(1) Compact of Free Association (COFA) islander health care ((is a))and COFA islander dental care are state-funded programs administered by the health care authority (the agency) to pay the monthly premiums and out-of-pocket expenses for silver level qualified health plans or qualified dental plans for eligible COFA islanders.

(2) For the purpose of this chapter, "our," "us," and "we" refer to the agency or the agency's designee and "you" refers to the applicant for, or recipient of, COFA islander health care.

(3) You have the right to appeal any adverse agency action regarding COFA islander health care or COFA islander dental care as described in chapter 182-526 WAC. For coordinated appeals with the Washington health benefit exchange, as described under WAC 182-526-0102, we treat appeals made to either the Washington health benefit exchange or us as filed on the same day. You will not have to submit any information that you have previously submitted to either the Washington health benefit exchange or us.

This section defines terms used in this chapter. See chapter 182-500 WAC for additional definitions.

"Advance premium tax credit (APTC)" - A tax credit taken in advance to lower a monthly health insurance payment (or premium).

"COFA islander" – A person who is a citizen of the Federated States of Micronesia, the Republic of the Marshall Islands, or the Republic of Palau.

"COFA islander health care" - An agency-administered program that pays the premium and out-of-pocket costs for a silver level qualified health plan for eligible COFA islanders.

"Compact of Free Association (COFA)" - A legal agreement between the government of the United States and the governments of the Federated States of Micronesia (U.S. Pub. L. 108-188); the Republic of the Marshall Islands (U.S. Pub. L. 108-188); and the Republic of Palau (U.S. Pub. L. 99-658).

"Cost-sharing funds" - Agency-provided funds for out-of-pocket costs.

"Out-of-pocket costs" - Copayments, coinsurance, deductibles, and other cost-sharing requirements imposed under a qualified health plan for services, pharmaceuticals, devices, and other health benefits covered by the plan and rendered as in-network. Excludes premiums, balance billing amounts for out-of-network providers, and spending for noncovered services.

"Premium cost" – A person's premium for a qualified health plan, minus the amount of the person's advanced premium tax credit.

"Silver level qualified health plan (QHP)" - Silver level indicates the category of a qualified health plan (QHP) offered by the Washington health benefit exchange (HBE). For a definition of QHP, see WAC 182-500-0090.

You apply for COFA islander dental care the same way you would apply for COFA islander health care as described in WAC 182-524-0250.

(1) To be eligible for state-funded COFA islander dental care, you must enroll in a qualified dental plan (QDP) through the Washington health benefit exchange (HBE) during open enrollment or when you qualify for a special enrollment period as described in 45 C.F.R. 155.410 and 45 C.F.R. 420.

(2) You are eligible for COFA islander dental care administered by us no earlier than January 1, 2021, if you enroll in a QDP and:

(a) Meet the requirements of COFA islander health care as described in WAC 182-524-0300 (1)(a) through (f); or

(b) Are enrolled in medicare, meet the requirements as described in WAC 182-524-0300 (1)(a) and (c) and:

(i) Are a resident as described in WAC 182-524-0400 (1) through (3).

(ii) You can be temporarily out-of-state and remain on COFA islander dental care if you:

(A) Intend to return once the purpose of your absence concludes; and

(B) Meet the eligibility requirements described in this section.

(3) Eligibility for COFA islander dental care under subsection (2) of this section is subject to the availability of amounts appropriated for the program as described in WAC 182-524-0300(2).

(4) Your COFA islander dental care begins the first day of the month your QDP coverage begins and you meet the other eligibility requirements described in subsection (2) of this section.

(5) We will pay for your premiums, QDP out-of-pocket costs and QDP-noncovered services the same way we pay your premiums and out-of-pocket costs for COFA islander health care as described in WAC 182-524-0600. We may require authorization for payment for QDP-noncovered services.

(6) We will not pay for expenses incurred by people not covered under COFA islander dental care or services excluded under the medicaid dental program as described in WAC 182-535-1100.

(7) We will send you notices and letters according to the same provisions and requirements as the letters we send regarding COFA islander health care as described in WAC 182-524-0500.

(8) We will terminate your COFA islander dental care if you:

(a) No longer meet the eligibility criteria described in subsection (2) of this section;

(b) Request termination;

(c) Perform an act, practice, or omission that constitutes fraud and your insurer rescinds your policy;

(d) Use your COFA islander dental care cost-sharing funds to pay for anything other than:

(i) Out-of-pocket costs for dental coverage under your QDP; or

(ii) Authorized QDP-noncovered services.

(9) We will reinstate your COFA islander dental care if you are:

(a) Terminated in error; or

(b) Successful in your appeal of a termination.

(10) If you report a change that makes you eligible for COFA islander dental care, your sponsorship begins either:

(a) The first day of the following month, if the change was reported on or before the fifteenth of the month; or

(b) The first day of the month after the following month, if the change was reported after the fifteenth of the month.

(11) Your COFA islander dental care ends the day your enrollment in a silver level QHP ends or the last day of the month your COFA islander dental care eligibility ends, whichever is earlier.