Date of Adoption: April 2, 2004.

     Purpose: This new WAC 388-505-0211 implements the premium requirement for Medicaid children. The rule includes SCHIP children and increases the current premium amount for children eligible under the state health insurance program coverage.

     Statutory Authority for Adoption: RCW 74.08.090.

     Other Authority: RCW 74.09.055, ESHB 2459 (2004 regular session, the 2003-05 supplemental operating budget).

      Adopted under notice filed as WSR 03-21-152 on October 22, 2003.

     Changes Other than Editing from Proposed to Adopted Version: The following changes were made at the direction of the 2004 legislature in ESHB 2459, the 2003-05 supplemental operating budget bill.

     1. The revised subsection language in WAC 388-505-0211 allows exemption from the premium for:

     (6)(c) A child whose assistance unit's net available income is equal to or less than 150% FPL. An optional child exempted from the premium requirement under this subsection is treated as if the child is a mandatory child.

     2. The revised subsection language in WAC 388-505-0211 reduces the proposed premium amounts from:

     (9)(a) Fifteen to zero dollars per month when the assistance unit's net available income is above one hundred percent FPL and equal to or less than one hundred fifty percent FPL.

     (9)(b) Twenty to ten dollars per month when the assistance unit's net available income is above one hundred fifty percent FPL and equal to or less than two hundred percent FPL.

     (10) The premium amount for each SCHIP child is fifteen (instead of twenty-five) dollars.

     (11) The maximum premium amount for a family is reduced from seventy-five to forty-five dollars per month.

     Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 1, Amended 0, Repealed 0.

     Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0;      Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 1, Amended 0, Repealed 0.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

April 2, 2004

Brian H. Lindgren, Manager

Rules and Policies Assistance Unit

     (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;

     (b) The child is an American Indian or Alaska native;

     (c) A child whose assistance unit's net available income is equal to or less than one hundred fifty percent FPL. An optional child exempted from the premium requirement under this subsection is treated as if the child is a mandatory child.

     (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) Zero dollars per month when the assistance unit's net available income is above one hundred percent FPL and equal to or less than one hundred fifty percent FPL; or

     (b) Ten dollars per month when the assistance unit's net available income is above one hundred fifty percent FPL and equal to or less than two hundred percent FPL.

     (10) The premium amount for each SCHIP child is fifteen dollars per month.

     (11) The department bills the family for the lesser of:

     (a) A maximum of forty-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.

     (14) The department writes off past-due premiums after twelve months.

     (15) 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.

     (16) 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.

     (17) A change that affects the premium amount is effective the month after the change is reported and processed.

     (18) 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.

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