AN ACT
Relating to coordination of the basic health plan with medical assistance;
amending RCW 70.47.030, 70.47.060, and 70.47.110; providing an effective date;
and declaring an emergency.
BE IT
ENACTED BY THE LEGISLATURE OF THE STATE OF WASHINGTON:
Sec.
1. RCW
70.47.030 and 1987 1st ex.s. c 5 s 5 are each amended to read as follows:
The
basic health plan trust account is hereby established in the state treasury.
All nongeneral fund-state funds ((appropriated)) collected
for this ((chapter)) program shall be deposited in the basic
health plan trust account and may be expended without further appropriation.
((Disbursements from other moneys in the account shall be made pursuant to
appropriation and upon warrants drawn by the Washington basic health plan administrator.))
Moneys in the account shall be used exclusively for the purposes of this
chapter, including payments to participating managed health care systems on
behalf of enrollees in the plan and payment of costs of administering the
plan. ((The earnings on any surplus balances in the basic health plan trust
account shall be credited to the account, notwithstanding RCW 43.84.090.))
After ((January 1, 1988)) July 1, 1991, the administrator shall
not expend or encumber for an ensuing fiscal period amounts exceeding ((ninety))
ninety-five percent of the amount((s)) anticipated to ((accrue
in the account)) be spent for purchased services during the fiscal
((period)) year.
Sec.
2. RCW
70.47.060 and 1987 1st ex.s. c 5 s 8 are each amended to read as follows:
The
administrator has the following powers and duties:
(1) To
design and from time to time revise a schedule of covered basic health care
services, including physician services, inpatient and outpatient hospital
services, and other services that may be necessary for basic health care, which
enrollees in any participating managed health care system under the Washington
basic health plan shall be entitled to receive in return for premium payments
to the plan. The schedule of services shall emphasize proven preventive and
primary health care, shall include all services necessary for prenatal,
postnatal, and well-child care, and shall include a separate schedule of basic
health care services for children, eighteen years of age and younger, for those
enrollees who choose to secure basic coverage through the plan only for their
dependent children. In designing and revising the schedule of services, the
administrator shall consider the guidelines for assessing health services under
the mandated benefits act of 1984, RCW 48.42.080, and such other factors as the
administrator deems appropriate.
(2) To
design and implement a structure of periodic premiums due the administrator
from enrollees that is based upon gross family income, giving appropriate
consideration to family size as well as the ages of all family members. The
enrollment of children shall not require the enrollment of their parent or
parents who are eligible for the plan.
(3) To
design and implement a structure of nominal copayments due a managed health
care system from enrollees. The structure shall discourage inappropriate
enrollee utilization of health care services, but shall not be so costly to
enrollees as to constitute a barrier to appropriate utilization of necessary
health care services.
(4) To
design and implement, in concert with a sufficient number of potential
providers in a discrete area, an enrollee financial participation structure,
separate from that otherwise established under this chapter, that has the
following characteristics:
(a)
Nominal premiums that are based upon ability to pay, but not set at a level
that would discourage enrollment;
(b) A
modified fee-for-services payment schedule for providers;
(c)
Coinsurance rates that are established based on specific service and procedure
costs and the enrollee's ability to pay for the care. However, coinsurance
rates for families with incomes below one hundred twenty percent of the federal
poverty level shall be nominal. No coinsurance shall be required for specific
proven prevention programs, such as prenatal care. The coinsurance rate levels
shall not have a measurable negative effect upon the enrollee's health status;
and
(d) A
case management system that fosters a provider-enrollee relationship whereby,
in an effort to control cost, maintain or improve the health status of the
enrollee, and maximize patient involvement in her or his health care
decision-making process, every effort is made by the provider to inform the
enrollee of the cost of the specific services and procedures and related health
benefits.
The
potential financial liability of the plan to any such providers shall not
exceed in the aggregate an amount greater than that which might otherwise have
been incurred by the plan on the basis of the number of enrollees multiplied by
the average of the prepaid capitated rates negotiated with participating
managed health care systems under RCW 70.47.100 and reduced by any sums charged
enrollees on the basis of the coinsurance rates that are established under this
subsection.
(5) To
limit enrollment of persons who qualify for subsidies so as to prevent an
overexpenditure of appropriations for such purposes. Whenever the
administrator finds that there is danger of such an overexpenditure, the administrator
shall close enrollment until the administrator finds the danger no longer
exists.
(6) To
adopt a schedule for the orderly development of the delivery of services and
availability of the plan to residents of the state, subject to the limitations
contained in RCW 70.47.080.
In the
selection of any area of the state for the initial operation of the plan, the
administrator shall take into account the levels and rates of unemployment in
different areas of the state, the need to provide basic health care coverage to
a population reasonably representative of the portion of the state's population
that lacks such coverage, and the need for geographic, demographic, and
economic diversity.
Before
July 1, 1988, the administrator shall endeavor to secure participation
contracts with managed health care systems in discrete geographic areas within
at least five congressional districts.
(7) To
solicit and accept applications from managed health care systems, as defined in
this chapter, for inclusion as eligible basic health care providers under the
plan. The administrator shall endeavor to assure that covered basic health
care services are available to any enrollee of the plan from among a selection
of two or more participating managed health care systems. In adopting any rules
or procedures applicable to managed health care systems and in its dealings
with such systems, the administrator shall consider and make suitable allowance
for the need for health care services and the differences in local availability
of health care resources, along with other resources, within and among the
several areas of the state.
(8) To
receive periodic premiums from enrollees, deposit them in the basic health plan
operating account, keep records of enrollee status, and authorize periodic
payments to managed health care systems on the basis of the number of enrollees
participating in the respective managed health care systems.
(9) To
accept applications from individuals residing in areas served by the plan, on
behalf of themselves and their spouses and dependent children, for enrollment
in the Washington basic health plan, to establish appropriate
minimum-enrollment periods for enrollees as may be necessary, and to determine,
upon application and at least annually thereafter, or at the request of any
enrollee, eligibility due to current gross family income for sliding scale
premiums. An enrollee who remains current in payment of the sliding-scale
premium, as determined under subsection (2) of this section, and whose gross
family income has risen above twice the federal poverty level, may continue
enrollment unless and until the enrollee's gross family income has remained
above twice the poverty level for six consecutive months, by making payment at
the unsubsidized rate required for the managed health care system in which he
or she may be enrolled. No subsidy may be paid with respect to any enrollee
whose current gross family income exceeds twice the federal poverty level or,
subject to RCW 70.47.110, who is a recipient of medical assistance or medical
care services under chapter 74.09 RCW. If a number of enrollees drop their
enrollment for no apparent good cause, the administrator may establish
appropriate rules or requirements that are applicable to such individuals
before they will be allowed to re-enroll in the plan.
(10)
((To require that prospective enrollees who may be eligible for
categorically needy medical coverage under RCW 74.09.510 or whose income does
not exceed the medically needy income level under RCW 74.09.700 apply for such
coverage, but the administrator shall enroll the individuals in the plan
pending the determination of eligibility under chapter 74.09 RCW.
(11))) To
determine the rate to be paid to each participating managed health care system
in return for the provision of covered basic health care services to enrollees
in the system. Although the schedule of covered basic health care services
will be the same for similar enrollees, the rates negotiated with participating
managed health care systems may vary among the systems. In negotiating rates
with participating systems, the administrator shall consider the
characteristics of the populations served by the respective systems, economic
circumstances of the local area, the need to conserve the resources of the
basic health plan trust account, and other factors the administrator finds
relevant.
(((12)))
(11) To monitor the provision of covered services to enrollees by
participating managed health care systems in order to assure enrollee access to
good quality basic health care, to require periodic data reports concerning the
utilization of health care services rendered to enrollees in order to provide
adequate information for evaluation, and to inspect the books and records of
participating managed health care systems to assure compliance with the
purposes of this chapter. In requiring reports from participating managed health
care systems, including data on services rendered enrollees, the administrator
shall endeavor to minimize costs, both to the managed health care systems and
to the administrator. The administrator shall coordinate any such reporting
requirements with other state agencies, such as the insurance commissioner and
the ((hospital commission)) department of health, to minimize
duplication of effort.
(((13)))
(12) To monitor the access that state residents have to adequate and
necessary health care services, determine the extent of any unmet needs for
such services or lack of access that may exist from time to time, and make such
reports and recommendations to the legislature as the administrator deems
appropriate.
(((14)))
(13) To evaluate the effects this chapter has on private employer-based
health care coverage and to take appropriate measures consistent with state and
federal statutes that will discourage the reduction of such coverage in the
state.
(((15)))
(14) To develop a program of proven preventive health measures and to
integrate it into the plan wherever possible and consistent with this chapter.
(((16)))
(15) To provide, consistent with available resources, technical
assistance for rural health activities that endeavor to develop needed health
care services in rural parts of the state.
Sec.
3. RCW
70.47.110 and 1987 1st ex.s. c 5 s 13 are each amended to read as follows:
The
department of social and health services ((shall)) may make ((periodic))
payments to the administrator ((as an agent for the)) or to
participating managed health care systems on behalf of any enrollee who is a
recipient of ((medical assistance, medical care--limited casualty program,
or)) medical care ((services)) under chapter 74.09 RCW, at the
maximum rate allowable for federal matching purposes under Title XIX of the
social security act((, but not to exceed the rate negotiated by the
administrator with the participating managed health care system for the
services covered by the plan, and no premium or copayment may be charged to
such an enrollee)). Any enrollee on whose behalf the department of social
and health services makes such payments ((to the administrator under
this section and chapter 74.09 RCW)) may continue as an enrollee, making
premium payments based on the enrollee's own income as determined under the
sliding scale, after eligibility for coverage under chapter 74.09 RCW has
ended, as long as the enrollee remains eligible under this chapter. Nothing in
this section affects the right of any person eligible for coverage under
chapter 74.09 RCW to receive the services offered to other persons under that
chapter but not included in the schedule of basic health care services covered
by the plan. The administrator shall seek to determine which enrollees or
prospective enrollees may be eligible for medical care under chapter 74.09 RCW
and may require these individuals to complete the eligibility determination
process under chapter 74.09 RCW prior to enrollment or continued participation
in the plan. The administrator and the department of social and health
services shall cooperatively adopt procedures to facilitate the transition of
plan enrollees and payments on their behalf between the plan and the programs
established under chapter 74.09 RCW.
NEW
SECTION. Sec. 4. This
act is necessary for the immediate preservation of the public peace, health, or
safety, or support of the state government and its existing public
institutions, and shall take effect July 1, 1991.
