AN ACT Relating to
modifying time periods for adoption of health benefits and standards; amending
RCW 43.72.090, 43.72.180, 70.47.020, and 70.47.060; and declaring an emergency.
BE IT ENACTED BY THE
LEGISLATURE OF THE STATE OF WASHINGTON:
Sec. 1. RCW 43.72.090 and 1993 c
492 s 427 are each amended to read as follows:
(1) On and after ((July
1)) December 31, 1995, no person or entity in this state shall
provide the uniform benefits package and supplemental benefits as defined in
RCW 43.72.010 without being certified as a certified health plan by the
insurance commissioner.
(2) On and after ((July
1)) December 31, 1995, no certified health plan may offer less than
the uniform benefits package to residents of this state and no registered
employer health plan may provide less than the uniform benefits package to its
employees and their dependents.
(3) The health
services commission may authorize renewal or continuation until December 31,
1996, of health care service contracts, disability group insurance, or health
maintenance policies in effect on December 31, 1995.
Sec. 2. RCW 43.72.180 and 1993 c
492 s 454 are each amended to read as follows:
The legislature may
disapprove of the uniform benefits package developed under RCW 43.72.130 and
medical risk adjustment mechanisms developed under RCW 43.72.040(7) by an act
of law at any time prior to the ((thirtieth)) last day of the
following regular legislative session. If such disapproval action is taken,
the commission shall resubmit a modified package to the legislature within
fifteen days of the disapproval. If the legislature does not disapprove or
modify the package by an act of law by the end of that regular session, the
package is deemed approved.
Sec. 3. RCW 70.47.020 and 1994 c
309 s 4 are each amended to read as follows:
As used in this
chapter:
(1) "Washington
basic health plan" or "plan" means the system of enrollment and
payment on a prepaid capitated basis for basic health care services,
administered by the plan administrator through participating managed health
care systems, created by this chapter.
(2)
"Administrator" means the Washington basic health plan administrator,
who also holds the position of administrator of the Washington state health
care authority.
(3) "Managed
health care system" means any health care organization, including health
care providers, insurers, health care service contractors, health maintenance
organizations, or any combination thereof, that provides directly or by
contract basic health care services, as defined by the administrator and
rendered by duly licensed providers, on a prepaid capitated basis to a defined
patient population enrolled in the plan and in the managed health care system.
On and after ((July 1)) December 31, 1995, "managed health
care system" means a certified health plan, as defined in RCW 43.72.010.
(4) "Subsidized
enrollee" means an individual, or an individual plus the individual's
spouse or dependent children, not eligible for medicare, who resides in an area
of the state served by a managed health care system participating in the plan,
whose gross family income at the time of enrollment does not exceed twice the
federal poverty level as adjusted for family size and determined annually by
the federal department of health and human services, who the administrator
determines shall not have, or shall not have voluntarily relinquished health
insurance more comprehensive than that offered by the plan as of the effective
date of enrollment, and who chooses to obtain basic health care coverage from a
particular managed health care system in return for periodic payments to the plan.
(5) "Nonsubsidized
enrollee" means an individual, or an individual plus the individual's
spouse or dependent children, not eligible for medicare, who resides in an area
of the state served by a managed health care system participating in the plan,
who the administrator determines shall not have, or shall not have voluntarily
relinquished health insurance more comprehensive than that offered by the plan
as of the effective date of enrollment, and who chooses to obtain basic health
care coverage from a particular managed health care system, and who pays or on
whose behalf is paid the full costs for participation in the plan, without any
subsidy from the plan.
(6) "Subsidy"
means the difference between the amount of periodic payment the administrator
makes to a managed health care system on behalf of a subsidized enrollee plus
the administrative cost to the plan of providing the plan to that subsidized
enrollee, and the amount determined to be the subsidized enrollee's
responsibility under RCW 70.47.060(2).
(7) "Premium"
means a periodic payment, based upon gross family income which an individual,
their employer or another financial sponsor makes to the plan as consideration
for enrollment in the plan as a subsidized enrollee or a nonsubsidized
enrollee.
(8) "Rate"
means the per capita amount, negotiated by the administrator with and paid to a
participating managed health care system, that is based upon the enrollment of
subsidized and nonsubsidized enrollees in the plan and in that system.
Sec. 4. RCW 70.47.060 and 1994 c
309 s 5 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, prescription
drugs and medications, and other services that may be necessary for basic
health care, which subsidized and nonsubsidized 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 and shall
include all services necessary for prenatal, postnatal, and well-child care.
However, with respect to coverage for groups of subsidized enrollees who are
eligible to receive prenatal and postnatal services through the medical
assistance program under chapter 74.09 RCW, the administrator shall not
contract for such services except to the extent that such services are
necessary over not more than a one-month period in order to maintain continuity
of care after diagnosis of pregnancy by the managed care provider. The
schedule of services shall also include a separate schedule of basic health
care services for children, eighteen years of age and younger, for those
subsidized or nonsubsidized 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. On
and after ((July 1)) December 31, 1995, the uniform benefits
package adopted and from time to time revised by the Washington health services
commission pursuant to RCW 43.72.130 shall be implemented by the administrator
as the schedule of covered basic health care services. However, with respect
to coverage for subsidized enrollees who are eligible to receive prenatal and
postnatal services through the medical assistance program under chapter 74.09
RCW, the administrator shall not contract for such services except to the
extent that the services are necessary over not more than a one-month period in
order to maintain continuity of care after diagnosis of pregnancy by the
managed care provider.
(2)(a) To design and
implement a structure of periodic premiums due the administrator from
subsidized enrollees that is based upon gross family income, giving appropriate
consideration to family size and 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. The structure of periodic premiums
shall be applied to subsidized enrollees entering the plan as individuals
pursuant to subsection (9) of this section and to the share of the cost of the
plan due from subsidized enrollees entering the plan as employees pursuant to
subsection (10) of this section.
(b) To determine the
periodic premiums due the administrator from nonsubsidized enrollees. Premiums
due from nonsubsidized enrollees shall be in an amount equal to the cost
charged by the managed health care system provider to the state for the plan
plus the administrative cost of providing the plan to those enrollees and the
premium tax under RCW 48.14.0201.
(c) An employer or
other financial sponsor may, with the prior approval of the administrator, pay
the premium, rate, or any other amount on behalf of a subsidized or
nonsubsidized enrollee, by arrangement with the enrollee and through a
mechanism acceptable to the administrator, but in no case shall the payment
made on behalf of the enrollee exceed the total premiums due from the enrollee.
(3) To design and
implement a structure of copayments due a managed health care system from subsidized
and nonsubsidized 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. On and after July 1, 1995, the administrator shall
endeavor to make the copayments structure of the plan consistent with enrollee
point of service cost-sharing levels adopted by the Washington health services
commission, giving consideration to funding available to the plan.
(4) 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.
(5) To limit the
payment of subsidies to subsidized enrollees, as defined in RCW 70.47.020.
(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 or any act appropriating funds for the plan.
(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. Contracts with participating managed health care systems
shall ensure that basic health plan enrollees who become eligible for medical
assistance may, at their option, continue to receive services from their
existing providers within the managed health care system if such providers have
entered into provider agreements with the department of social and health
services.
(8) To receive periodic
premiums from or on behalf of subsidized and nonsubsidized 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 as subsidized or nonsubsidized enrollees, to
establish appropriate minimum-enrollment periods for enrollees as may be
necessary, and to determine, upon application and at least semiannually
thereafter, or at the request of any enrollee, eligibility due to current gross
family income for sliding scale premiums. 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, as a result
of an eligibility review, the administrator determines that a subsidized
enrollee's income exceeds twice the federal poverty level and that the enrollee
knowingly failed to inform the plan of such increase in income, the
administrator may bill the enrollee for the subsidy paid on the enrollee's
behalf during the period of time that the enrollee's income exceeded twice the
federal poverty level. 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 accept
applications from business owners on behalf of themselves and their employees,
spouses, and dependent children, as subsidized or nonsubsidized enrollees, who
reside in an area served by the plan. The administrator may require all or the
substantial majority of the eligible employees of such businesses to enroll in
the plan and establish those procedures necessary to facilitate the orderly
enrollment of groups in the plan and into a managed health care system. The
administrator shall require that a business owner pay at least fifty percent of
the nonsubsidized premium cost of the plan on behalf of each employee enrolled
in the plan. Enrollment is limited to those not eligible for medicare who wish
to enroll in the plan and choose to obtain the basic health care coverage and services
from a managed care system participating in the plan. The administrator shall
adjust the amount determined to be due on behalf of or from all such enrollees
whenever the amount negotiated by the administrator with the participating
managed health care system or systems is modified or the administrative cost of
providing the plan to such enrollees changes.
(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) 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 plan. The
administrator shall coordinate any such reporting requirements with other state
agencies, such as the insurance commissioner and the department of health, to
minimize duplication of effort.
(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.
(14) To develop a
program of proven preventive health measures and to integrate it into the plan
wherever possible and consistent with this chapter.
(15) To provide,
consistent with available funding, assistance for rural residents, underserved
populations, and persons of color.
NEW SECTION. Sec.
5. 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 immediately.
