HEALTH CARE AUTHORITY
(Basic Health Plan)
[Filed July 3, 1997, 11:25 a.m.]
Date of Adoption: July 3, 1997.
Purpose: Rules for eligibility and enrollment processes and for administering the Washington Basic Health Plan.
Citation of Existing Rules Affected by this Order: Amending WAC 182-25-010, 182-25-020, 182-25-030, 182-25-040, and 182-25-090.
Statutory Authority for Adoption: RCW 70.47.050.
Adopted under notice filed as WSR 97-08-067 on April 1, 1997.
Changes Other than Editing from Proposed to Adopted Version: Modified language in WAC 182-25-030(4), 182-25-040(9) and 182-25-090(2) for clarification, based on comments received during public comment period. No substantive changes made.
Number of Sections Adopted in Order to Comply with Federal Statute: New 0, amended 0, repealed 0; Federal Rules or Standards: New 0, amended 0, repealed 0; or Recently Enacted State Statutes: New 0, amended 0, repealed 0.
Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, amended 0, repealed 0.
Number of Sections Adopted on the Agency's own Initiative: New 0, amended 5, repealed 0.
Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, amended 5, repealed 0.
Number of Sections Adopted using Negotiated Rule Making: New 0, amended 0, repealed 0; Pilot Rule Making: New 0, amended 0, repealed 0; or Other Alternative Rule Making: New 0, amended 5, repealed 0.
Effective Date of Rule: Thirty-one days after filing.
July 2, 1997
AMENDATORY SECTION (Amending WSR 96-15-024, filed 7/9/96, effective
WAC 182-25-010 Definitions. The following definitions apply throughout these rules.
(1) "Administrator" means the administrator of the Washington state health care authority (HCA) or designee.
(2) "Appeal procedure" means a formal written procedure for resolution of problems or concerns raised by enrollees which cannot be resolved in an informal manner to the enrollee's satisfaction.
(3) "Basic health plan" (or BHP) means the system of enrollment and payment on a prepaid capitated basis for basic health care services administered by the administrator through managed health care systems.
(4) "BHP plus" means the program of expanded benefits available to children through coordination between the department of social and health services (DSHS) and basic health plan. To be eligible for the program children must be under age nineteen, with a family income at or below two hundred percent of federal poverty level, as defined by the United States Department of Health and Human Services. They must be Washington state residents, not eligible for Medicare, and may be required to meet additional DSHS eligibility requirements.
(5) "Co-payment" means a payment indicated in the schedule of benefits which is made by an enrollee to a health care provider or to the MHCS.
(6) "Covered services" means those services and benefits in the BHP schedule of benefits (as outlined in the member handbook issued to the enrollee, or to a subscriber on behalf of the enrollee), which an enrollee shall be entitled to receive from a managed health care system in exchange for payment of premium and applicable co-payments.
(7) "Disenrollment" means the termination of covered services in BHP for a subscriber and dependents, if any.
(8) "Effective date of enrollment" means the first date, as established by BHP, on which an enrollee is entitled to receive covered services from the enrollee's respective managed health care system.
(9) "Dependent." The following are eligible as dependents under BHP:
(a) Lawful spouse of the subscriber, if not legally separated, who resides in the same residence.
(b) Dependent child who is an unmarried child and who is:
(i) Younger than age nineteen and is one of the following: A natural child, stepchild or legally adopted child of a subscriber; or a child who has been placed with a subscriber pending adoption or is under legal guardianship of a subscriber.
(ii) Younger than age twenty-three and is a registered student in
full-time attendance at an accredited secondary school, college,
university, technical college or school of nursing. Dependent student
eligibility continues year-round, including the quarter or semester
following graduation, for those who attend full time (except for school
holidays and scheduled spring and summer breaks) provided ((
subscriber is covered at the same time;)) the dependent limiting age has
not been exceeded; and the dependent meets all other eligibility
(c) Legal dependent of any age who is incapable of self-support due to disability.
(10) "Eligible full-time employee" means an employee who meets all eligibility requirements in WAC 182-25-030 and who is regularly scheduled to work thirty or more hours per week for an employer. The term includes a self-employed individual (including a sole proprietor or a partner of a partnership, and may include an independent contractor) if the individual:
(a) Is regularly scheduled to work thirty hours or more per week; and
(b) Derives at least seventy-five percent of his or her income from a trade or business that is licensed to do business in Washington.
Persons covered under a health benefit plan pursuant to the Consolidated Omnibus Budget Reconciliation Act of 1986 shall not be considered eligible employees for purposes of minimum participation requirements.
(11) "Eligible part-time employee" means an employee who meets all the criteria in subsection (10) of this section, but who is regularly scheduled to work fewer than thirty hours per week for an employer.
(12) "Employee" means one who is in the employment of an employer, as defined by RCW 50.04.080.
(13) "Employer" means an enterprise licensed to do business in Washington state, as defined by RCW 50.04.080.
(14) "Enrollee" means a person who meets all eligibility requirements, who is enrolled in BHP, and for whom applicable premium payments have been made.
(15) "Family" means an individual or an individual and spouse, if not legally separated, and dependents. For purposes of eligibility determination and enrollment in the plan, an individual cannot be a member of more than one family.
(16) "Financial sponsor" means a person, organization or other entity, approved by the administrator, that is responsible for payment of all or a designated portion of the monthly premiums on behalf of a subscriber and any dependents.
(17) "Gross family income" means total cash receipts, as defined in (a) of this subsection, before taxes, from all sources, for subscriber and dependents whether or not they are enrolled in BHP, with the exceptions noted in (b) of this subsection.
(a) Income includes:
(i) Money wages, tips and salaries before any deductions;
(ii) Net receipts from nonfarm self-employment (receipts from a person's own unincorporated business, professional enterprise, or partnership, after deductions for business expenses);
(iii) Net receipts from farm self-employment (receipts from a farm which one operates as an owner, renter, or sharecropper, after deductions for farm operating expenses);
(iv) Regular payments from Social Security, railroad retirement, unemployment compensation, strike benefits from union funds, workers' compensation, veterans' payments, public assistance, alimony, child support, military family allotments, private pensions, government employee pensions (including military retirement pay), and regular insurance or annuity payments;
(v) Work study or training stipends;
College or university scholarships, grants, fellowships and
assistantships, if received as or convertible by the recipient into cash;
(vii))) Dividends and interest accessible to the enrollee without
(viii))) (vii) Net rental income, net royalties, periodic receipts
from estates or trusts, and net gambling or lottery winnings.
(b) Income does not include the following types of money received:
(i) Capital gains;
(ii) Any assets drawn down as withdrawals from a bank, the sale of property, a house or a car;
(iii) Tax refunds, gifts, loans, lump-sum inheritances, one-time insurance payments, or compensation for injury (except workers' compensation);
(iv) Noncash benefits, such as the employer-paid or union-paid portion of health insurance or other employee fringe benefits, food or housing received in lieu of wages, the value of food and fuel produced and consumed on farms, the imputed value of rent from owner-occupied nonfarm or farm housing, and such noncash benefit programs as Medicare, Medicaid, food stamps, school lunches, and housing assistance;
(v) Income earned by dependent children;
(vi) Income of a family member who resides in another household when such income is not available to the subscriber or dependents seeking enrollment in BHP;
(vii) College or university scholarships, grants, fellowships and
if not convertible to cash));
(viii) Documented child care expenses for the care of a dependent child of a subscriber may be deducted (at a rate set by the administrator and consistent with Internal Revenue Service requirements) when calculating gross family income. To qualify for this deduction, the subscriber must be employed during the time the child care expenses were paid, and payment may not be paid to a parent or step parent of the child or to a dependent child of the subscriber or his/her spouse.
(18) "Home care agency" means a private or public agency or organization that administers or provides home care services directly or through a contract arrangement to ill, disabled, or infirm persons in places of temporary or permanent residence, and is licensed by the department of social and health services (DSHS) as a home care agency. In order to qualify, the agency must be under contract with one of the following DSHS programs: Chore, Medicaid Personal Care, Community Options Program Entry System (COPES) or Respite Care (up to level three).
(19) "Insurance broker" or "agent" means a person who is currently licensed as a disability insurance broker or agent, according to the laws administered by the office of the insurance commissioner under chapter 48.17 RCW.
(20) "Managed health care system" (or "MHCS") means any health care organization (including health care providers, insurers, health care service contractors, health maintenance organizations, or any combination thereof) which has entered into a contract with the HCA to provide basic health care services.
(21) "Medicaid" means the Title XIX Medicaid program administered by the department of social and health services, and includes the medical care programs provided to the "categorically needy" and the "medically needy" as defined in chapter 388-503 WAC.
(22) "Medicare" means programs established by Title XVIII of Public Law 89-97, as amended, "Health Insurance for the Aged and Disabled."
(23) "Nonsubsidized enrollee" or "full premium enrollee" means an individual who enrolls in BHP, as the subscriber or dependent, and who pays or on whose behalf is paid the full costs for participation in BHP, without subsidy from the HCA.
(24) "Open enrollment" means a time period designated by the administrator during which enrollees may enroll additional dependents or apply to transfer their enrollment from one managed health care system to another. There shall be at least one annual open enrollment period of at least twenty consecutive days.
(25) "Participating employee" means an employee of a participating employer or home care agency who has met all the eligibility requirements and has been enrolled for coverage under BHP.
(26) "Participating employer" means an employer who has been approved for enrollment in BHP as an employer group.
(27) "Preexisting condition" means any illness, injury or condition for which, in the three months immediately preceding an enrollee's effective date of enrollment in BHP:
(a) Treatment, consultation or a diagnostic test was recommended for or received by the enrollee; or
(b) The enrollee was prescribed or recommended medication; or
(c) Symptoms existed which would ordinarily cause a reasonably prudent individual to seek medical diagnosis, care or treatment.
(28) "Premium" means a periodic payment, based upon gross family income and determined under RCW 70.47.060(2), which an individual, their employer or a financial sponsor makes to BHP for subsidized or nonsubsidized enrollment in BHP.
(29) "Provider" or "health care provider" means a health care professional or institution duly licensed and accredited to provide covered services in the state of Washington.
(30) "Rate" means the per capita amount, including administrative charges and any applicable premium and prepayment tax imposed under RCW 48.14.020, negotiated by the administrator with and paid to a managed health care system, to provide BHP health care benefits to enrollees.
(31) "Schedule of benefits" means the basic health care services adopted and from time to time amended by the administrator, which an enrollee shall be entitled to receive from a managed health care system in exchange for payment of premium and applicable co-payments, as described in the member handbook.
(32) "Service area" means the geographic area served by a managed health care system as defined in its contract with HCA.
(33) "Subscriber" is a person who applies to BHP on his/her own behalf and/or on behalf of his/her dependents, if any, who meets all applicable eligibility requirements, is enrolled in BHP, and for whom the monthly premium has been paid. Notices to a subscriber and, if applicable, a financial sponsor or employer shall be considered notice to the subscriber and his/her enrolled dependents.
(34) "Subsidized enrollee" or "reduced premium enrollee" means an individual who enrolls in BHP, either as the subscriber or an eligible dependent, whose current gross family income does not exceed twice the federal poverty level as adjusted for family size and determined annually by the federal Department of Health and Human Services, and who receives a premium subsidy from the HCA.
(35) "Subsidy" means the difference between the amount of periodic
payment the HCA makes to a managed health care system on behalf of a
subsidized enrollee, and the amount determined to be the subsidized
enrollee's responsibility under RCW 70.47.060(2).
[Statutory Authority: RCW 70.47.050. 96-15-024, 182-25-010, filed
7/9/96, effective 8/9/96.]
AMENDATORY SECTION (Amending WSR 96-15-024, filed 7/9/96, effective
WAC 182-25-020 BHP benefits. (1) The administrator shall design and from time to time may revise BHP benefits, according to the requirements of chapter 70.47 RCW, as amended. These benefits will include physician services, prescription drugs and medications, and inpatient and outpatient hospital services, limited mental health care services, limited chemical dependency services, limited organ transplant services, and all services necessary for prenatal, postnatal and well-child care, and will emphasize proven preventive and primary care services. The Medicaid scope of benefits may be provided by BHP as the BHP plus program through coordination with DSHS for children under the age of nineteen, who are found to be Medicaid eligible. BHP benefits may include co-payments, waiting periods, limitations and exclusions which the administrator determines are appropriate and consistent with the goals and objectives of the plan. BHP benefits will be subject to a three-month waiting period for preexisting conditions. Exceptions (for example, maternity, prescription drugs, services for a newborn or newly adopted child) are outlined in the schedule of benefits. Credit toward the waiting period will be given for any continuous period of time for which an enrollee was covered under similar health coverage if that coverage was in effect at any time during the three-month period immediately preceding the date of reservation or application for coverage under BHP. A list of BHP benefits, including co-payments, waiting periods, limitations and exclusions, will be provided to the subscriber.
(2) In designing and revising BHP benefits, the administrator will consider the effects of particular benefits, co-payments, limitations and exclusions on access to necessary health care services, as well as the cost to the enrollees and to the state, and will also consider generally accepted practices of the health insurance and managed health care industries.
(3) Prior to enrolling in BHP, each applicant will be given a written description of covered benefits, including all co-payments, waiting periods, limitations and exclusions, and be advised how to access information on the services, providers, facilities, hours of operation, and other information descriptive of the managed health care system(s) available to enrollees in a given service area.
(4) BHP will mail to all subscribers written notice of any changes
in the amount and scope of benefits provided under BHP, or policy changes
regarding premiums and co-payments at least thirty days prior to the due
date of the premium payment for the month in which such revisions are to
take effect. The administrator may make available a separate schedule
of benefits for children, eighteen years of age and younger, for those
dependent children in the plan.
[Statutory Authority: RCW 70.47.050. 96-15-024, 182-25-020, filed
7/9/96, effective 8/9/96.]
AMENDATORY SECTION (Amending WSR 96-15-024, filed 7/9/96, effective
WAC 182-25-030 Eligibility. (1) To be eligible for enrollment in BHP, an individual must:
(a) Not be eligible for Medicare; and
(b) Reside within the state of Washington.
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 subsequently fails to meet these criteria, or who is later determined to have failed to meet the criteria at the time of enrollment, will be disenrolled from the plan as provided in WAC 182-25-090.
(2) To be eligible for subsidized enrollment in BHP, an individual must have a gross family income that does not exceed two hundred percent of federal poverty level as adjusted for family size and determined annually by the U.S. Department of Health and Human Services, and must pay, or have paid on their behalf, the monthly BHP premium.
(3) To be eligible for nonsubsidized enrollment in BHP, an individual may have any income level 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.
(4) 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. In the event that the administrator closes
or limits enrollment and to the extent funding is available, BHP will
continue to accept and process applications for enrollment((
, but will
not process those applications for determination of eligibility. BHP
will place the names of applicants on a waiting list in the order in
which applications are received, and will so notify the applicants))
(a) Applicants who will pay the full premium;
(b) Children eligible for BHP Plus;
(c) Pregnant women who, prior to April 1, 1997, apply to BHP, are referred and qualify for maternity benefits through DSHS;
(d) Children eligible for subsidized BHP, who were referred to DSHS for BHP Plus coverage, but were found ineligible for BHP Plus;
(e) Employees of a home care agency group enrolled or applying for coverage under WAC 182-25-060;
(f) Eligible individual home care providers;
(g) Licensed foster care workers;
(h) Limited enrollment of new employer groups; and
(i) 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.)
Applicants for subsidized BHP who are not in any of these categories
may reserve space on a reservation list to be processed according to the
date the reservation or application is received by BHP. In the event
that enrollment is reopened by the administrator, applicants whose names
appear on the ((
waiting)) reservation list will be notified by BHP of the
opportunity to enroll. BHP may require new application forms and
documentation from applicants on the (( waiting)) reservation list, or may
contact applicants to verify continued interest in applying, prior to
determining their eligibility.
[Statutory Authority: RCW 70.47.050. 96-15-024, 182-25-030, filed
7/9/96, effective 8/9/96.]
AMENDATORY SECTION (Amending WSR 96-15-024, filed 7/9/96, effective
WAC 182-25-040 Enrollment in the plan. (1) Any individual applying for enrollment in BHP must submit a signed, completed BHP application for enrollment. Applications for enrollment of children under the age of eighteen must be signed by the child's parent or legal guardian, who shall also be held responsible for payment of premiums due on behalf of the child. If an applicant is accepted for enrollment, the applicant's signature acknowledges the applicant's obligation to pay the monthly premium in accordance with the terms and conditions identified in the member handbook. Applications for subsidized enrollment on behalf of children under the age of nineteen shall be referred to the department of social and health services for Medicaid eligibility determination, unless the family chooses not to access this option.
(2) Each applicant shall list all eligible dependents to be enrolled and supply other information and documentation as required by BHP and, where applicable, DSHS medical assistance.
(a) Documentation will be required, showing the amount and sources of the applicant's gross family income. Acceptable documentation will include a copy of the applicant's most recently filed federal income tax form, and/or other documentation that shows year-to-date income, or income for the most recent thirty days or complete calendar month as of the date of application. An average of documented income received over a period of several months may be used for purposes of eligibility determination. Income documentation shall be required for the subscriber and dependents, with the exceptions listed under WAC 182-25-010 (17)(b).
(b) Documentation of Washington state residency shall also be required, displaying the applicant's name and address. Other documentation may be accepted if the applicant does not have a physical residence.
(c) BHP may request additional information from applicants for purposes of establishing or verifying eligibility, premium responsibility or managed health care system selection.
(d) Submission of incomplete or inaccurate information may delay or prevent an applicant's enrollment in BHP. Intentional submission of false information may result in disenrollment of the subscriber and all enrolled dependents.
(3) Each member may be enrolled in only one BHP account. Each family applying for enrollment must designate a managed health care system from which the applicant and all enrolled dependents will receive covered services. All applicants from the same family who are covered under the same account must receive covered services from the same managed health care system (with the exception of cases in which a subscriber who is paying child support for his/her dependents lives in a different service area). No applicant will be enrolled for whom designation of a managed health care system has not been made as part of the application for enrollment. The administrator will establish procedures for the selection of managed health care systems, which will include conditions under which an enrollee may change from one managed health care system to another. Such procedures will allow enrollees to change from one managed health care system to another during open enrollment, or otherwise upon showing of good cause for the transfer.
(4) Managed health care systems may assist BHP applicants in the enrollment process, but must provide them with the toll-free number for BHP, information on all MHCS available within the applicant's county of residence and an estimate of the premium the applicant would pay for each available MHCS.
(5) Insurance brokers or agents who have met all statutory and regulatory requirements of the office of the insurance commissioner, are currently licensed through the office of the insurance commissioner, and who have completed BHP's training program, will be paid a commission for assisting eligible applicants to enroll in BHP.
(a) Individual policy commission: Subject to availability of funds, and as a pilot program, BHP will pay a one-time fee to any currently licensed insurance broker or agent who sells BHP to an eligible individual applicant if that applicant has never been a BHP member in the past.
(b) Group policy commission: Subject to availability of funds, and as a pilot program, fees paid for the sale of BHP group coverage to an eligible employer will be based on the number of employees in the group for the first and second months of the group's enrollment.
(c) Insurance brokers or agents must provide the prospective applicant with the BHP toll-free information number and inform them of BHP benefits, limitations, exclusions, waiting periods, co-payments, all managed health care systems available to the applicant within his/her county of residence and the estimated premium for each of them.
(d) All statutes and regulations of the office of the insurance commissioner will apply to brokers or agents who sell BHP, except they will not be required to be appointed by the MHCS.
(e) BHP will not pay renewal commissions.
(6) Except as provided in WAC 182-25-030(4), applications for enrollment will be reviewed by BHP within thirty days of receipt and those applicants satisfying the eligibility criteria and who have provided all required information, documentation and premium payments will be notified of their effective date of enrollment.
(7) Eligible applicants will be enrolled in BHP in the order in which their completed applications, including all required documentation, have been received by BHP, provided that the applicant also remits full payment of the first premium bill to BHP by the due date specified by BHP. In the event a reservation list is implemented, eligible applicants will be enrolled in accordance with WAC 182-25-030(4).
(8) Not all family members are required to apply for enrollment in BHP; however, any family member for whom application for enrollment is not made at the same time that other family members apply, may not subsequently enroll as a family member until the next open enrollment period, unless the subscriber has experienced a qualifying change in family status:
(a) The loss of other continuous health care coverage, for family members who have previously waived coverage, upon proof of continuous medical coverage from the date the subscriber enrolled;
(b) Marriage; or
(c) Birth, adoption or change in dependency or custody of a child or adult dependent. Eligible newborn or newly adopted children may be enrolled effective from the date of birth or physical placement for adoption provided that application for enrollment is submitted to BHP within sixty days of the date of birth or such placement for adoption.
(9) Any enrollee who voluntarily disenrolls from BHP for reasons
other than ineligibility or enrollment in other health care coverage may
not reenroll for a period of twelve months from the effective date of
disenrollment. After the twelve-month period, or if the enrollee
disenrolled for reasons of ineligibility or enrollment in other health
care coverage, he/she may reenroll in BHP, subject to enrollment limits
and portability and preexisting condition policies as referenced in WAC
182-25-020(1) and 182-25-030(4) and specified in the member handbook,
provided he/she is determined by BHP to be otherwise eligible for
enrollment as of the date of application. ((
With the exception of))
Enrollees who are not under group coverage, (( enrollees who are
disenrolled from BHP for nonpayment, in accordance with WAC 182-25-090(2), more than twice in a twelve-month period, and who have a lapse
in coverage of one month or more,)) may not reenroll for a (( period))
minimum of twelve months from the effective date of (( the third
disenrollment)) their last suspension if they are disenrolled from BHP
for nonpayment under WAC 182-25-090 (2)(b) because:
(a) They failed to pay the premium within the billing cycle for the next coverage month following a suspension of coverage; or
(b) They have been suspended from coverage more than two times in a twelve-month period for failure to pay their premium by the due date.
If a reservation list has been implemented, an enrollee who was disenrolled in accordance with WAC 182-25-090(2) and is eligible to enroll from the reservation list prior to the end of the required twelve-month wait for reenrollment, will not be reenrolled until the end of the twelve-month period. If an enrollee who was disenrolled in accordance with WAC 182-25-090(2) satisfies the required twelve-month wait for reenrollment while on the reservation list, enrollment will not be completed until funding is available to enroll him or her from the reservation list.
(10) On a schedule approved by the administrator, BHP will request
verification of information from all or a subset of enrollees
("recertification"), requiring new documentation of income if the
enrollee has had a change in income that would result in a different
subsidy level. For good cause, BHP may require recertification on a more
widespread or more frequent basis. Enrollees who fail to comply with a
recertification request will be ((
disenrolled from BHP)) converted to
nonsubsidized enrollment for at least one month, until new income
documentation has been submitted and processed. Each enrollee is
responsible for notifying BHP within thirty days of any changes which
could affect the enrollee's eligibility or premium responsibility. If,
as a result of recertification, BHP determines that a subsidized
enrollee's income exceeds twice the poverty level according to the
federal income guidelines, and that the enrollee knowingly failed to
inform BHP of such increase in income, BHP may bill the enrollee for the
subsidy paid on the enrollee's behalf during the period of time that the
enrollee's income exceeded twice the poverty level.
[Statutory Authority: RCW 70.47.050. 96-15-024, 182-25-040, filed
7/9/96, effective 8/9/96.]
AMENDATORY SECTION (Amending WSR 96-15-024, filed 7/9/96, effective
WAC 182-25-090 Disenrollment from BHP. (1) An enrollee or employer group may disenroll effective the first day of any month by giving BHP at least ten days prior written notice of the intention to disenroll. Reenrollment in BHP shall be subject to the provisions of WAC 182-25-040(9). The administrator shall also establish procedures for notice by an enrollee of a disenrollment decision, including the date upon which disenrollment shall become effective. Nonpayment of premium by an enrollee shall be considered an indication of the enrollee's intention to disenroll from BHP.
(2) BHP may disenroll any enrollee or group from BHP for good cause, which shall include:
(a) Failure to meet the eligibility requirements set forth in WAC 182-25-030, 182-25-050, 182-25-060, and 182-25-070;
(b) Nonpayment of premium;
(c) Repeated failure to pay co-payments in full on a timely basis;
(d) Fraud or knowingly providing false information;
(e) Abuse or intentional misconduct; ((
(f) Risk to the safety or property of MHCS staff, providers, patients or visitors; and
(g) Refusal to accept or follow procedures or treatment determined by a MHCS to be essential to the health of the enrollee, where the managed health care system demonstrates to the satisfaction of BHP that no professionally acceptable alternative form of treatment is available from the managed health care system, and the enrollee has been so advised by the managed health care system.
In the event that an employer group, a home care agency group or a financial sponsor group is disenrolled under these provisions, the employer or sponsor and all members of that group will be notified of the disenrollment and the enrollees will be offered coverage under individual accounts. BHP will make every effort to transfer the enrollees to individual accounts without a break in coverage; however, the enrollee will be responsible for ensuring that payment is received by BHP prior to the final disenrollment date for that month.
Enrollees who are disenrolled from BHP in accordance with (c), (d),
(e) or (f) of this subsection may not reenroll for a period of twelve
months from the effective date of disenrollment. ((
With the exception
of)) Enrollees who are not under group coverage, who fail to pay their
premium by the due date will be suspended from coverage for one month.
If payment is not received within the billing cycle for the next coverage
month, the enrollee(( s who are)) will be disenrolled from BHP for
nonpayment, (( in accordance with)) under (b) of this subsection(( , more
than twice in a twelve-month period, and who have a lapse in coverage of
one month or more,)). If an enrollee's coverage is suspended more than
two times in a twelve-month period, the enrollee will be disenrolled for
nonpayment under (b) of this subsection. Enrollees who are disenrolled
for nonpayment under (b) of this subsection may not reenroll for a
(( period)) minimum of twelve months from the effective date of (( the
third disenrollment)) the last suspension. If a reservation list has
been implemented, an enrollee who was disenrolled in accordance with WAC
182-25-090(2) and is eligible to enroll from the reservation list prior
to the end of the required twelve-month wait for reenrollment, will not
be reenrolled until the end of the twelve-month period. If an enrollee
who was disenrolled in accordance with WAC 182-25-090(2) satisfies the
required twelve-month wait for reenrollment while on the reservation
list, enrollment will not be completed until funding is available to
enroll him or her from the reservation list.
BHP shall provide the enrollee or the parent, legal guardian or sponsor of an enrolled dependent with advance written notice of its intent to disenroll the enrollee. Such notice shall specify an effective date of disenrollment, which shall be at least ten days from the date of the notice, and shall describe the procedures for disenrollment, including the enrollee's right to appeal the disenrollment decision as set forth in WAC 182-25-100 and 182-25-105. Prior to the effective date specified, if the enrollee submits an appeal to BHP contesting the disenrollment decision, as provided in WAC 182-25-105, disenrollment shall not become effective until the date, if any, established as a result of BHP's appeal procedure, provided that the enrollee otherwise remains eligible and continues to make all premium payments when due; and further provided that the enrollee does not create a risk of violent, aggressive or harassing behavior, assault or battery or purposeful damage to or theft of managed health care system property, or the property of staff or providers, patients or visitors while on the property of the managed health care system or one of its participating providers.
(3) Any enrollee who knowingly provides false information to BHP or
to a participating managed health care system may be disenrolled by BHP
and may be held financially responsible for any covered services
fraudulently obtained through BHP.
[Statutory Authority: RCW 70.47.050. 96-15-024, 182-25-090, filed 7/9/96, effective 8/9/96.]