SOCIAL AND HEALTH SERVICES
(Medical Assistance Administration)
Preproposal statement of inquiry was filed as WSR 03-14-079.
Title of Rule: WAC 388-505-0211 Premium requirements for Medicaid and SCHIP children.
Purpose: This new WAC is necessary to implement the premium requirements for medicaid children. The rules will include SCHIP children and increase the premium amount for SCHIP (state children's health insurance program) coverage.
Statutory Authority for Adoption: RCW 74.08.090.
Statute Being Implemented: RCW 74.09.055, chapter 14, Laws of 2003 1st sp.s.
Summary: See Purpose above.
Name of Agency Personnel Responsible for Drafting, Implementation and Enforcement: Joanie Scotson, MAA, P.O. Box 45534, Olympia, WA 98504-5534, (360) 725-1330.
Name of Proponent: Department of Social and Health Services, governmental.
Rule is not necessitated by federal law, federal or state court decision.
Explanation of Rule, its Purpose, and Anticipated Effects: See Purpose above.
Proposal does not change existing rules. The new chapter increases the amount of premium charged for children to receive coverage under SCHIP. The chapter implements premium requirements for certain optional children receiving Medicaid.
No small business economic impact statement has been prepared under chapter 19.85 RCW. This rule applies solely to Medicaid eligibility.
RCW 34.05.328 does not apply to this rule adoption. RCW 34.05.328 (5)(b)(vii) exempts DSHS rules related to client financial or medical eligibility. The proposed rule requires families to pay premium amount to be eligible for SCHIP coverage.
Hearing Location: Blake Office Park (behind Goodyear Courtesy Tire), 4500 10th Avenue S.E., Rose Room, Lacey, WA 98503, on November 25, 2003, at 10:00 a.m.
Assistance for Persons with Disabilities: Contact Andy Fernando, DSHS Rules Coordinator, by November 21, 2003, phone (360) 664-6097, TTY (360) 664-6178, e-mail firstname.lastname@example.org.
Submit Written Comments to: Identify WAC Numbers, DSHS Rules Coordinator, Rules and Policies Assistance Unit, mail to P.O. Box 45850, Olympia, WA 98504-5850, deliver to 4500 10th Avenue S.E., Lacey, WA, fax (360) 664-6185, e-mail email@example.com, by 5:00 p.m. on November 25, 2003.
Date of Intended Adoption: Not sooner than November 26, 2003.
October 17, 2003
Brian H. Lindgren, Manager
Rules and Policies Assistance Unit3324.3
(a) "Mandatory children" means all states are required by federal rule to provide Medicaid coverage for these children; and
(b) "Optional children" means the state of Washington chose to provide Medicaid coverage to children that are not included in the mandatory population.
(c) "Premium" means an amount paid for medical coverage.
(2) Optional children include:
(a) A child under the age of one year, whose assistance unit's net available income exceeds one hundred eighty-five percent FPL as described in WAC 388-478-0075;
(b) A child over age one but who has not yet attained age six whose assistance unit's net available income exceeds one hundred thirty-three percent FPL as described in WAC 388-478-0075; and
(c) A child over age six whose assistance unit's net available income exceeds one hundred percent FPL as described in WAC 388-478-0075.
(3) For optional children found eligible for Medicaid coverage under WAC 388-505-0210(2), payment of a premium is required as a condition of eligibility. See subsection (6) of this section for exemptions for optional children.
(4) A child found eligible for Medicaid coverage under WAC 388-505-0210(2) that does not meet the conditions of subsection (2) of this section is a mandatory recipient of Medicaid and is not subject to the premium requirement.
(5) For a child found eligible for the state children's health insurance program (SCHIP) under WAC 388-505-0210(3), payment of a premium is required as a condition of eligibility.
(6) An optional child is exempt from the premium requirement if the child meets one of the following:
(a) The child is pregnant; or
(b) The child is an American Indian or Alaska native.
(7) The premium requirement begins the first of the month following the determination of eligibility. There is no premium requirement for medical coverage received in a month or months before the determination of eligibility.
(8) The premium amount for the assistance unit is based on the net available income as described in WAC 388-450-0005. If the household includes more than one assistance unit, the premium amount billed for the assistance units may be different amounts.
(9) The premium amount for each optional Medicaid child is:
(a) Fifteen dollars per month when the assistance unit's net available income is above one hundred percent FPL and at or below one hundred fifty percent FPL; or
(b) Twenty dollars per month when the assistance unit's net available income is above one hundred fifty percent FPL and at or below two hundred percent FPL.
(10) The premium amount for each SCHIP child is twenty-five dollars per month.
(11) The department bills the family for the lesser of:
(a) A maximum of seventy-five dollars per month; or
(b) The total of the highest premiums, for up to three children in the assistance unit.
(12) Premium payment is a condition of eligibility for assistance units that include optional children. All optional children in an assistance unit are ineligible for medical coverage when the head of household's premium payments are three months in arrears. Three months in arrears means a balance exists for three months.
(13) When the department terminates the medical coverage of an optional child due to nonpayment of premiums, the child has a three-month period of ineligibility beginning the first of the following month. The three month period of ineligibility is rescinded only when the:
(a) Past due premiums are paid in full prior to the begin date of the period of ineligibility; or
(b) Optional child has a change in circumstances such that the child becomes a mandatory child. The department cannot rescind the three-month period of ineligibility for reasons other than the criteria described in subsection (13) of this section.
(15) The department writes off past-due premiums after twelve months.
(16) When the designated three-month period of ineligibility is over, all past due premiums that are an obligation of the head of household must be paid or written off before an optional child can become eligible for medical coverage.
(17) A family cannot designate partial payment of the billed premium amount as payment for a specific child in the assistance unit. The full amount of the premium bill is the obligation of the head of household of the assistance unit. A family can decide to request medical coverage only for certain children in the assistance unit, if they want to reduce premium obligation.
(18) A change that affects the premium amount is effective the month after the change is reported and processed.
(19) A sponsor or other third party may pay the premium on behalf of the child or children in the assistance unit. The premium payment requirement remains the obligation of head of household of the assistance unit. The failure of a sponsor or other third party to pay the premium does not eliminate the:
(a) Establishment of the period of ineligibility described in subsection (13) of this section; or
(b) Obligation of the head of household to pay past-due premiums.
Reviser's note: The typographical error in the above section occurred in the copy filed by the agency and appears in the Register pursuant to the requirements of RCW 34.08.040.