2341-S AMS ZARE MOOR 090
SHB 2341 - S AMD 484
By Senator Zarelli
PULLED 4/25/2009
On page 2, beginning on line 34, strike the remainder of the bill and insert the following:
"Sec. 2. RCW 70.47.020 and 2007 c 259 s 35 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 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) "Health coverage tax credit program" means the program created by the Trade Act of 2002 (P.L. 107-210) that provides a federal tax credit that subsidizes private health insurance coverage for displaced workers certified to receive certain trade adjustment assistance benefits and for individuals receiving benefits from the pension benefit guaranty corporation.
(4) "Health coverage tax credit eligible enrollee" means individual workers and their qualified family members who lose their jobs due to the effects of international trade and are eligible for certain trade adjustment assistance benefits; or are eligible for benefits under the alternative trade adjustment assistance program; or are people who receive benefits from the pension benefit guaranty corporation and are at least fifty-five years old.
(5) "Managed health care system" means: (a) 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, to a defined patient population enrolled in the plan and in the managed health care system; or (b) a self-funded or self-insured method of providing insurance coverage to subsidized enrollees provided under RCW 41.05.140 and subject to the limitations under RCW 70.47.100(7).
(6) "Subsidized enrollee" means:
(a) An individual, or an individual plus the individual's spouse or dependent children:
(i) Who is not eligible for medicare;
(ii) Who is not confined or residing in a government-operated institution, unless he or she meets eligibility criteria adopted by the administrator;
(iii) Who is not a full-time student who has received a temporary visa to study in the United States;
(iv) Who resides in an area of the state served by a managed health care system participating in the plan;
(v) Whose gross family income at the time of enrollment
does not exceed two hundred percent of the federal poverty level as adjusted
for family size and determined annually by the federal department of health and
human services; ((and))
(vi) Who chooses to obtain basic health care coverage from a particular managed health care system in return for periodic payments to the plan;
(vii) Who is a United States citizen or legally admitted
for permanent residence; and
(viii) Whose family liquid assets do not exceed an amount established by
the administrator in rule;
(b) An individual who meets the requirements in (a)(i) through (iv) and (vi) through (viii) of this subsection and who is a foster parent licensed under chapter 74.15 RCW and whose gross family income at the time of enrollment does not exceed three hundred percent of the federal poverty level as adjusted for family size and determined annually by the federal department of health and human services; and
(c) To the extent that state funds are specifically appropriated for this purpose, with a corresponding federal match, an individual, or an individual's spouse or dependent children, who meets the requirements in (a)(i) through (iv) and (vi) through (viii) of this subsection and whose gross family income at the time of enrollment is more than two hundred percent, but less than two hundred fifty-one percent, of the federal poverty level as adjusted for family size and determined annually by the federal department of health and human services.
(7) "Nonsubsidized enrollee" means an individual, or an individual plus the individual's spouse or dependent children: (a) Who is not eligible for medicare; (b) who is not confined or residing in a government-operated institution, unless he or she meets eligibility criteria adopted by the administrator; (c) who is accepted for enrollment by the administrator as provided in RCW 48.43.018, either because the potential enrollee cannot be required to complete the standard health questionnaire under RCW 48.43.018, or, based upon the results of the standard health questionnaire, the potential enrollee would not qualify for coverage under the Washington state health insurance pool; (d) who resides in an area of the state served by a managed health care system participating in the plan; (e) who chooses to obtain basic health care coverage from a particular managed health care system; and (f) who pays or on whose behalf is paid the full costs for participation in the plan, without any subsidy from the plan.
(8) "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).
(9) "Premium" means a periodic payment, which an individual, their employer or another financial sponsor makes to the plan as consideration for enrollment in the plan as a subsidized enrollee, a nonsubsidized enrollee, or a health coverage tax credit eligible enrollee.
(10) "Rate" means the amount, negotiated by the administrator with and paid to a participating managed health care system, that is based upon the enrollment of subsidized, nonsubsidized, and health coverage tax credit eligible enrollees in the plan and in that system.
NEW SECTION. Sec. 3. A new section is added to chapter 70.47 RCW to read as follows:
The administrator shall establish a waiting period that subsidized enrollee applicants must complete without private insurance before enrolling in the program under this chapter. The waiting period shall be at least four months and waived only when:
(1) The prospective enrollee has a medical condition that, without treatment, would be life-threatening or cause serious disability; or
(2) The loss of employer-sponsored dependent coverage is due to either loss of employment, the death of the employee, or the employer discontinues the option of dependent coverage.
Sec. 4. RCW 70.47.060 and 2007 c 259 s 36 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. In addition, the administrator may, to the extent that funds are available, offer as basic health plan services chemical dependency services, mental health services and organ transplant services; however, no one service or any combination of these three services shall increase the actuarial value of the basic health plan benefits by more than five percent excluding inflation, as determined by the office of financial management. All subsidized and nonsubsidized enrollees in any participating managed health care system under the Washington basic health plan shall be entitled to receive covered basic health care services 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 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 48.47.030, and such other factors as the administrator deems appropriate.
(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 (((11))) (12)
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 (((12)))
(13) of this section.
(b) To determine the periodic premiums due the administrator from subsidized enrollees under RCW 70.47.020(6)(b). Premiums due for foster parents with gross family income up to two hundred percent of the federal poverty level shall be set at the minimum premium amount charged to enrollees with income below sixty‑five percent of the federal poverty level. Premiums due for foster parents with gross family income between two hundred percent and three hundred percent of the federal poverty level shall not exceed one hundred dollars per month.
(c) 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.
(d) To determine the periodic premiums due the administrator from health coverage tax credit eligible enrollees. Premiums due from health coverage tax credit eligible enrollees must 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. The administrator will consider the impact of eligibility determination by the appropriate federal agency designated by the Trade Act of 2002 (P.L. 107-210) as well as the premium collection and remittance activities by the United States internal revenue service when determining the administrative cost charged for health coverage tax credit eligible enrollees.
(e) 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. The administrator shall establish a mechanism for receiving premium payments from the United States internal revenue service for health coverage tax credit eligible enrollees.
(f) To develop, as an offering by every health carrier providing coverage identical to the basic health plan, as configured on January 1, 2001, a basic health plan model plan with uniformity in enrollee cost-sharing requirements.
(3) To evaluate, with the cooperation of participating managed health care system providers, the impact on the basic health plan of enrolling health coverage tax credit eligible enrollees. The administrator shall issue to the appropriate committees of the legislature preliminary evaluations on June 1, 2005, and January 1, 2006, and a final evaluation by June 1, 2006. The evaluation shall address the number of persons enrolled, the duration of their enrollment, their utilization of covered services relative to other basic health plan enrollees, and the extent to which their enrollment contributed to any change in the cost of the basic health plan.
(4) To end the participation of health coverage tax credit eligible enrollees in the basic health plan if the federal government reduces or terminates premium payments on their behalf through the United States internal revenue service.
(5) To design and implement a structure of enrollee cost-sharing due a managed health care system from subsidized, nonsubsidized, and health coverage tax credit eligible enrollees. The structure shall discourage inappropriate enrollee utilization of health care services, and may utilize copayments, deductibles, and other cost-sharing mechanisms, but shall not be so costly to enrollees as to constitute a barrier to appropriate utilization of necessary health care services.
(6) 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. Such a closure does not apply to health coverage tax credit eligible enrollees who receive a premium subsidy from the United States internal revenue service as long as the enrollees qualify for the health coverage tax credit program.
(7) Subject to subsection (6) of this section and
section 2 of this act, to enroll any person who meets the eligibility standards
in RCW 70.47.020 and for whom a completed application is submitted. In
determining eligibility, the administrator shall require submission of income tax
returns, or verification that income tax returns were not filed, and recent
income history for any applicant, the applicant's spouse, and his or her
dependents.
(8) To limit the payment of subsidies to subsidized enrollees, as
defined in RCW 70.47.020. The level of subsidy provided to persons who qualify
may be based on the lowest cost plans, as defined by the administrator.
(((8))) (9) 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 this chapter or any act appropriating funds for the
plan.
(((9))) (10) 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 for subsidized
enrollees, nonsubsidized enrollees, or health coverage tax credit eligible
enrollees. 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.
(((10))) (11) To receive periodic premiums
from or on behalf of subsidized, nonsubsidized, and health coverage tax credit
eligible 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.
(((11))) (12) 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, nonsubsidized, or health coverage tax credit
eligible enrollees, to give priority to members of the Washington national
guard and reserves who served in Operation Enduring Freedom, Operation Iraqi
Freedom, or Operation Noble Eagle, and their spouses and dependents, 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 on a reasonable schedule defined by the authority, or at
the request of any enrollee, eligibility due to current gross family income for
sliding scale premiums. Funds received by a family as part of participation in
the adoption support program authorized under RCW 26.33.320 and 74.13.100
through 74.13.145 shall not be counted toward a family's current gross family
income for the purposes of this chapter. When an enrollee fails to report
income or income changes accurately, the administrator shall have the authority
either to bill the enrollee for the amounts overpaid by the state or to impose
civil penalties of up to two hundred percent of the amount of subsidy overpaid
due to the enrollee incorrectly reporting income. The administrator shall
adopt rules to define the appropriate application of these sanctions and the
processes to implement the sanctions provided in this subsection, within
available resources. 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 reenroll in the plan.
(((12))) (13) 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
may require that a business owner pay at least an amount equal to what the
employee pays after the state pays its portion of the subsidized 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.
(((13))) (14) 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 or
actuarially equivalent 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.
(((14))) (15) 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.
(((15))) (16) 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.
(((16))) (17) To develop a program of
proven preventive health measures and to integrate it into the plan wherever
possible and consistent with this chapter.
(((17))) (18) To provide, consistent with
available funding, assistance for rural residents, underserved populations, and
persons of color.
(((18))) (19) In consultation with
appropriate state and local government agencies, to establish criteria defining
eligibility for persons confined or residing in government-operated
institutions.
(((19))) (20) To administer the premium
discounts provided under RCW 48.41.200(3)(a) (i) and (ii) pursuant to a
contract with the Washington state health insurance pool.
(((20))) (21) To give priority in
enrollment to persons who disenrolled from the program in order to enroll in
medicaid, and subsequently became ineligible for medicaid coverage.
(22)(a) To disenroll any enrollee:
(i) Whose premium payments to the plan are delinquent, except that an
enrollee whose premium is the responsibility of the department of social and
health services under RCW 70.47.110 may not be dropped solely because of
nonpayment by the department;
(ii) Who, as reported by health care providers and confirmed by the
administrator, repeatedly fails to pay the required copayments or coinsurance
in full on a timely basis;
(iii) Who does not meet the criteria for a "subsidized
enrollee" under RCW 70.47.020; or
(iv) As necessary to meet the requirements of subsection (6) of this
section;
(b) To verify continued eligibility, check employment security payroll
records at least once every twelve months on all enrollees; require any
enrollee whose family income, as indicated by payroll records, exceeds that
upon which his or her enrollment and subsidy level is based to document his or
her current family income as a condition of continued eligibility; and require
any enrollee for whom employment security payroll records cannot be obtained to
document his or her current family income at least once every six months;
(c) To provide an enrollee subject to disenrollment with advance written
notice. Upon disenrollment, the administrator shall promptly notify the
managed health care system in which the enrollee has been enrolled, and shall
not be responsible for payment of health care services provided to the
enrollee, including if applicable members of the enrollee's family, after the
date of notification.
NEW SECTION. Sec. 5. The following acts or parts of acts are each repealed:
(1) RCW 70.47.080 (Enrollment of applicants‑-Participation limitations) and 1993 c 492 s 213 & 1987 1st ex.s. c 5 s 10; and
(2) RCW 70.47.090 (Removal of enrollees) and 1987 1st ex.s. c 5 s 11."
Renumber the sections consecutively and correct any internal references accordingly.
SHB 2361 - S AMD 484
By Senator Zarelli
PULLED 4/25/2009
On page 1, line 3 of the title, after "70.47.020," strike the remainder of the title and insert "and 70.47.060; adding a new section to chapter 70.47 RCW; repealing RCW 70.47.080 and 70.47.090; and declaring an emergency."
EFFECT: Makes changes to subsidized basic health plan eligibility criteria including: (a) requiring enrollees to be legally admitted to the United States, (b) requiring an asset test to be established by the health care authority administrator in rule, and (c) requiring a four month waiting period without private insurance, unless the prospective enrollee has a serious medical condition. (Retains section 1 of the bill prohibiting dual enrollees in basic health plan and Medicaid.)
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