Medicaid clients/metrics

AN ACT Relating to improving performance on maternal health and 1
preventative cancer screening metrics for medicaid clients; adding a 2
new section to chapter 74.09 RCW; and creating new sections.3
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF WASHINGTON:4
NEW SECTION. Sec. 1. (1) The legislature finds that:5
(a) To optimize the health of women and infants, it is important 6
to improve the continuum of care from encouraging a healthy pregnancy 7
to having a healthy birth and receiving postpartum care. Prenatal 8
care can help prevent and address health problems for both women and 9
their infants. It is most effective when it starts early and can be 10
continued through the entire pregnancy. It is also recognized that 11
interventions to increase access to health care can help more women 12
get the prenatal care they need. After the birth, it is also 13
important that postpartum care is an ongoing process with services 14
and supports that women receive specific to their individual needs so 15
that they can recover from birth and nurture their infants. The time 16
following birth is a critical period for a woman and her infant, and 17
it sets the stage for long-term health and well-being;18
(b) Breast cancer is the second most common cancer in women in 19
the United States behind only skin cancer. Breast cancer is also the 20
second-leading cause of cancer death in women; 21
S-1024.2
SENATE BILL 5642
State of Washington 69th Legislature 2025 Regular Session
By Senators Torres, Dozier, and Hasegawa
Read first time 02/03/25. Referred to Committee on Health & Long-
Term Care.
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(c) Other cancers, like cervical cancer, rarely occur in women 1
who have been getting regular screenings before age 65;2
(d) The state of Washington has substantial public interest in 3
the quality, price, and cost of health care, and ensuring that 4
managed care organizations are delivering quality health care. 5
Oversight of performance management of managed care organizations 6
providing health care services to medicaid clients contracted by the 7
health care authority is necessary to provide accountability for 8
state purchased health care; 9
(e) Services provided in a fee-for-service environment also 10
require oversight and accountability; and 11
(f) Health care costs are rising, and that containing health care 12
costs while ensuring positive health outcomes, appropriate 13
performance management, and accountability for dollars spent on state 14
purchased health care is essential. The legislature must hold both 15
the health care authority and the managed care organizations that 16
provide services to medicaid clients accountable for performance and 17
performance improvement. 18
(2) The legislature therefore intends to ensure medicaid clients 19
receive appropriate care in the right setting, at the right time, for 20
the right cost by providing oversight for performance management and 21
accountability for state purchased health care. 22
NEW SECTION. Sec. 2. (1) The health care authority, in 23
collaboration with the department of health, the Robert Bree 24
collaborative under chapter 70.250 RCW, and medicaid managed care 25
organizations, shall develop education and outreach material by 26
December 31, 2025, to encourage better health outcomes for medicaid 27
clients receiving services in a fee-for-service setting or managed 28
care setting for the following performance measures: Breast cancer 29
screening; cervical cancer screening; the timeliness of prenatal 30
care; and postpartum care.31
(2) The health care authority and medicaid managed care 32
organizations shall also seek collaboration from representatives of 33
the American cancer society and the American college of obstetricians 34
and gynecologists as the education and outreach materials outlined in 35
this section are being developed. 36
NEW SECTION. Sec. 3. A new section is added to chapter 74.09 37
RCW to read as follows: 38
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(1) By December 31, 2025, the authority shall develop an 1
implementation plan to incentivize medicaid managed care 2
organizations to improve their performance measures as measured by 3
the external quality improvement organization and to improve fee-for-4
service performance metrics related to providing the following 5
services to clients under this chapter: Breast cancer screening; 6
cervical cancer screening; the timeliness of prenatal care; and 7
postpartum care. 8
(2) The authority shall submit a report to the governor and the 9
relevant committees of the legislature by November 30, 2028, and 10
annually thereafter, that details any savings from improvements made 11
based on the performance measures referenced in subsection (1) of 12
this section for each prior plan year up to the previous three plan 13
years and additional data including, at a minimum:14
(a) The implementation plan developed by the authority as 15
outlined in subsection (1) of this section, delineated between fee-16
for-service and managed care; 17
(b) The work conducted by the authority to incentivize the 18
managed care organizations to improve each of the specific 19
performance measurements; 20
(c) The work conducted by the authority to improve fee-for-21
service service delivery; 22
(d) What offsets were outlined by the authority;23
(e) The number of clients enrolled with managed care 24
organizations; 25
(f) The number of clients enrolled with managed care 26
organizations eligible for: (i) Breast cancer screening; (ii) 27
cervical cancer screening; (iii) prenatal care; or (iv) postpartum 28
care; 29
(g) The number of clients in fee-for-service; 30
(h) The number of clients in fee-for-service eligible for: (i) 31
Breast cancer screening; (ii) cervical cancer screening; (iii) 32
prenatal care; or (iv) postpartum care; 33
(i) The number and percentage of clients who received a breast 34
cancer screening; 35
(j) The number and percentage of clients who received a cervical 36
cancer screening; 37
(k) The number and percentage of clients who received prenatal 38
care and the timeliness of the prenatal care; 39
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(l) The number and percentage of clients who received postpartum 1
care; and 2
(m) The annual comparison of each performance measure for the 3
previous three plan years. 4
(3) For the purposes of this section, "external quality 5
improvement organization" means an organization that meets the 6
competence and independence requirements under 42 C.F.R. Sec. 7
438.354, as it existed on the effective date of this section.8
NEW SECTION. Sec. 4. (1) By December 31, 2025, the health care 9
authority shall develop billing guide instructions for fee-for-10
service providers and amend contracts with managed care organizations 11
to encourage the use of current procedural terminology code 0500F for 12
earlier identification of pregnant women.13
(2) The health care authority may incentivize the use of current 14
procedural terminology code 0500F as part of its implementation plan 15
with managed care organizations as described in section 3 of this 16
act. 17
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