wa-law.org > bill > 2025-26 > SB 5642 > Original Bill
The legislature finds that:
To optimize the health of women and infants, it is important to improve the continuum of care from encouraging a healthy pregnancy to having a healthy birth and receiving postpartum care. Prenatal care can help prevent and address health problems for both women and their infants. It is most effective when it starts early and can be continued through the entire pregnancy. It is also recognized that interventions to increase access to health care can help more women get the prenatal care they need. After the birth, it is also important that postpartum care is an ongoing process with services and supports that women receive specific to their individual needs so that they can recover from birth and nurture their infants. The time following birth is a critical period for a woman and her infant, and it sets the stage for long-term health and well-being;
Breast cancer is the second most common cancer in women in the United States behind only skin cancer. Breast cancer is also the second-leading cause of cancer death in women;
Other cancers, like cervical cancer, rarely occur in women who have been getting regular screenings before age 65;
The state of Washington has substantial public interest in the quality, price, and cost of health care, and ensuring that managed care organizations are delivering quality health care. Oversight of performance management of managed care organizations providing health care services to medicaid clients contracted by the health care authority is necessary to provide accountability for state purchased health care;
Services provided in a fee-for-service environment also require oversight and accountability; and
Health care costs are rising, and that containing health care costs while ensuring positive health outcomes, appropriate performance management, and accountability for dollars spent on state purchased health care is essential. The legislature must hold both the health care authority and the managed care organizations that provide services to medicaid clients accountable for performance and performance improvement.
The legislature therefore intends to ensure medicaid clients receive appropriate care in the right setting, at the right time, for the right cost by providing oversight for performance management and accountability for state purchased health care.
The health care authority, in collaboration with the department of health, the Robert Bree collaborative under chapter 70.250 RCW, and medicaid managed care organizations, shall develop education and outreach material by December 31, 2025, to encourage better health outcomes for medicaid clients receiving services in a fee-for-service setting or managed care setting for the following performance measures: Breast cancer screening; cervical cancer screening; the timeliness of prenatal care; and postpartum care.
The health care authority and medicaid managed care organizations shall also seek collaboration from representatives of the American cancer society and the American college of obstetricians and gynecologists as the education and outreach materials outlined in this section are being developed.
By December 31, 2025, the authority shall develop an implementation plan to incentivize medicaid managed care organizations to improve their performance measures as measured by the external quality improvement organization and to improve fee-for-service performance metrics related to providing the following services to clients under this chapter: Breast cancer screening; cervical cancer screening; the timeliness of prenatal care; and postpartum care.
The authority shall submit a report to the governor and the relevant committees of the legislature by November 30, 2028, and annually thereafter, that details any savings from improvements made based on the performance measures referenced in subsection (1) of this section for each prior plan year up to the previous three plan years and additional data including, at a minimum:
The implementation plan developed by the authority as outlined in subsection (1) of this section, delineated between fee-for-service and managed care;
The work conducted by the authority to incentivize the managed care organizations to improve each of the specific performance measurements;
The work conducted by the authority to improve fee-for-service service delivery;
What offsets were outlined by the authority;
The number of clients enrolled with managed care organizations;
The number of clients enrolled with managed care organizations eligible for: (i) Breast cancer screening; (ii) cervical cancer screening; (iii) prenatal care; or (iv) postpartum care;
The number of clients in fee-for-service;
The number of clients in fee-for-service eligible for: (i) Breast cancer screening; (ii) cervical cancer screening; (iii) prenatal care; or (iv) postpartum care;
The number and percentage of clients who received a cervical cancer screening;
The number and percentage of clients who received prenatal care and the timeliness of the prenatal care;
The number and percentage of clients who received postpartum care; and
The annual comparison of each performance measure for the previous three plan years.
For the purposes of this section, "external quality improvement organization" means an organization that meets the competence and independence requirements under 42 C.F.R. Sec. 438.354, as it existed on the effective date of this section.
By December 31, 2025, the health care authority shall develop billing guide instructions for fee-for-service providers and amend contracts with managed care organizations to encourage the use of current procedural terminology code 0500F for earlier identification of pregnant women.
The health care authority may incentivize the use of current procedural terminology code 0500F as part of its implementation plan with managed care organizations as described in section 3 of this act.