WSR 98-07-002
PERMANENT RULES
HEALTH CARE AUTHORITY
[Filed March 5, 1998, 11:16 a.m.]
Date of Adoption: March 5, 1998
Purpose: Updates basic health plan rules to incorporate legislative and administrative changes
Citation of Existing Rules Affected by this Order: Amending WAC 182-25-010, 182-25-020, 182-25-030, 182-25-040, 182-25-070, 182-25-080, 182-25-090, 182-25-100, and 182-25-105
Statutory Authority for Adoption: RCW 70.47.050
Adopted under notice filed as WSR 98-01-220 on December 24, 1997
Number of Sections Adopted in Order to Comply with Federal Statute: New 0, amended 0, repealed 0; Federal Rules or Standards: New 0, amended 0, repealed 0; or Recently Enacted State Statutes: New 0, amended 4, repealed 0.
Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, amended 0, repealed 0.
Number of Sections Adopted on the Agency's Own Initiative: New 0, amended 8, repealed 0.
Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, amended 8, repealed 0.
Number of Sections Adopted Using Negotiated Rule Making: New 0, amended 9, repealed 0; Pilot Rule Making: New 0, amended 0, repealed 0; or Other Alternative Rule Making: New 0, amended 0, repealed 0.
Effective Date of Rule: Thirty-one days after filing.
March 3, 1998
Elin Meyer
Rules Coordinator
OTS-1752.6
AMENDATORY SECTION (Amending WSR 97-15-003, filed 7/3/97, effective 8/3/97)
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. Eligibility for BHP Plus is determined by the department of social and health services, based on Medicaid eligibility criteria. 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 the dependent limiting age has
not been exceeded; and the dependent meets all other eligibility
requirements.
(c) Legal dependent of any age who is incapable of self-support due to disability.)) "Dependent" means:
(a) The subscriber's lawful spouse, not legally separated, who resides with the subscriber; or
(b) The unmarried child of the subscriber or the subscriber's dependent spouse, whether by birth, adoption, legal guardianship, or placement pending adoption, who is:
(i) Younger than age nineteen, and who has not been relinquished for adoption by the subscriber or the subscriber's dependent spouse; or
(ii) Younger than age twenty-three, and a registered student at an accredited secondary school, college, university, technical college, or school of nursing, attending full time, other than during holidays, summer and scheduled breaks; or
(c) A person of any age who is under legal guardianship of the subscriber or the subscriber's dependent spouse, and 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, with employees in addition to the employer, whose wages or salaries are paid by the employer.
(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;
(vi) Dividends and interest accessible to the enrollee without a penalty;
(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 assistantships;
(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) "Institution" means a federal, state, county, city or other government correctional or detention facility or government-funded facility where health care historically has been provided and funded through the budget of the operating agency, and includes, but is not limited to: Washington state department of corrections institutions; federal, county and municipal government jail and detention institutions; Washington state department of veterans affairs soldiers' and veterans' homes; department of social and health services state hospitals and facilities and juvenile rehabilitation institutions and group homes. An institution does not include: Educational institutions; government-funded acute health care or mental health facilities except as provided above; chemical dependency facilities; and nursing homes.
(20) "Institutionalized" means to be confined, voluntarily or involuntarily, by court order or health status, in an institution, as defined in subsection (19) of this section. This does not include persons on work release or who are residents of higher education institutions, acute health care facilities, alcohol and chemical dependency facilities, or nursing homes.
(21) "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))) (22) "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))) (23) "Maternity benefits through medical
assistance," also known as S-Medical, means the coordinated
program between BHP and DSHS for eligible pregnant women. This
program includes all Medicaid benefits, including maternity
coverage. Eligible members must be at or below one hundred
eighty-five percent of the federal poverty level. Eligibility
for this program is determined by DSHS, based on Medicaid
eligibility criteria.
(24) "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))) (25) "Medicare" means programs established by Title
XVIII of Public Law 89-97, as amended, "Health Insurance for the
Aged and Disabled."
(((23))) (26) "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))) (27) "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))) (28) "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))) (29) "Participating employer" means an employer who
has been approved for enrollment in BHP as an employer group.
(((27))) (30) "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))) (31) "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))) (32) "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))) (33) "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))) (34) "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))) (35) "Service area" means the geographic area
served by a managed health care system as defined in its contract
with HCA.
(((33))) (36) "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))) (37) "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))) (38) "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. 97-15-003, § 182-25-010, filed 7/3/97, effective 8/3/97; 96-15-024, § 182-25-010, filed 7/9/96, effective 8/9/96.]
AMENDATORY SECTION (Amending WSR 97-15-003, filed 7/3/97, effective 8/3/97)
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. Similar coverage includes BHP; all DSHS programs administered by the medical assistance administration which have the Medicaid scope of benefits; the DSHS program for the medically indigent; Indian health services; most coverages offered by health carriers; and most self-insured health plans. 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. 97-15-003, § 182-25-020, filed 7/3/97, effective 8/3/97; 96-15-024, § 182-25-020, filed 7/9/96, effective 8/9/96.]
AMENDATORY SECTION (Amending WSR 97-15-003, filed 7/3/97, effective 8/3/97)
WAC 182-25-030 Eligibility. (1) To be eligible for enrollment in BHP, an individual must:
(a) Reside within the state of Washington;
(b) Not be eligible for Medicare; and
(((b) Reside within the state of Washington.)) (c) Not be
institutionalized at the time of enrollment.
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)) the criteria in (a) and (b)
of this subsection, or who is later determined to have failed to
meet ((the)) 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.
(2) Eligibility for DSHS-coordinated programs, such as BHP Plus and S-Medical, are determined by DSHS, based on Medicaid eligibility criteria.
(3) 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))) (4) 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))) (5) 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
from:
(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 for reasons other than noncompliance;
(((e))) (d) Employees of a home care agency group enrolled
or applying for coverage under WAC 182-25-060;
(((f))) (e) Eligible individual home care providers;
(((g))) (f) Licensed foster care workers;
(((h))) (g) Limited enrollment of new employer groups; and
(((i))) (h) 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 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.
[Statutory Authority: RCW 70.47.050. 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.]
AMENDATORY SECTION (Amending WSR 97-15-003, filed 7/3/97, effective 8/3/97)
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)) required 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 BHP coverage for his/her dependent((s)) who
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) If specific funding has been appropriated for that purpose, 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))
not been a BHP member ((in the past)) within the previous five
years.
(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. Enrollees who are not under group coverage, may not reenroll for a minimum of twelve months from the effective date of 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 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. 97-15-003, § 182-25-040, filed 7/3/97, effective 8/3/97; 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 8/9/96)
WAC 182-25-070 Financial sponsors. (1) A third party may, with the approval of the administrator, become a financial sponsor to BHP enrollees. Financial sponsors may not be a state agency or a managed health care system.
(2) BHP may require a minimum financial contribution from financial sponsors who are paid to deliver BHP services. Sponsors who meet the following criteria will be exempt from the minimum contribution:
(a) Organizations that are not paid to perform any function related to the delivery of BHP services, and do not receive contributions from other organizations paid to deliver BHP services;
(b) Charitable, fraternal or government organizations (other than state agencies) that are not paid to perform any function related to the delivery of BHP services, who receive contributions from other individuals or organizations who may be paid to deliver BHP services, if the organization can demonstrate all of the following:
(i) Organizational autonomy (the organization's governance is separate and distinct from any organization that is paid to deliver BHP services);
(ii) Financial autonomy and control over the funds contributed (contributors relinquish control of the donated funds);
(iii) Sponsored enrollees are selected by the sponsoring organization from all persons within the geographic boundaries established by the sponsor organization who meet the selection criteria agreed upon by the sponsor organization and the HCA; and
(iv) There is no direct financial gain to the sponsoring entity.
(c) Charitable, fraternal, or government organizations (other than state agencies) that are paid to perform a health care function related to the delivery of BHP services, if the organization can demonstrate all of the following:
(i) The organization's primary purpose is not the provision of health care or health care insurance, including activities as a third-party administrator or holding company;
(ii) There is organizational and financial autonomy (the organization's governance and funding of sponsored enrollees is separate and distinct from the function that is paid to deliver BHP services);
(iii) The selection of sponsored enrollees is made by the organization separate and distinct from the function that is paid to deliver BHP services, and sponsored enrollees are selected from all eligible persons who meet the selection criteria agreed upon by the sponsor organization and the HCA, who live within the geographic boundaries established by the sponsor organization; and
(iv) There is no direct financial gain to the sponsoring entity.
(3) The financial sponsor will establish eligibility for participation in that particular financial sponsor group; however, sponsored enrollees must meet all BHP eligibility requirements as outlined in WAC 182-25-030.
(((3))) (4) The financial sponsor will pay all or a
designated portion of the premium on behalf of the sponsored
enrollee. It is the financial sponsor's responsibility to
collect the enrollee's portion of the premium, if any, and remit
the entire payment to BHP and to notify BHP of any changes in the
sponsored enrollee's account.
(((4))) (5) A financial sponsor must inform sponsored
enrollees and BHP of the minimum time period for which they will
act as sponsor. At least sixty days before the end of that time
period, it is the responsibility of the financial sponsor to
notify sponsored enrollees and BHP if the sponsorship will or
will not be extended.
(((5))) (6) A financial sponsor must not discriminate for or
against potential group members based on health status, race,
color, creed, political beliefs, national origin, religion, age,
sex or disability.
(((6))) (7) A financial sponsor ((may choose the managed
health care system available to sponsored enrollees who
participate in that financial sponsor group; however, the
sponsor)) must disclose to the sponsored enrollee all the managed
health care systems within the enrollee's county of residence,
the estimated premiums for each of them, and the BHP toll-free
information number.
(((7))) (8) BHP may periodically conduct a review of the
financial sponsor group members to verify the eligibility of all
enrollees.
[Statutory Authority: RCW 70.47.050. 96-15-024, § 182-25-070, filed 7/9/96, effective 8/9/96.]
AMENDATORY SECTION (Amending WSR 96-15-024, filed 7/9/96, effective 8/9/96)
WAC 182-25-080 Premiums and co-payments. (1) Subscribers or their employer or financial sponsor shall be responsible for paying the full monthly premium to BHP, on behalf of the subscriber and all enrolled dependents, according to the most current premium schedule. A third party may, with the approval of the administrator, become a financial sponsor and pay all or a designated portion of the premium on behalf of a subscriber and dependents, if any.
(2) The amount of premium due from or on behalf of a subscriber will be based upon the subscriber's gross family income, the managed health care system selected by the subscriber, rates payable to managed health care systems, and the number and ages of individuals in the subscriber's family.
(3) Once BHP has determined that an applicant and his/her dependents (if any) are eligible for enrollment, the applicant or employer or financial sponsor will be informed of the amount of the first month's premium for the applicant and his/her enrolled dependents. New enrollees will not be eligible to receive covered services on the effective date of enrollment specified by BHP unless the premium has been paid. Thereafter, BHP will bill each subscriber or employer or financial sponsor monthly.
(4) Full payment for premiums due must be received by BHP by
the date specified on the bill. If BHP does not receive full
payment of a premium by the date specified on the bill, BHP shall
issue a notice of delinquency to the subscriber, at the
subscriber's last address on file with BHP or, in the case of
group or financial sponsor coverage, to the employer or financial
sponsor. If full payment is not received by the date specified
in the delinquency notice, the subscriber and enrolled family
members will be suspended from coverage for one month. If
payment is not received by the due date on the notice of
suspension, the subscriber and enrolled family members will be
disenrolled effective the ((first day of the month following the
last month for which full premium payment was received, as
provided in)) date of the initial suspension. If an enrollee's
coverage is suspended more than two times in a twelve-month
period, the enrollee will be disenrolled for nonpayment under the
provisions of WAC 182-25-090(2). Partial payment of premiums due
or payment by check which is returned due to nonsufficient funds
will be regarded as nonpayment.
(5) Enrollees shall be responsible for paying any required co-payment directly to the provider of a covered service at the time of service or directly to the MHCS. Repeated failure to pay co-payments in full on a timely basis may result in disenrollment, as provided in WAC 182-25-090(2).
[Statutory Authority: RCW 70.47.050. 96-15-024, § 182-25-080, filed 7/9/96, effective 8/9/96.]
AMENDATORY SECTION (Amending WSR 97-15-003, filed 7/3/97, effective 8/3/97)
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 (BHP Plus or S-Medical coverage will not be affected if other enrolled family members are disenrolled for 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.
(3) Enrollees who are disenrolled from BHP in accordance
with subsection (2)(c), (d), (e), (f) or (((f))) (g) of this
((subsection)) section may not reenroll for a period of twelve
months from the effective date of disenrollment. Enrollees ((who
are not under group coverage,)) who fail to pay their premium by
the due date on the delinquency notice will be suspended from
coverage for one month. If payment is not received within the
billing cycle for the next coverage month, the enrollee will be
disenrolled from BHP for nonpayment, under subsection (2)(b) of
this ((subsection)) section. If an enrollee's coverage is
suspended more than two times in a twelve-month period, the
enrollee will be disenrolled for nonpayment under subsection
(2)(b) of this ((subsection)) section. In these cases, BHP will
provide notice to the enrollee indicating intent to disenroll and
the effective date of disenrollment, which will be at least ten
days from the date of the notice, and informing the enrollee of
his or her right to appeal. Enrollees who are disenrolled for
nonpayment under subsection (2)(b) of this ((subsection)) section
may not reenroll for a minimum of twelve months from the
effective date of the last suspension. An exception to the
twelve-month wait for reenrollment will be made for enrollees
who:
(a) Voluntarily disenrolled or were disenrolled from nonsubsidized BHP for nonpayment of premiums;
(b) Were on the reservation list for subsidized BHP on or before the date their nonsubsidized coverage began;
(c) Have been offered coverage from the reservation list; and
(d) Are at that time enrolling in subsidized BHP.
This exception will not be allowed if the member is applying to reenroll in nonsubsidized BHP.
(4) 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)) suspend coverage.
Such notice shall specify an effective date of ((disenrollment))
suspension, which shall be at least ten days from the date of the
notice((, and shall describe the procedures for disenrollment,
including the enrollee's)). If an enrollee's coverage is
suspended, BHP will also send final written notice of suspension
to the subscriber, indicating an effective date of the
suspension; establishing a final due date for payment to restore
coverage; informing the enrollee of the intent to disenroll if
payment is not received by the final due date; and of his or her
right to appeal the suspension decision. If an enrollee is
disenrolled, BHP will send final written notice of disenrollment
to the subscriber, indicating the effective date of the
disenrollment, describing the procedures for disenrollment, and
informing the enrollee of his or her 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))) (5) 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. 97-15-003, § 182-25-090, filed 7/3/97, effective 8/3/97; 96-15-024, § 182-25-090, filed 7/9/96, effective 8/9/96.]
AMENDATORY SECTION (Amending WSR 96-15-024, filed 7/9/96, effective 8/9/96)
WAC 182-25-100 Appeals and mediation of grievances. (1) HCA decisions regarding basic health plan eligibility, premium, enrollment, suspension, disenrollment or change of MHCS may be appealed pursuant to WAC 182-25-105.
(2) The HCA will not hear appeals of decisions regarding children covered under BHP plus. Those decisions must be appealed through the department of social and health services, according to the provisions of chapters 388-08 and 388-526 WAC, as amended.
(3) Decisions made by a MHCS, such as coverage disputes or benefits interpretation may be appealed pursuant to WAC 182-25-110.
[Statutory Authority: RCW 70.47.050. 96-15-024, § 182-25-100, filed 7/9/96, effective 8/9/96.]
AMENDATORY SECTION (Amending WSR 96-15-024, filed 7/9/96, effective 8/9/96)
WAC 182-25-105 Appeals of HCA decisions regarding BHP. (1) If a subscriber or applicant wishes to appeal a HCA decision regarding BHP eligibility, premium, enrollment, suspension, disenrollment or change of MHCS, he/she must send a letter of appeal, signed by the appealing party, to the HCA appeals committee no more than thirty days after the date the HCA's decision was sent to the subscriber or applicant. The letter should include the name, address and BHP account number of the enrollee and subscriber or the applicant and a statement of:
(a) The decision being appealed;
(b) Why the enrollee considers the decision to be incorrect; and
(c) The facts upon which the appeal is based, including any supporting documents.
(2) When the letter of appeal is received, the HCA appeals coordinator will contact the subscriber to explain his/her appeal rights and the appeal procedure used by the HCA appeals committee to conduct a brief adjudicative proceeding pursuant to RCW 34.05.482 through 34.05.494, as amended. Generally, the appeal will be limited to a review of submitted documents, but may also include a telephone or in-person conference. The HCA appeals committee will send its written initial decision to the subscriber or applicant within sixty days of receipt of the subscriber's or applicant's letter of appeal. The written initial decision will include reasons for the decision and information and instructions on further appeal rights. The appeals committee may also elect to convert the brief adjudicative proceeding to a formal adjudicative proceeding when it is more appropriate to resolve issues affecting the participants, and refer the appeal to the hearing officer.
(3) If the HCA appeals committee decision results in disenrollment, the enrollee may request a review hearing by the office of administrative hearings, pursuant to chapter 34.12 RCW and RCW 34.05.488 through 34.05.494, as amended. An enrollee or applicant may request review of all other initial decisions of the HCA appeals committee by a HCA hearings officer, pursuant to RCW 34.05.488 through 34.05.494, as amended. A request for review of the initial decision must be made in writing within twenty-one days after service of the written statement as required by RCW 34.05.485(3), as amended. Otherwise, the HCA appeals committee decision will be the final agency decision.
(4) ((If the HCA receives a timely appeal of a disenrollment
decision, disenrollment shall not become effective pending the
resolution of the appeal, provided that:
(a) The enrollee otherwise remains eligible and continues to
make all premium payments when due (if the premium amount is the
subject of the dispute, the premium will be billed at the rate
the subscriber was paying prior to the dispute);
(b) The enrollee does not create a risk of violent,
aggressive or harassing behavior, assault or battery or
purposeful damage to or theft of MHCS property, or the property
of staff or providers, patients or visitors while on the property
of the MHCS or one of its participating providers.)) An enrollee
who has appealed a disenrollment decision will remain disenrolled
pending the appeal decision, with the exception of enrollees who
have filed a timely appeal of a disenrollment decision that was
due to an issue of eligibility. In appeals of a disenrollment
for ineligibility, the disenrollment will not become effective
pending the appeal decision, provided:
(a) The enrollee otherwise remains eligible and continues to make all premium payments when due; and
(b) The enrollee has not demonstrated a risk to the safety or property of MHCS or health care authority staff, providers, patients or visitors.
[Statutory Authority: RCW 70.47.050. 96-15-024, § 182-25-105, filed 7/9/96, effective 8/9/96.]