Original Notice.

     Preproposal statement of inquiry was filed as WSR 03-18-121.

     Title of Rule: Revising rules regarding disenrollment of Basic Health enrollees.

     Purpose: Revisions for clarity and to update rules regarding disenrollment and reenrollment after disenrollment.

     Statutory Authority for Adoption: RCW 70.47.050.

     Statute Being Implemented: RCW 70.47.060 (4) and (9), 70.47.089, 70.47.090, and section 213(5), chapter 25, Laws of 2003.

     Summary: Updates rules for disenrollment and reenrollment to incorporate contract changes for 2004 and to allow an exception to the twelve-month wait for reenrollment.

     Reasons Supporting Proposal: Contract changes for 2004 will include coinsurance and a deductible, so disenrollment for failing to pay cost-sharing needs to incorporate these changes. Enrollees who were attempting to comply with a documentation request but were not able to meet the deadline will have a break in coverage, but should not be required to wait twelve months to reenroll. These enrollees have proven they are eligible for the program. Other changes are for clarification, and to update rules to reflect changes in procedures.

     Name of Agency Personnel Responsible for Drafting: Rosanne Reynolds, Lacey, Washington, (360) 923-2948; Implementation and Enforcement: Kathy Eberle, Lacey, Washington, (360) 412-4307.

     Name of Proponent: Health Care Authority, governmental.

     Rule is not necessitated by federal law, federal or state court decision.

     Explanation of Rule, its Purpose, and Anticipated Effects:

•     Clarifies that disenrollment for repeatedly failing to pay enrollee cost-sharing includes coinsurance and other cost-sharing, not just copayments. The effect of this change is to update rules to reflect contract changes for 2004.

•     Allows an exception to the twelve-month wait to reenroll after disenrolling, for those who are disenrolled in the process of a recertification. The effect of this change is to allow some leniency for enrollees who were attempting to comply with a recertification request but were unable to meet the deadlines. If they are able to provide proof of their eligibility, these enrollees will have a break in coverage, but will not be required to wait twelve months to reenroll.

•     Removes disenrollment for nonpayment of a civil penalty, since enrollees will have been disenrolled under the provisions of WAC 182-25-090 (2)(e). This change is not expected to have any impact on enrollees, but removes an inconsistency from the rule.

•     Clarifies that a voluntary disenrollment is not required to be in writing. This change is not expected to have any impact on enrollees.

•     Other minor edits are for clarity only. They are not expected to have any impact on enrollees.

     Proposal Changes the Following Existing Rules:

•     Deletes WAC 182-25-090 (2)(c).

•     Adds coinsurance and other cost-sharing to the provisions for disenrollment because of repeated failure to pay copayments.

•     Adds an exception to the twelve-month wait for reenrollment for enrollees who attempted to comply with a request for documentation but were unable to meet the deadline.

•     Various edits to update and for clarity.

     No small business economic impact statement has been prepared under chapter 19.85 RCW. The Health Care Authority is not required by chapter 19.85 RCW to prepare a small business economic impact statement. There will be little, if any, cost to small business.

     RCW 34.05.328 does not apply to this rule adoption. RCW 34.05.328 does not apply to the Health Care Authority rules unless requested by the Joint Administrative Rules Review Committee or applied voluntarily.

     Hearing Location: 676 Woodland Square Loop S.E., East Wing, Fourth Floor Conference Room, Lacey, WA, on November 25, 2003, at 3:00 p.m.

     Assistance for Persons with Disabilities: Contact Nikki Johnson by November 17, 2003, TDD (888) 923-5622 or (360) 923-2805.

     Submit Written Comments to: Rosanne Reynolds, P.O. Box 42686, Olympia, WA 98504-2686, e-mail Rrey107@hca.wa.gov, fax (360) 923-2605, by November 25, 2003.

     Date of Intended Adoption: November 26, 2003.

October 22, 2003

Melodie Bankers

Rules Coordinator

OTS-6751.1

AMENDATORY SECTION(Amending Order 01-07, filed 9/12/02, effective 10/13/02)

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.

     (2) BHP may disenroll any enrollee or group from BHP for good cause, which 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 under the provisions of subsection (6) of this section;

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

     (d))) Changes in MHCS or program availability when the enrollee's MHCS will no longer be available to him or her and no other MHCS in the area where the enrollee lives is accepting new enrollment in the enrollee's program;

     (((e))) (d) Repeated failure to pay co-payments, coinsurance, or other cost-sharing in full on a timely basis. This provision will only be imposed if requested by the MHCS and approved by BHP;

     (((f))) (e) Fraud, intentional misrepresentation of information or withholding information that the enrollee knew or should have known was material or necessary to accurately determine their eligibility or premium responsibility, failure to provide requested verification of eligibility or income, or knowingly providing false information;

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

     (((h))) (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

     (((i))) (h) Refusal to accept or follow procedures or treatment determined by a MHCS to be essential to the health of the enrollee, 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 MHCS.

     (3) In addition to being disenrolled, any enrollee who knowingly provides false information to BHP or to a participating managed health care system may be held financially responsible for any covered services fraudulently obtained through BHP.

     (4) At least ten days prior to the effective date of disenrollment under subsection (2)(a) and (c) through (((i))) (h) 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.

     (5) 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 remain eligible for those programs.

     (6) 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, if any. 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 final due date and a notice that BHP coverage will lapse unless payment is received by the final 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 final due date, as shown on the delinquency notice. BHP will send written notice of suspension to the subscriber, ((stating)) which will include:

     (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) Notification that 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)) Instructions for filing an 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, ((stating)) which will include:

     (i) The effective date of the disenrollment; and

     (ii) ((The enrollee's right to)) Instructions for filing an appeal under WAC 182-25-105.

     (7)(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 and until all other requirements for enrollment have been satisfied. 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.

     (iv) Enrollees who were disenrolled by BHP because no MHCS was contracted to serve the program in which they were enrolled in the geographic area where they live; these enrollees may reenroll, provided all enrollment requirements are met, if a MHCS begins accepting enrollment for their program in their area or if they become eligible and apply for another BHP program.

     (v) Enrollees who were disenrolled for failing to provide requested documentation of income or eligibility, who had attempted to comply with the request but were unable to meet the due date, and who provide all required documentation within six months of disenrollment and are eligible to reenroll.

     (b) An enrollee who is required to wait twelve months for reenrollment under (a) of this subsection may not reenroll prior to the end of the required twelve-month wait. If an enrollee satisfies the required twelve-month wait after applying for subsidized coverage and while waiting to be offered coverage, enrollment will not be completed until funding is available to enroll him or her.

[Statutory Authority: RCW 70.47.050, 70.47.060(9), and 2002 c 371 § 212(5). 02-19-054 (Order 01-07), § 182-25-090, filed 9/12/02, effective 10/13/02. Statutory Authority: RCW 70.47.050, 70.47.060 and 70.47.100. 99-24-005 (Order 99-06), § 182-25-090, filed 11/18/99, effective 12/19/99. Statutory Authority: RCW 70.47.050, 70.47.060 and 70.47.090. 99-12-033 (Order 99-01), § 182-25-090, filed 5/26/99, effective 6/26/99. 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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