AN
ACT Relating to defining basic health plan eligibility for persons in
institutions; and reenacting and amending RCW 70.47.020 and 70.47.060.
BE IT ENACTED BY THE
LEGISLATURE OF THE STATE OF WASHINGTON:
Sec.
1. RCW
70.47.020 and 1995 c 266 s 2 and 1995 c 2 s 3 are each reenacted and 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.
(4)
"Subsidized 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 resides in an area of the state
served by a managed health care system participating in the plan((,));
(d) 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((,));
and (e) 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((,)): (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 resides in an area of the
state served by a managed health care system participating in the plan((,
and)); (d) who chooses to obtain basic health care coverage from a
particular managed health care system((,)); and (e) 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.
2. RCW
70.47.060 and 1995 c 266 s 1 and 1995 c 2 s 4 are each reenacted and 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 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 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 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.
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.
(d)
To develop, as an offering by all health carriers providing coverage identical
to the basic health plan, a model plan benefits package with uniformity in
enrollee cost-sharing requirements.
(3)
To design and implement a structure of enrollee cost sharing due a managed
health care system from subsidized and nonsubsidized 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.
(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. The level of subsidy provided to persons who qualify may be based
on the lowest cost plans, as defined by the administrator.
(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 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. 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 reenroll 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 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.
(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.
(16) In consultation with appropriate state and local government
agencies, to establish criteria defining eligibility for persons confined or
residing in government-operated institutions.
