Date of Adoption: May 26, 1999.

Purpose: Creates new WAC 182-25-085 for recoupment of subsidy overpayments or assessing penalties for failure to report income or income changes correctly. Revises WAC 182-25-090 to incorporate changes related to recoupment and penalties and to remove duplication or unnecessary language, as required by Executive Order 97-02.

Citation of Existing Rules Affected by this Order: Amending WAC 182-25-090.

Statutory Authority for Adoption: RCW 70.47.050, 70.47.060, and 70.47.090.

Adopted under notice filed as WSR 99-08-106 on April 7, 1999.

Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 1, Amended 1, Repealed 0.

Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 1, Repealed 0.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 1, Repealed 0.

Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 1, Amended 1, Repealed 0. Effective Date of Rule: Thirty-one days after filing.

May 26, 1999

Elin Meyer

Rules Coordinator

OTS-3014.2

NEW SECTION
WAC 182-25-085
Enrollees' failure to report correct income.

(1) If the HCA determines that the enrollee has received a subsidy overpayment due to failure to report income correctly, the HCA may:

(a) Bill the enrollee for the amount of subsidy overpaid by the state; or

(b) Impose civil penalties of up to two hundred percent of the subsidy overpayment.

(2) Any HCA determination under subsection (1) of this section is subject to the enrollee appeal provisions in WAC 182-25-105.

(3) When a decision under subsection (1)(a) of this section is final, the HCA may establish a payment schedule and collect the amount owed through future premium statements. The payment schedule will be for a period of no more than six months, unless the HCA approves an alternative payment schedule requested by the enrollee. When a payment schedule is established, the HCA will send the enrollee advance written notice of the schedule and the total amount due. The total amount due each month will include the regular monthly premium plus charges for subsidy overpayment. If an enrollee does not pay the amount due, including charges for subsidy overpayment, the enrollee and all family members enrolled on the account will be disenrolled for nonpayment under WAC 182-25-090 (2)(b).

(4) When a decision under subsection (1)(b) of this section becomes final, the HCA will send the enrollee notice that payment of the civil penalty is due within thirty days after the decision becomes final, unless the HCA approves a different due date at the enrollee's request. If the enrollee does not pay the civil penalty by the due date, the enrollee and all family members on the account will be disenrolled for nonpayment under WAC 182-25-090 (2)(c).

(5) Individuals who are disenrolled from BHP may not reenroll until charges for subsidy overpayments or civil penalties imposed under subsection (1) of this section have been paid or the HCA has approved a payment schedule.

(6) The HCA will take all necessary and appropriate administrative and legal actions to collect the unpaid amount of any subsidy overpayment or civil penalty.

(7) Enrollees under employer group or financial sponsor group coverage who do not follow the income reporting procedures established by BHP and their employer or financial sponsor may be billed directly by the HCA for subsidy overpayments or civil penalties assessed under subsection (1) of this section. Enrollees who do not pay the amount due will be disenrolled under WAC 182-25-090 (2)(b) or (c). Enrollees who are disenrolled for nonpayment of a subsidy overpayment or civil penalties will be excluded from the minimum participation calculation for employer groups under WAC 182-25-050(2).

[]

(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)) includes:

(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))) under the provisions of subsection (5) of this section;

(c) Nonpayment of civil penalties assessed under WAC 182-25-085;

(d) Repeated failure to pay co-payments in full on a timely basis;

(((d))) (e) Fraud, failure to provide requested verification of eligibility, or knowingly providing false information;

(((e))) (f) Abuse or intentional misconduct;

(((f) Risk)) (g) Danger or threat to the safety or property of the MHCS or the health care authority or their staff, providers, patients or visitors; and

(((g))) (h) 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)) when the MHCS has advised the enrollee and demonstrated 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 (g) of this section may not reenroll for a period of twelve months from the effective date of disenrollment.  Enrollees 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 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 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 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 suspend coverage.  Such notice shall specify an effective date of suspension, which shall be at least ten days from the date of the notice.  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.

(5))) MHCS.

In addition to being disenrolled, 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.

(3) At least ten days prior to the effective date of disenrollment under subsection (2) of this section, BHP will send enrollees written notice of disenrollment.

(a) The notice of disenrollment will:

(i) State the reason for the disenrollment;

(ii) State the effective date of the disenrollment;

(iii) Describe the procedures for disenrollment; and

(iv) Inform the enrollee of his or her right to appeal the disenrollment decision as set forth in WAC 182-25-100 and 182-25-105.

(b) The notice of disenrollment will be sent to both the employer or sponsor and to all members of an employer group, home care agency group or financial sponsor group that is disenrolled under these provisions. Enrollees affected by the disenrollment of a group account will be offered coverage under individual accounts. Coverage under individual accounts will not begin unless the premium for individual coverage is paid by the due date for the coverage month. A one-month break in coverage may occur for enrollees who choose to transfer to individual accounts.

(4) Enrollees covered under BHP Plus or receiving maternity benefits through medical assistance will not be disenrolled from those programs when other family members lose BHP coverage, as long as they are still eligible for those programs.

(5) Under the provisions of this subsection, BHP will suspend or disenroll enrollees and groups who do not pay their premiums when due, including amounts owed for subsidy overpayment. Partial payment or payment by check which cannot be processed or is returned due to nonsufficient funds will be regarded as nonpayment.

(a) At least ten days before coverage will lapse, BHP will send a delinquency notice to each subscriber whose premium payment has not been received by the due date. The delinquency notice will include a delinquency due date and a notice that BHP coverage will lapse unless payment is received by the delinquency due date.

(b) Except as provided in (c) of this subsection, coverage will be suspended for one month if an enrollee's premium payment is not received by the delinquency due date. BHP will send written notice of suspension to the subscriber, stating:

(i) The effective date of the suspension;

(ii) The due date by which payment must be received to restore coverage after the one-month suspension;

(iii) The subscriber and any enrolled dependents will be disenrolled if payment is not received by the final due date; and

(iv) The enrollee's right to appeal under WAC 182-25-105.

(c) Enrollees whose premium payment has not been received by the delinquency due date, and who have been suspended twice within the previous twelve months will be disenrolled for nonpayment as of the effective date of the third suspension.

(d) Enrollees who are suspended and do not pay the premium for the next coverage month by the due date on the notice of suspension will be immediately disenrolled and issued a notice of disenrollment as provided in subsection (3)(a) of this section.

(6)(a) Enrollees who voluntarily disenroll or are disenrolled from BHP may not reenroll for a period of twelve months from the date their coverage ended. An exception to this provision will be made for:

(i) Enrollees who left BHP for other health insurance, who are able to provide proof of continuous coverage from the date of disenrollment, and who apply to reenroll in BHP within thirty days of losing the other coverage;

(ii) Enrollees who left BHP because they lost eligibility and who subsequently become eligible to reenroll; and

(iii) Persons enrolling in subsidized BHP, who had enrolled and subsequently disenrolled from nonsubsidized BHP under subsection (1) or (2)(b) of this section while waiting on a reservation list for subsidized coverage.

(b) An enrollee who is required to wait twelve months for reenrollment under (a) of this subsection and who has been waiting on a reservation list for subsidized BHP may not reenroll prior to the end of the required twelve-month wait. If the enrollee 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.

[Statutory Authority: RCW 70.47.050.  98-07-002, § 182-25-090, filed 3/5/98, effective 4/5/98; 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.]

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