WSR 04-13-140

PROPOSED RULES

DEPARTMENT OF

SOCIAL AND HEALTH SERVICES
(Medical Assistance Administration)

[ Filed June 22, 2004, 3:14 p.m. ]

     Original Notice.

     Preproposal statement of inquiry was filed as WSR 04-10-093.

     Title of Rule and Other Identifying Information: Chapter 388-542 WAC, State children's health insurance program (SCHIP) and WAC 388-505-0211 Premium requirements for SCHIP children.

     Hearing Location(s): Blake Office Park East (behind Goodyear Courtesy Tire), 4500 10th Avenue S.E., Rose Room, Lacey, WA, on July 27, 2004, at 10:00 a.m.

     Date of Intended Adoption: Not sooner than July 28, 2004.

     Submit Written Comments to: DSHS Rules Coordinator, P.O. Box 45850, Olympia, WA 98504, delivery 4500 10th Avenue S.E., Lacey, WA, e-mail fernaax@dshs.wa.gov, fax (360) 664-6185, by 5:00 p.m., July 27, 2004.

     Assistance for Persons with Disabilities: Contact Fred Swenson, DSHS Rules Consultant, by July 23, 2004, TTY (360) 664-6178 or (360) 664-6097.

     Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: The following cost-saving changes to the SCHIP program are being proposed:
The monthly premium for a child will increase from $10 to $15.
The maximum monthly premium paid per family will increase from $30 to $45.
A client's eligibility for the program will end after three consecutive months of nonpayment of premiums; the current rule allows four consecutive months.
The wait period before CHIP coverage can be reinstated for a client, whose coverage was terminated for not paying the premiums for three consecutive months, is being reduced from four months to three months.
     For simplification purposes, MAA is also repealing several sections of the SCHIP chapter 388-542 WAC that are redundant to other rules.

     Statutory Authority for Adoption: RCW 74.08.090 and 74.09.522.

     Statute Being Implemented: RCW 74.09.510, 74.09.522 and 74.09.450, and 2003-05 Revised Omnibus Operating Budget - 2004 Supplement (ESSB 2459, chapter 276, Laws of 2004).

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

     Name of Proponent: Department of Social and Health Services, governmental.

     Name of Agency Personnel Responsible for Drafting: Kevin Sullivan, P.O. Box 45533, Olympia, WA 98504-5533, (360) 725-1344; Implementation and Enforcement: Diane Kessel, P.O. Box 45536, Olympia, WA 98504-5536, (360) 725-1715.

     No small business economic impact statement has been prepared under chapter 19.85 RCW. This rule does not impact small businesses.

     A cost-benefit analysis is not required under RCW 34.05.328. RCW 34.05.328 (5)(b)(vii) exempts DSHS rules related to client medical eligibility.

June 18, 2004

Brian H. Lindgren, Manager

Rules and Policies Assistance Unit

3423.2
Chapter 388-542 WAC

STATE CHILDREN'S HEALTH INSURANCE ((PLAN (CHIP))) PROGRAM (SCHIP)


NEW SECTION
WAC 388-542-0010   Purpose and scope of SCHIP.   The medical assistance administration (MAA) administers the state children's health insurance program (SCHIP) to provide access to medical care for children whose family income exceeds the limit for Medicaid eligibility but is not greater than two hundred fifty percent of the federal poverty level (FPL). SCHIP is authorized by Title XXI of the Social Security Act and by RCW 74.09.450.

[]


NEW SECTION
WAC 388-542-0020   Other rules that apply to SCHIP.   In addition to the rules of this chapter, SCHIP clients are subject to the following rules:

     (1) Chapter 388-538 WAC, Managed care (except WAC 388-538-065);

     (2) WAC 388-505-0210 (3) and (8), Children's medical eligibility;

     (3) WAC 388-505-0211, Premium requirements for SCHIP children;

     (4) WAC 388-416-0015(10), Certification periods; and

     (5) WAC 388-418-0025 (4) and (5), Change of circumstance.

[]


AMENDATORY SECTION(Amending WSR 02-01-075, filed 12/14/01, effective 1/14/02)

WAC 388-542-0050   Definitions for ((children's health insurance program (CHIP))) SCHIP terms.   The following definitions ((and abbreviations)), as well as those found in WAC 388-538-050 and in 388-500-0005 Medical definitions, apply to ((this chapter)) the state children's health insurance program (SCHIP).

     (("Children's health insurance program (CHIP)" means the health insurance program authorized by Title XXI of the Social Security Act and administered by the department of social and health services (DSHS). This program also is referred to as the state children's health insurance program (SCHIP).

     "Client premium" means a monthly payment a client makes to the department of social and health services (DSHS) for CHIP coverage.))

     "Creditable coverage" means most types of public and private health coverage, except Indian health services, that provides access to physicians, hospitals, laboratory services, and radiology services. This term applies to the coverage whether or not the coverage is equivalent to that offered under ((CHIP)) SCHIP. "Creditable coverage" is described in 42 U.S.C. Sec. 1397jj.

     "Employer-sponsored dependent coverage" means creditable health coverage for dependents offered by a family member's employer or union, for which the employer or union may contribute in whole or part towards the premium. Extensions of such coverage (e.g., COBRA extensions) also qualify as employer-sponsored dependent coverage as long as there remains a contribution toward the premiums by the employer or union.

     (("Finance division" means the division of the department of social and health services that sends out billing statements, monitors accounts, and collects the CHIP client premiums.))

[Statutory Authority: RCW 74.09.080, 74.08.510, [74.08.]522, 74.09.450, 1115 Waiver, 42 U.S.C. 1396. 02-01-075, § 388-542-0050, filed 12/14/01, effective 1/14/02. Statutory Authority: RCW 74.08.090, 74.09.450. 00-07-103, § 388-542-0050, filed 3/17/00, effective 4/17/00.]


AMENDATORY SECTION(Amending WSR 02-01-075, filed 12/14/01, effective 1/14/02)

WAC 388-542-0300   Waiting period for ((CHIP)) SCHIP coverage following employer coverage.   (1) The medical assistance administration (MAA) requires applicants to serve a ((full four-consecutive-month)) waiting period ((for CHIP)) of four full consecutive months before SCHIP coverage if the client or family:

     (a) Chooses to end employer sponsored dependent coverage. The waiting period begins the day after the employment-based coverage ends((, and ends on the last day of the fourth full month of noncoverage)); or

     (b) Fails to exercise an optional coverage extension (e.g., COBRA) that meets the following conditions. The waiting period begins on the day there is a documented refusal of the coverage extension when the extended coverage is:

     (i) Subsidized in part or in whole by the employer or union;

     (ii) Available and accessible to the applicant or family; and

     (iii) At a monthly cost to the family meeting the limitation of subsection (2)(b)(iv).

     (2) MAA does not require a waiting period prior to ((CHIP)) SCHIP coverage when:

     (a) The client or family member has a medical condition that, without treatment, would be life-threatening or cause serious disability or loss of function; or

     (b) The loss of employer sponsored dependent coverage is due to any of the following:

     (i) Loss of employment with no post-employment subsidized coverage as described in subsection (1)(b);

     (ii) Death of the employee;

     (iii) The employer discontinues employer-sponsored dependent coverage;

     (iv) The family's total out-of-pocket maximum for employer-sponsored dependent coverage is fifty dollars per month or more;

     (v) The plan terminates employer-sponsored dependent coverage for the client because the client reached the maximum lifetime coverage amount;

     (vi) Coverage under a COBRA extension period expired;

     (vii) Employer-sponsored dependent coverage is not reasonably available (e.g., client would have to travel to another city or state to access care); or

     (viii) Domestic violence caused the loss of coverage for the victim.

[Statutory Authority: RCW 74.09.080, 74.08.510, [74.08.]522, 74.09.450, 1115 Waiver, 42 U.S.C. 1396. 02-01-075, § 388-542-0300, filed 12/14/01, effective 1/14/02. Statutory Authority: RCW 74.08.090, 74.09.450. 00-07-103, § 388-542-0300, filed 3/17/00, effective 4/17/00.]


REPEALER

     The following sections of the Washington Administrative Code are repealed:
WAC 388-542-0100 CHIP scope of care.
WAC 388-542-0125 Access to care.
WAC 388-542-0150 Client eligibility requirements for CHIP.
WAC 388-542-0200 CHIP enrollment.
WAC 388-542-0220 Ending CHIP client eligibility.
WAC 388-542-0250 CHIP client costs.
WAC 388-542-0275 Reimbursement.
WAC 388-542-0500 Managed care rules that apply to CHIP.
3422.2
AMENDATORY SECTION(Amending WSR 04-08-125, filed 4/7/04, effective 5/8/04)

WAC 388-505-0211   Premium requirements for ((Medicaid and)) SCHIP children.   (1) For the purposes of this chapter((:

     (a) "Mandatory children" means all states are required by federal rule to provide Medicaid coverage for these children; and

     (b) "Optional children" means the state of Washington chose to provide Medicaid coverage to children that are not included in the mandatory population.

     (c))), "premium" means an amount paid for medical coverage.

     (2) ((Optional children include:

     (a) A child under the age of one year, whose assistance unit's net available income exceeds one hundred eighty-five percent FPL as described in WAC 388-478-0075;

     (b) A child over age one but who has not yet attained age six whose assistance unit's net available income exceeds one hundred thirty-three percent FPL as described in WAC 388-478-0075; and

     (c) A child over age six whose assistance unit's net available income exceeds one hundred percent FPL as described in WAC 388-478-0075.

     (3) For optional children found eligible for Medicaid coverage under WAC 388-505-0210(2), payment of a premium is required as a condition of eligibility. See subsection (6) of this section for exemptions for optional children.

     (4) A child found eligible for Medicaid coverage under WAC 388-505-0210(2) that does not meet the conditions of subsection (2) of this section is a mandatory recipient of Medicaid and is not subject to the premium requirement.

     (5))) For a child found eligible for the state children's health insurance program (SCHIP) under WAC 388-505-0210(3), payment of a premium is required as a condition of eligibility.

     (((6) An optional))

     (3) A child is exempt from the premium requirement if the child meets one of the following:

     (a) The child is pregnant; or

     (b) The child is an American Indian or Alaska native((;

     (c) A child whose assistance unit's net available income is equal to or less than one hundred fifty percent FPL. An optional child exempted from the premium requirement under this subsection is treated as if the child is a mandatory child)).

     (((7))) (4) The premium requirement begins the first of the month following the determination of eligibility. There is no premium requirement for medical coverage received in a month or months before the determination of eligibility.

     (((8))) (5) The premium amount for the assistance unit is based on the net available income as described in WAC 388-450-0005. If the household includes more than one assistance unit, the premium amount billed for the assistance units may be different amounts.

     (((9) The premium amount for each optional Medicaid child is:

     (a) Zero dollars per month when the assistance unit's net available income is above one hundred percent FPL and equal to or less than one hundred fifty percent FPL; or

     (b) Ten dollars per month when the assistance unit's net available income is above one hundred fifty percent FPL and equal to or less than two hundred percent FPL.

     (10))) (6) The premium amount for each SCHIP child is fifteen dollars per month.

     (((11))) (7) The department bills the family for the lesser of:

     (a) A maximum of forty-five dollars per month; or

     (b) The total of the highest premiums, for up to three children in the assistance unit.

     (((12))) (8) Premium payment is a condition of eligibility for assistance units that include ((optional)) SCHIP children. All ((optional)) SCHIP children in an assistance unit are ineligible for medical coverage when the head of household's premium payments are three months in arrears. Three months in arrears means a balance exists for three months.

     (((13))) (9) When the department terminates the medical coverage of ((an optional)) a SCHIP child due to nonpayment of premiums, the child has a three-month period of ineligibility beginning the first of the following month. The three month period of ineligibility is rescinded only when the:

     (a) Past due premiums are paid in full prior to the begin date of the period of ineligibility; or

     (b) ((Optional)) SCHIP child has a change in circumstances such that the child becomes ((a mandatory child)) eligible for Medicaid. The department cannot rescind the three-month period of ineligibility for reasons other than the criteria described in this subsection (((13) of this section)).

     (((14))) (10) The department writes off past-due premiums after twelve months.

     (((15))) (11) When the designated three-month period of ineligibility is over, all past due premiums that are an obligation of the head of household must be paid or written off before ((an optional)) a child can become eligible for ((medical coverage)) SCHIP.

     (((16))) (12) A family cannot designate partial payment of the billed premium amount as payment for a specific child in the assistance unit. The full amount of the premium bill is the obligation of the head of household of the assistance unit. A family can decide to request medical coverage only for certain children in the assistance unit, if they want to reduce premium obligation.

     (((17))) (13) A change that affects the premium amount is effective the month after the change is reported and processed.

     (((18))) (14) A sponsor or other third party may pay the premium on behalf of the child or children in the assistance unit. The premium payment requirement remains the obligation of head of household of the assistance unit. The failure of a sponsor or other third party to pay the premium does not eliminate the:

     (a) Establishment of the period of ineligibility described in subsection (((13))) (9) of this section; or

     (b) Obligation of the head of household to pay past-due premiums.

[Statutory Authority: RCW 74.08.090, 74.09.055, 2004 c 276. 04-08-125, § 388-505-0211, filed 4/7/04, effective 5/8/04.]

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