BILL REQ. #: S-3979.1
State of Washington | 62nd Legislature | 2012 Regular Session |
Read first time 01/25/12. Referred to Committee on Health & Long-Term Care.
AN ACT Relating to the expiration of provisions concerning managed health care systems' participation in the basic health plan; and reenacting and amending RCW 70.47.100.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF WASHINGTON:
Sec. 1 RCW 70.47.100 and 2011 1st sp.s. c 9 s 4 and 2011 c 316 s
5 are each reenacted and amended to read as follows:
(1) A managed health care system participating in the plan shall do
so by contract with the ((administrator)) director and shall provide,
directly or by contract with other health care providers, covered basic
health care services to each enrollee covered by its contract with the
((administrator)) director as long as payments from the
((administrator)) director on behalf of the enrollee are current. A
participating managed health care system may offer, without additional
cost, health care benefits or services not included in the schedule of
covered services under the plan. A participating managed health care
system shall not give preference in enrollment to enrollees who accept
such additional health care benefits or services. Managed health care
systems participating in the plan shall not discriminate against any
potential or current enrollee based upon health status, sex, race,
ethnicity, or religion. The ((administrator)) director may receive and
act upon complaints from enrollees regarding failure to provide covered
services or efforts to obtain payment, other than authorized
copayments, for covered services directly from enrollees, but nothing
in this chapter empowers the ((administrator)) director to impose any
sanctions under Title 18 RCW or any other professional or facility
licensing statute.
(2) A managed health care system shall pay a nonparticipating
provider that provides a service covered under this chapter to the
system's enrollee no more than the lowest amount paid for that service
under the managed health care system's contracts with similar providers
in the state.
(3) Pursuant to federal managed care access standards, 42 C.F.R.
Sec. 438, managed health care systems must maintain a network of
appropriate providers that is supported by written agreements
sufficient to provide adequate access to all services covered under the
contract with the authority, including hospital-based physician
services. The authority will monitor and periodically report on the
proportion of services provided by contracted providers and
nonparticipating providers, by county, for each managed health care
system to ensure that managed health care systems are meeting network
adequacy requirements. No later than January 1st of each year, the
authority will review and report its findings to the appropriate policy
and fiscal committees of the legislature for the preceding state fiscal
year.
(4) The plan shall allow, at least annually, an opportunity for
enrollees to transfer their enrollments among participating managed
health care systems serving their respective areas. The
((administrator)) director shall establish a period of at least twenty
days in a given year when this opportunity is afforded enrollees, and
in those areas served by more than one participating managed health
care system the ((administrator)) director shall endeavor to establish
a uniform period for such opportunity. The plan shall allow enrollees
to transfer their enrollment to another participating managed health
care system at any time upon a showing of good cause for the transfer.
(5) Prior to negotiating with any managed health care system, the
((administrator)) director shall determine, on an actuarially sound
basis, the reasonable cost of providing the schedule of basic health
care services, expressed in terms of upper and lower limits, and
recognizing variations in the cost of providing the services through
the various systems and in different areas of the state.
(6) In negotiating with managed health care systems for
participation in the plan, the ((administrator)) director shall adopt
a uniform procedure that includes at least the following:
(a) The ((administrator)) director shall issue a request for
proposals, including standards regarding the quality of services to be
provided; financial integrity of the responding systems; and
responsiveness to the unmet health care needs of the local communities
or populations that may be served;
(b) The ((administrator)) director shall then review responsive
proposals and may negotiate with respondents to the extent necessary to
refine any proposals;
(c) The ((administrator)) director may then select one or more
systems to provide the covered services within a local area; and
(d) The ((administrator)) director may adopt a policy that gives
preference to respondents, such as nonprofit community health clinics,
that have a history of providing quality health care services to low-income persons.
(7)(a) The ((administrator)) director may contract with a managed
health care system to provide covered basic health care services to
subsidized enrollees, nonsubsidized enrollees, health coverage tax
credit eligible enrollees, or any combination thereof. At a minimum,
such contracts issued on or after January 1, 2012, must include:
(i) Provider reimbursement methods that incentivize chronic care
management within health homes;
(ii) Provider reimbursement methods that reward health homes that,
by using chronic care management, reduce emergency department and
inpatient use; and
(iii) Promoting provider participation in the program of training
and technical assistance regarding care of people with chronic
conditions described in RCW 43.70.533, including allocation of funds to
support provider participation in the training unless the managed care
system is an integrated health delivery system that has programs in
place for chronic care management.
(b) Health home services contracted for under this subsection may
be prioritized to enrollees with complex, high cost, or multiple
chronic conditions.
(c) For the purposes of this subsection, "chronic care management,"
"chronic condition," and "health home" have the same meaning as in RCW
74.09.010.
(d) Contracts that include the items in (a)(i) through (iii) of
this subsection must not exceed the rates that would be paid in the
absence of these provisions.
(8) The ((administrator)) director may establish procedures and
policies to further negotiate and contract with managed health care
systems following completion of the request for proposal process in
subsection (6) of this section, upon a determination by the
((administrator)) director that it is necessary to provide access, as
defined in the request for proposal documents, to covered basic health
care services for enrollees.
(9) The ((administrator)) director may implement a self-funded or
self-insured method of providing insurance coverage to subsidized
enrollees, as provided under RCW 41.05.140. Prior to implementing a
self-funded or self-insured method, the ((administrator)) director
shall ensure that funding available in the basic health plan self-insurance reserve account is sufficient for the self-funded or self-insured risk assumed, or expected to be assumed, by the
((administrator)) director. If implementing a self-funded or self-insured method, the ((administrator)) director may request funds to be
moved from the basic health plan trust account or the basic health plan
subscription account to the basic health plan self-insurance reserve
account established in RCW 41.05.140.
(10) Subsections (2) and (3) of this section expire July 1,
((2016)) 2014.