CHP). This is an expansion of the GA-U managed care pilot program run by CHP in King and Pierce counties. These managed care clients will now receive mental health services.
A recent communication from DSHS states that managed care is mandatory for all GA-U enrollees except: (1) Native Americans/Alaskan Natives (they can enroll in managed care if they choose); and (2) people living in nursing facility for long-term care, as determined by the Aging and Disability Services Administration (ADSA). Clients on ADATSA are not enrolled in GA-U managed care. (See "DSHS Managed care and GA-U.")
Although not mentioned in the attachment, we have confirmed that non-citizens (legal permanent residents and others whose immigration status qualifies them for GA-U) remain on fee-for-service medical coverage and are not transferred to CHP. Also, clients on GA-X will continue on fee-for-service coverage.
GA-U Managed Care - Providers
According to CHP, the majority of GA-U clients have historically been served by the Community Health Centers (CHCs), who all belong to the CHP network. These clients will not have to change providers. In areas where there is not a strong CHC presence, CHP is filling those gaps with like-minded, mission-focused PCPs. The CHP website has the most up-to-date information on participating providers. The website is updated on the 10th of each month. CHP expects to add a number of PCPs during the next few months to ensure network adequacy and access. If you have questions about he CHP network, you may contact Abie Castillo, CHP's Vice President for Network Development/Support Services, at abie.castillo@chpw.org.
CHP recognizes that during this transition period, GA-U clients may require ongoing care for existing and/or urgent medical conditions. They will reimburse non-contracted providers on a fee-for-service basis at DSHS rates through December 31, 2009. The provider can bill CHP directly. For questions regarding how best to do this, please call CHP Customer Service at 1-800-440-1561.
Durable Medical Equipment (DME) changes
According to HRSA, DME is no longer covered for GA-U managed care clients see attached Stakeholder letter from CHP and Exception to Benefit addendum). DME includes: wheelchairs and other DME; rosthetic/orthotic devices; surgical/ostomy appliances and urological supplies; bandages, dressings and tapes; equipment and supplies for the management of diabetes; and other medical equipment and supplies listed in department published issuances. CHP has indicated that under some circumstances, it may provide DME coverage, but it is not yet clear what types or to what extent. GA-U clients should work with their CHP providers to obtain prior authorization.
DSHS will be using its Exception to Rule policy when reviewing DME requests for GA-U clients who remain on fee-for-service. DME requests will be handled on a case-by-case basis in the Division of HealthCare services's Office of Medical Benefits and Clinical Review.
DSHS has not yet adopted regulations stating DME is not covered for GA-U clients. We encourage GA-U clients to continue to request coverage for DME and appeal if denied.
Mental Health Services
The GA-U managed care mental health benefit includes:
- Unlimited medication management provided by a client's Primary Care Provider or in conjunction with mental health treatment.
- Level one mental health services, including brief mental health services from the care coordinator at the primary care clinic.
- Level two mental health services, including six months of mental health services from a Community Mental Health Agency (by referral from a care coordinator).
Making a GA-U Mental Health Referral - Step-by-Step:
- Verify that the client has GA-U managed care coverage with Community Health Plan.
- Identify client's primary care clinic and Primary Care Provider (PCP) (if unsure, contact CHP customer service at 1-800-440-1561)
- Schedule a primary care appointment.
- The PCP may make a referral to the GA-U care coordinator for a mental health assessment at the time of the office visit. If the primary care clinic does not have an onsite care coordinator, outreach care coordination services are available.
- If no care coordination services are available through the primary care office, call Community Health Plan customer service for more information (1-800-440-1561).
- If GA-U client is in crisis refer to the RSN crisis services, as usual. RSN crisis services are available for clients in crisis.
Chemical Dependency Services
Enrollees in GA-U managed care will continue to receive their chemical dependency services through the Division of Behavioral Health and Recovery. The client's care coordinator will help connect the client to these services.
Enrollment of New GA-U Clients
The attached DSHS communication states that once a client has been determined to be eligible for GA-U, he or she will first be placed in the Fee-for-Service (FFS) delivery system. It will take approximately three to six weeks for the automated enrollment process to find and enroll newly eligible GA-U clients into managed care. If new GA-U clients want to be enrolled in managed care sooner, they should call the MACSC toll-free line (1-800-562-3022) and ask to be enrolled. CHP has sent notices to current GA-U clients describing the change in benefits and providing CHP contact information (see attached "GAU managed care client notice eff 11-09").
Legal Assistance
If a GA-U client is denied DME, supplies, or mental health services, attorneys are available to help. Contact Solid Ground (206-694-6742) or Northwest Justice Project's CLEAR line (1-888-201-1014, 9:15 am-12:15 pm).
Thanks to Becky McAninch Dake at HRSA and Abie Castillo at CHP for their review of this update.