WSR 03-05-094

PROPOSED RULES

HEALTH CARE AUTHORITY


(Basic Health)

[ Order 03-01 -- Filed February 19, 2003, 11:27 a.m. ]

Original Notice.

Preproposal statement of inquiry was filed as WSR 03-02-096.

Title of Rule: Limiting or closing basic health enrollment.

Purpose: Revises rules regarding enrollment limits for subsidized basic health, to simplify the process if the administrator finds that a danger of overexpenditure of appropriations exists, requiring that enrollment be limited or closed.

Statutory Authority for Adoption: RCW 70.47.050.

Statute Being Implemented: RCW 70.47.060(4) and 70.47.080.

Summary: Basic health is required to be prepared to limit or close enrollment if the administrator finds that continued enrollment is likely to lead to an overexpenditure of appropriations. These revisions are intended to simplify the processes used, both for applicants and for program administration, if enrollment must be limited or closed.

Reasons Supporting Proposal: These revisions are intended to reduce costs and simplify the process currently in rule, for applicants and the agency.

Name of Agency Personnel Responsible for Drafting: Rosanne Reynolds, Lacey, Washington, (360) 923-2948; Implementation and Enforcement: Kathy Eberle, Lacey, Washington, (360) 412-4307.

Name of Proponent: Washington State Health Care Authority, governmental.

Rule is not necessitated by federal law, federal or state court decision.

Explanation of Rule, its Purpose, and Anticipated Effects: This proposed rule is intended to simplify the processes used when the administrator finds that enrollment must be limited or closed because continued enrollment is likely to lead to an overexpenditure of appropriations. The rules regarding closing enrollment are not intended to replace the current managed enrollment process, but would take effect when managed enrollment can no longer be used effectively.

Proposal Changes the Following Existing Rules: Deletes this information from WAC 182-25-030 and moves the revisions to a new section, WAC 182-25-035.

No small business economic impact statement has been prepared under chapter 19.85 RCW. The Health Care Authority is not required by chapter 19.85 RCW to prepare a small business economic impact statement. There will be little, if any, cost to small business.

RCW 34.05.328 does not apply to this rule adoption. RCW 34.05.328 does not apply to the Health Care Authority rules unless requested by the Joint Administrative Rules Review Committee or applied voluntarily.

Hearing Location: 676 Woodland Square Loop S.E., Third Floor Conference Room (W302), Lacey, WA, on March 26, 2003, at 3:30 p.m.

Assistance for Persons with Disabilities: Contact Nikki Johnson by March 12, 2003, TDD (888) 923-5622 or (360) 923-2805.

Submit Written Comments to: Rosanne Reynolds, P.O. Box 42686, Olympia, WA 98504-2686, e-mail Rrey107@hca.wa.gov, fax (360) 923-2605, by March 26, 2003.

Date of Intended Adoption: March 27, 2003.

February 19, 2003

Melodie Bankers

Rules Coordinator

OTS-6218.1


AMENDATORY SECTION(Amending Order 00-04, filed 12/20/00, effective 1/20/01)

WAC 182-25-030   Eligibility.   (1) To be eligible for enrollment in BHP, an individual must be a Washington state resident who is not:

(a) Eligible for free Medicare coverage or eligible to buy Medicare coverage; or

(b) Institutionalized at the time of enrollment.

(2) Persons not meeting these criteria, as evidenced by information submitted on the application for enrollment or otherwise obtained by BHP, will not be enrolled. An enrollee who is no longer a Washington resident, who becomes eligible for free or purchased Medicare, or who is later determined to have failed to meet BHP's eligibility criteria at the time of enrollment, will be disenrolled from the plan as provided in WAC 182-25-090. An enrollee who was not confined to an institution at the time of enrollment, who is subsequently confined to an institution, will not be disenrolled, provided he or she remains otherwise eligible and continues to make all premium payments when due.

(3) Eligibility for BHP Plus and maternity benefits through medical assistance is determined by DSHS, based on Medicaid eligibility criteria.

(4) For subsidized enrollment in BHP, an individual must meet the eligibility criteria in subsection (1) of this section and the definition of "subsidized enrollee" in WAC 182-25-010(38), and must pay, or have paid on his or her behalf, the monthly BHP premium.

(5) To be eligible for nonsubsidized enrollment in BHP, an individual may have any income level, must meet the eligibility criteria in subsection (1) of this section, and must pay, or have paid on their behalf, the full costs for participation in BHP, including the cost of administration, without subsidy from the HCA.

(6)(a) An individual otherwise eligible for enrollment in BHP may be denied enrollment if the administrator has determined that acceptance of additional enrollment would exceed limits established by the legislature, would jeopardize the orderly development of BHP, or would result in an overexpenditure of BHP funds. An individual otherwise eligible for enrollment in either the subsidized or nonsubsidized program may also be denied enrollment if no MHCS is accepting new enrollment in that program or from the geographic area where the applicant lives.

(b) If the administrator closes or limits subsidized enrollment, to the extent funding is available, BHP ((will)) may continue to accept and process applications for enrollment ((from:

(i) Applicants who will pay the full premium, provided at least one MHCS is accepting new nonsubsidized enrollment from the geographic area where the applicant lives;

(ii) Children eligible for BHP Plus;

(iii) Children eligible for subsidized BHP, who were referred to DSHS for BHP Plus coverage, but were found ineligible for BHP Plus for reasons other than noncompliance;

(iv) Employees of a home care agency group enrolled or applying for coverage under WAC 182-25-060;

(v) Eligible individual home care providers;

(vi) Licensed foster care workers;

(vii) Limited enrollment of new employer groups; and

(viii) Subject to availability of funding, additional space for enrollment may be reserved for other applicants as determined by the administrator, in order to ensure continuous coverage and service for current individual and group accounts. (For example: Within established guidelines, processing routine income changes that may affect subsidy eligibility for current enrollees; adding new family members to an existing account; transferring enrollees between group and individual accounts; restoring coverage for enrollees who are otherwise eligible for continued enrollment under WAC 182-25-090 after a limited suspension of coverage due to late payment or other health care coverage; adding newly hired employees to an existing employer group; or adding new or returning members of federally recognized native American tribes to that tribe's currently approved financial sponsor group.)

(c) If the administrator has closed or limited subsidized enrollment, applicants for subsidized BHP who are not in any of the categories in (b) of this subsection may reserve space on a reservation list to be processed according to the date the reservation or application is received by BHP. When enrollment is reopened by the administrator, applicants whose names appear on the reservation list will be notified by BHP of the opportunity to enroll. BHP may require new application forms and documentation from applicants on the reservation list, or may contact applicants to verify continued interest in applying, prior to determining their eligibility)) as described in WAC 182-25-035.

[Statutory Authority: RCW 70.47.050 and 70.47.020 as revised by E2SSB 6067. 01-01-134 (Order 00-04), 182-25-030, filed 12/20/00, effective 1/20/01. Statutory Authority: RCW 70.47.050, 70.47.060 and 70.47.100. 99-24-005 (Order 99-06), 182-25-030, filed 11/18/99, effective 12/19/99. Statutory Authority: RCW 70.47.050 and 70.47.060. 99-16-022 (Order 99-02), 182-25-030, filed 7/26/99, effective 8/26/99. Statutory Authority: RCW 70.47.050. 98-07-002, 182-25-030, filed 3/5/98, effective 4/5/98; 97-15-003, 182-25-030, filed 7/3/97, effective 8/3/97; 96-15-024, 182-25-030, filed 7/9/96, effective 8/9/96.]


NEW SECTION
WAC 182-25-035   Limiting or closing enrollment.   If the administrator finds that there is a danger that acceptance of additional enrollment would exceed limits established by the legislature, jeopardize the orderly development of BHP, or would result in an overexpenditure of appropriated funds, enrollment may be delayed, limited, or closed.

(1) If the administrator finds that enrollment must be delayed for an extended period of time, enrollment may be closed.

(2) If the administrator closes enrollment, applications for new enrollment will no longer be accepted or processed, with the exceptions noted in subsection (3) of this section. Applicants whose applications have already been accepted, but who have not yet been enrolled, will be notified that enrollment has closed and that they will not be enrolled.

(3) To the extent funding is available and with the priorities of providing coverage for children and ensuring continuous coverage for current BHP enrollees and their families, BHP may continue to accept and process applications from some or all of the following:

(a) Categories of enrollees for whom dedicated funding is specifically appropriated;

(b) Current enrollees whose coverage is being transferred from one category of BHP coverage to another, such as a dependent moving from the parent's account to his or her own account or a member moving from a group account to an individual account;

(c) Current enrollees who are otherwise eligible to return to coverage after a one-month break in coverage due to late payment under WAC 182-25-090(6);

(d) Within the guidelines established under WAC 182-25-040(9), adding new members to an existing account.

(4) If the administrator finds that enrollment of new applicants can resume, applicants must submit a new application and all necessary documentation, which must be current as of the date of the new application. Applications received after enrollment is reopened will be processed in the order in which they are received. An application received prior to or during a time when enrollment was closed will not be used, either for enrollment or to reserve space for enrollment.

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