Date of Adoption: July 26, 1999.

Purpose: WAC 182-25-030 is revised to clarify eligibility criteria, particularly as they apply to applicants or enrollees eligible for Medicare. WAC 182-25-040 is revised to incorporate changes related to recoupment of subsidy overpayments and to clarify current policy or reduce duplication or unnecessary language, as required by Executive Order 97-02.

Citation of Existing Rules Affected by this Order: Amending WAC 182-25-030 and 182-25-040.

Statutory Authority for Adoption: RCW 70.47.050 and 70.47.060.

Adopted under notice filed as WSR 99-12-032 on May 26, 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Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 2, Repealed 0.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 2, Repealed 0.

Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 2, Repealed 0. Effective Date of Rule: Thirty-one days after filing.

July 23, 1999

Elin Meyer

Rules Coordinator

OTS-3143.1

AMENDATORY SECTION(Amending WSR 98-07-002, filed 3/5/98, effective 4/5/98)

WAC 182-25-030
Eligibility.

(1) To be eligible for enrollment in BHP, an individual must be a Washington state resident who is not:

(a) ((Reside within the state of Washington;

(b) Not be)) Eligible for free Medicare((; and

(c) Not be)) coverage or eligible to buy Medicare coverage; or

(b) Institutionalized at the time of enrollment.

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

(((2))) (3) Eligibility for ((DSHS-coordinated programs, such as)) BHP Plus and ((S-Medical, are)) maternity benefits through medical assistance is determined by DSHS, based on Medicaid eligibility criteria.

(((3))) (4) To be eligible for subsidized enrollment in BHP, an individual must meet the eligibility criteria in subsection (1) of this section, 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.

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

(((5))) (6) 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) 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;

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

(e) Eligible individual home care providers;

(f) Licensed foster care workers;

(g) Limited enrollment of new employer groups; and

(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.   WSR 98-07-002, § 182-25-030, filed 3/5/98, effective 4/5/98; 97-15-003, § 182-25-030, filed 7/3/97, effective 8/3/97; 96-15-024, § 182-25-030, filed 7/9/96, effective 8/9/96.]

(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.  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 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 for BHP coverage for his/her dependent 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) When a managed health care system((s may)) assists BHP applicants in the enrollment process, ((but)) it must provide them with the toll-free number for BHP((,)) and information on all MHCS available within the applicant's county of residence and ((an estimate of)) the estimated premiums ((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 not been a BHP member 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))) (6), 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))) (6).

(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." "Qualifying changes in family status" include:

(a) The loss of other ((continuous)) health care coverage, for a family member((s)) who ((have)) has previously waived coverage, ((upon)) provided BHP receives the family member's application within thirty days of the loss of other coverage, along with proof of the family member's continuous medical coverage from the date the subscriber enrolled in BHP;

(b) Marriage or assuming custody or dependency of a child or adult dependent (other than newborn or newly adopted children), provided BHP receives the new family member's application within thirty days of the change in family status; or

(c) ((Birth, adoption or change in dependency or custody of a child or adult dependent.)) Addition of an eligible newborn child or ((newly adopted children may be enrolled effective from the date of birth or physical placement)) a child newly placed for adoption provided ((that)) BHP receives the child's application for enrollment ((is submitted to BHP)) within sixty days of the date of birth or ((such)) placement for adoption. These children may be enrolled effective from the date of birth or 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 to determine 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)) an enrollee(('s)) has not reported 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)) or income changes accurately, the enrollee will be subject to the provisions of WAC 182-25-085.

[Statutory Authority: RCW 70.47.050.   WSR 98-07-002, § 182-25-040, filed 3/5/98, effective 4/5/98; 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.]