2128-S AMH SEAQ KNUT 055

SHB 2128 - H AMD 157

By Representative Seaquist

ADOPTED 3/06/2009

    Strike everything after the enacting clause and insert the following:

"NEW SECTION.  Sec. 1. The legislature finds that substantial progress has been made toward achieving the equally important goals set in 2007 that all children in Washington state have health care coverage by 2010 and that child health outcomes improve.  The legislature also finds that continued steps are necessary to reach the goals that all children in Washington state shall have access to the health services they need to be healthy and ready to learn and that key measures of child health outcomes will show year by year improvement.  The legislature further finds that reaching these goals is integral to the state's ability to weather the current economic crisis.  The recent reauthorization of the federal children's health insurance program provides additional opportunities for the state to reach these goals.  In view of these important objectives, the legislature intends that the apple health for kids program be managed actively across administrations in the department of social and health services, and across state and local agencies, with clear accountability for achieving the intended program outcomes.

Sec. 2. RCW 74.09.470 and 2007 c 5 s 2 are each amended to read as follows:

    (1) Consistent with the goals established in RCW 74.09.402, through the apple health for kids program authorized in this section, the department shall provide affordable health care coverage to children under the age of nineteen who reside in Washington state and whose family income at the time of enrollment is not greater than two hundred fifty percent of the federal poverty level as adjusted for family size and determined annually by the federal department of health and human services, and effective January 1, 2009, and only to the extent that funds are specifically appropriated therefor, to children whose family income is not greater than three hundred percent of the federal poverty level.  In administering the program, the department shall take such actions as may be necessary to ensure the receipt of federal financial participation under the medical assistance program, as codified at Title XIX of the federal social security act, the state children's health insurance program, as codified at Title XXI of the federal social security act, and any other federal funding sources that are now available or may become available in the future.  The department and the caseload forecast council shall estimate the anticipated caseload and costs of the program established in this section.

    (2) The department shall accept applications for enrollment for children's health care coverage; establish appropriate minimum- enrollment periods, as may be necessary; and determine eligibility based on current family income.  The department shall make eligibility determinations within the time frames for establishing eligibility for children on medical assistance, as defined by RCW 74.09.510.  The application and annual renewal processes shall be designed to minimize administrative barriers for applicants and enrolled clients, and to minimize gaps in eligibility for families who are eligible for coverage.  If a change in family income results in a change in ((program eligibility)) the source of funding for coverage, the department shall transfer the family members to the appropriate ((programs)) source of funding and notify the family with respect to any change in premium obligation, without a break in eligibility.  The department shall use the same eligibility redetermination and appeals procedures as those provided for children on medical assistance programs.  The department shall modify its eligibility renewal procedures to lower the percentage of children failing to annually renew.  ((The department shall report to the appropriate committees of the legislature on its progress in this regard by December 2007.)) The department shall manage its outreach, application, and renewal procedures with the goals of:  (a) Achieving year by year improvements in enrollment, enrollment rates, renewals, and renewal rates; (b) maximizing the use of existing program databases to obtain information related to earned and unearned income for purposes of eligibility determination and renewals, including, but not limited to, the basic food program, the child care subsidy program, federal social security administration programs, and the employment security department wage database; (c) streamlining renewal processes to rely primarily upon data matches, online submissions, and telephone interviews; and (d) implementing any other eligibility determination and renewal processes to allow the state to receive an enhanced federal matching rate and additional federal outreach funding available through the federal children's health insurance program reauthorization act of 2009 by January 2010.  The department shall advise the governor and the legislature regarding the status of these efforts by September 30, 2009.  The information provided should include the status of the department's efforts, the anticipated impact of those efforts on enrollment, and the costs associated with that enrollment.  Each child enrolled in the apple health for kids program under this section will receive an eligibility card that clearly identifies the bearer, by text and logo, as a participant in the program.  The card also must include a statement that the goal of the apple health for kids program is to provide health care coverage so that all children in Washington state have the opportunity to succeed in school and live healthy lives.

    (3) To ensure continuity of care and ease of understanding for families and health care providers, and to maximize the efficiency of the program, the amount, scope, and duration of health care services provided to children under this section shall be the same as that provided to children under medical assistance, as defined in RCW 74.09.520.

    (4) The primary mechanism for purchasing health care coverage under this section shall be through contracts with managed health care systems as defined in RCW 74.09.522 ((except when utilization patterns suggest that fee‑for‑service purchasing could produce equally effective and cost‑efficient care)).  However, the department shall make every effort within available resources to purchase health care coverage for uninsured children whose families have access to dependent coverage through an employer-sponsored health plan or another source when it is cost-effective for the state to do so, and the purchase is consistent with requirements of Title XIX and Title XXI of the federal social security act.  To the extent allowable under federal law, the department shall require families to enroll in available employer- sponsored coverage, as a condition of participating in the program established under ((chapter 5, Laws of 2007)) this section, when it is cost-effective for the state to do so.  Families who enroll in available employer-sponsored coverage under ((chapter 5, Laws of 2007)) this section shall be accounted for separately in the annual report required by RCW 74.09.053.

    (5)(a) To reflect appropriate parental responsibility, the department shall develop and implement a schedule of premiums for children's health care coverage due to the department from families with income greater than two hundred percent of the federal poverty level.  For families with income greater than two hundred fifty percent of the federal poverty level, the premiums shall be established in consultation with the senate majority and minority leaders and the speaker and minority leader of the house of representatives.  Premiums shall be set at a reasonable level that does not pose a barrier to enrollment.  The amount of the premium shall be based upon family income and shall not exceed the premium limitations in Title XXI of the federal social security act.  Premiums shall not be imposed on children in households at or below two hundred percent of the federal poverty level as articulated in RCW 74.09.055.

    (b) Beginning no later than January 1, ((2009)) 2010, the department shall offer families whose income is greater than three hundred percent of the federal poverty level the opportunity to purchase health care coverage for their children through the programs administered under this section without ((a)) an explicit premium subsidy from the state.  The design of the health benefit package offered to these children should provide adequate and appropriate coverage, and may differ with respect to cost-sharing, covered services, and other appropriate elements from that provided to children under subsection (3) of this section only to the extent necessary to offer an affordable benefit package for the affected families.  The amount paid by the family shall be in an amount equal to the rate paid by the state to the managed health care system for coverage of the child, including any associated and administrative costs to the state of providing coverage for the child.

    (i) The activities and operations of the children's health coverage program under this subsection, including those of managed health care systems to the extent of their participation in the program, are exempt from the provisions of Title 48 RCW, except:
    (A) The coverage is subject to RCW 48.21.200 and is excess to the benefits payable under the terms of any insurance policy issued to or on the behalf of an enrollee that provides payments toward medical expenses without a determination of liability for the injury.
    (B) Managed health care systems are subject to the provisions of RCW 48.43.022, 48.43.500 through 48.43.535, 48.43.545, and 48.43.550.
    (ii) The activities and operations of the children's health coverage program under this subsection are subject to the provisions of RCW 43.70.235, 70.02.045, 70.02.110, and 70.02.900.
    (iii) Persons appointed or authorized to solicit applications for enrollment in nonsubsidized state children's health coverage, including employees of the department, must comply with chapter 48.17 RCW.   For purposes of this subsection, the term "solicit" does not include distributing information and applications for nonsubsidized state children's health coverage and responding to questions.
    (iv) Amounts paid to a managed health care system by the department for providing health care services pursuant to this subsection must comply with RCW 48.14.0201.

    (6) The department shall undertake and continue a proactive, targeted outreach and education effort with the goal of enrolling children in health coverage and improving the health literacy of youth and parents.  The department shall collaborate with the department of health, local public health jurisdictions, the office of (([the])) the superintendent of public instruction, the department of early learning, health educators, health care providers, health carriers, community- based organizations, and parents in the design and development of this effort.  The outreach and education effort shall include the following components:

    (a) Broad dissemination of information about the availability of coverage, including media campaigns;

    (b) Assistance with completing applications, and community-based outreach efforts to help people apply for coverage.  Community-based outreach efforts should be targeted to the populations least likely to be covered;

    (c) Use of existing systems, such as enrollment information from the free and reduced‑price lunch program, the department of early learning child care subsidy program, the department of health's women, infants, and children program, and the early childhood education and assistance program, to identify children who may be eligible but not enrolled in coverage;

    (d) Contracting with community-based organizations and government entities to support community-based outreach efforts to help families apply for coverage.  These efforts should be targeted to the populations least likely to be covered.  The department shall provide informational materials for use by government entities and community- based organizations in their outreach activities, and should identify any available federal matching funds to support these efforts;

    (e) Development and dissemination of materials to engage and inform parents and families statewide on issues such as:  The benefits of health insurance coverage; the appropriate use of health services, including primary care provided by health care practitioners licensed under chapters 18.71, 18.57, 18.36A, and 18.79 RCW, and emergency services; the value of a medical home, well-child services and immunization, and other preventive health services with linkages to department of health child profile efforts; identifying and managing chronic conditions such as asthma and diabetes; and the value of good nutrition and physical activity;

    (f) An evaluation of the outreach and education efforts, based upon clear, cost-effective outcome measures that are included in contracts with entities that undertake components of the outreach and education effort;

    (g) ((A feasibility study and)) An implementation plan to develop online application capability that is integrated with the department's automated client eligibility system, and to develop data linkages with the office of (([the])) the superintendent of public instruction for free and reduced‑price lunch enrollment information and the department of early learning for child care subsidy program enrollment information.  ((The department shall submit a feasibility study on the implementation of the requirements in this subsection to the governor and legislature by July 2008.))

    (7) The department shall take action to increase the number of primary care physicians providing dental disease preventive services including oral health screenings, risk assessment, family education, the application of fluoride varnish, and referral to a dentist as needed.

    (8) The department shall monitor the rates of substitution between private‑sector health care coverage and the coverage provided under this section and shall report to appropriate committees of the legislature by December 2010.

(9) To ensure planning and coordination of all aspects of the apple health for kids program across all the involved agencies and with the various stakeholders, and to facilitate the collection, reporting, and analysis of the outcome data required by section 3 of this act, the position of apple health executive is established and will report directly to the secretary.

Sec. 3. RCW 74.09.480 and 2007 c 5 s 4 are each amended to read as follows:

    (1) The department, in collaboration with the department of health, health carriers, local public health jurisdictions, children's health care providers including pediatricians, family practitioners, and pediatric subspecialists, community and migrant health centers, parents, and other purchasers, shall ((identify explicit performance measures that indicate that a child has an established and effective medical home, such as)) establish a concise set of explicit performance measures that can indicate whether children enrolled in the program are receiving health care through an established and effective medical home, and whether the overall health of enrolled children is improving.  Such indicators may include, but are not limited to:

    (a) Childhood immunization rates;

    (b) Well child care utilization rates, including the use of validated, structured developmental assessment tools that include behavioral and oral health screening;

    (c) Care management for children with chronic illnesses;

    (d) Emergency room utilization; ((and))

    (e) Visual acuity and eye health;
    (f) Preventive oral health service utilization; and
    (g) Children's mental health status.  In defining these measures the department shall be guided by the measures provided in RCW 71.36.025.

    Performance measures and targets for each performance measure must be ((reported to the appropriate committees of the senate and house of representatives by December 1, 2007)) established and monitored each biennium, with a goal of achieving measurable, improved health outcomes for the children of Washington state each biennium.

    (2) Beginning in calendar year 2009, targeted provider rate increases shall be linked to quality improvement measures established under this section.  The department, in conjunction with those groups identified in subsection (1) of this section, shall develop parameters for determining criteria for increased payment, alternative payment methodologies, or other incentives for those practices and health plans that incorporate evidence-based practice and improve and achieve sustained improvement with respect to the measures ((in both fee for service and managed care)).

    (3) The department shall provide ((an annual)) a report to the governor and the legislature related to provider performance on these measures, beginning in September 2010 for 2007 through 2009 and ((annually)) biennially thereafter.  The department shall advise the legislature as to its progress towards developing this biennial reporting system by September 30, 2009.

NEW SECTION.  Sec. 4. This act may be known and cited as the apple health for kids act."

EFFECT:  Provides the Department of Social and Health Services greater flexibility in designing a benefit package for children in families with a household income over three hundred percent of the federal poverty level.   The Department is directed to maximize the use of existing databases to determine eligibility and renewals and to streamline renewal processes.  The position of Apple Health Executive is created in the Department, and will report directly to the Secretary.  An eligibility card that identifies the bearer as a participant in the apple health for kids program will be created and distributed to every participant.  The card will include a statement of the program's goal that children succeed in school and live healthy lives. 

--- END ---