AN
ACT Relating to the basic health plan; amending RCW 70.47.015, 48.43.025,
48.43.035, 48.41.060, 48.41.030, 70.47.120, and 70.47.130; reenacting and
amending RCW 70.47.060; providing an effective date; and declaring an
emergency.
BE IT
ENACTED BY THE LEGISLATURE OF THE STATE OF WASHINGTON:
Sec.
1. RCW
70.47.015 and 1995 c 265 s 1 are each amended to read as follows:
(1)
The legislature finds that the basic health plan has been an effective program
in providing health coverage for uninsured residents. Further, since 1993,
substantial amounts of public funds have been allocated for subsidized basic
health plan enrollment.
(2)
It is the intent of the legislature that the basic health plan enrollment be
expanded expeditiously, consistent with funds available in the health services
account, with the goal of two hundred thousand adult subsidized basic health
plan enrollees and one hundred thirty thousand children covered through
expanded medical assistance services by June 30, 1997, with the priority of
providing needed health services to children in conjunction with other public
programs.
(3)
Effective January 1, 1996, basic health plan enrollees whose income is less
than one hundred twenty-five percent of the federal poverty level shall pay at
least a ten-dollar premium share.
(4)
No later than July 1, 1996, the administrator shall implement procedures
whereby hospitals licensed under chapters 70.41 and 71.12 RCW, health carrier,
rural health care facilities regulated under chapter 70.175 RCW, and community
and migrant health centers funded under RCW 41.05.220, may expeditiously assist
patients and their families in applying for basic health plan or medical
assistance coverage, and in submitting such applications directly to the health
care authority or the department of social and health services. The health
care authority and the department of social and health services shall make
every effort to simplify and expedite the application and enrollment process.
(5)
No later than July 1, 1996, the administrator shall implement procedures
whereby health insurance agents and brokers, licensed under chapter 48.17 RCW,
may expeditiously assist patients and their families in applying for basic
health plan or medical assistance coverage, and in submitting such applications
directly to the health care authority or the department of social and health
services. Brokers and agents ((shall be entitled to)) may
receive a commission for each individual sale of the basic health plan to
anyone not ((at anytime previously)) signed up within the previous
five years and a commission for each group sale of the basic health plan,
if funding for this purpose is provided in a specific appropriation to the
health care authority. No commission shall be provided upon a renewal.
Commissions shall be determined based on the estimated annual cost of the basic
health plan, however, commissions shall not result in a reduction in the
premium amount paid to health carriers. For purposes of this section "health
carrier" is as defined in RCW 48.43.005. The administrator may
establish: (a) Minimum educational requirements that must be completed by the
agents or brokers; (b) an appointment process for agents or brokers marketing
the basic health plan; or (c) standards for revocation of the appointment of an
agent or broker to submit applications for cause, including untrustworthy or
incompetent conduct or harm to the public. The health care authority and
the department of social and health services shall make every effort to
simplify and expedite the application and enrollment process.
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, 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])) 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 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.
*Sec.
3.
RCW 48.43.025 and 1997 c . . . s 203 (Engrossed Substitute House Bill
No. 2018) are each amended to read as follows:
(1)
Except as permitted in RCW 48.43.035 or otherwise specified in this
section ((and in RCW 48.43.035)):
(a)
No carrier may reject an individual for health plan coverage based upon
preexisting conditions of the individual.
(b)
No carrier may deny, exclude, or otherwise limit coverage for an individual's
preexisting health conditions; except that a carrier may impose a three-month benefit
waiting period for preexisting conditions for which medical advice was given,
or for which a health care provider recommended or provided treatment within
three months before the effective date of coverage.
(c)
Every health carrier offering any individual health plan to any individual must
allow open enrollment to eligible applicants into all individual health plans
offered by the carrier during the full months of July and August
of each year. The individual health plans exempt from guaranteed continuity
under RCW 48.43.035(4) are exempt from this requirement. All applications for
open enrollment coverage must be complete and postmarked to or received by the
carrier in the months of July or August in any year following July 27, 1997.
Coverage for these applicants must begin the first day of the next month
subject to receipt of timely payment consistent with the terms of the policies.
(d)
At any time other than the open enrollment period specified in (c) of this
subsection, a carrier may either decline to accept an applicant for enrollment
or apply to such applicant's coverage a preexisting condition benefit waiting
period not to exceed the amount of time remaining until the next open
enrollment period, or three months, whichever is greater, provided that in
either case all of the following conditions are met:
(i)
The applicant has not maintained coverage as required in (f) of this
subsection;
(ii)
The applicant is not applying as a newly eligible dependent meeting the
requirements of (g) of this subsection; and
(iii)
The carrier uses uniform health evaluation criteria and practices among all
individual health plans it offers.
(e)
If a carrier exercises the options specified in (d) of this subsection it must
advise the applicant in writing within ten business days of such decision.
Notice of the availability of Washington state health insurance pool coverage
and a brochure outlining the benefits and exclusions of the Washington state
health insurance pool policy or policies must be provided in accordance with
RCW 48.41.180 to any person rejected for individual health plan coverage, who
has had any health condition limited or excluded through health underwriting or
who otherwise meets requirements for notice in chapter 48.41 RCW. Provided
timely and complete application is received by the pool, eligible individuals
shall be enrolled in the Washington state health insurance pool in an
expeditious manner as determined by the board of directors of the pool.
(f)
A carrier may not refuse enrollment at any time based upon health evaluation
criteria to otherwise eligible applicants who have been covered for any part of
the three-month period immediately preceding the date of application for the
new individual health plan under a comparable group or individual health
benefit plan with substantially similar benefits. For purposes of this
subsection, in addition to provisions in RCW 48.43.015, the following publicly
administered coverage shall be considered comparable health benefit plans: The
basic health plan established by chapter 70.47 RCW; the medical assistance
program established by chapter 74.09 RCW; and the Washington state health
insurance pool, established by chapter 48.41 RCW, as long as the person is continuously
enrolled in the pool until the next open enrollment period. If the person is
enrolled in the pool for less than three months, she or he will be credited for
that period up to three months.
(g)
A carrier must accept for enrollment all newly eligible dependents of an
enrollee for enrollment onto the enrollee's individual health plan at any time
of the year, provided application is made within sixty-three days of
eligibility, or such longer time as provided by law or contract.
(h)
At no time are carriers required to accept for enrollment any individual
residing outside the state of Washington, except for qualifying dependents who
reside outside the carrier service area.
(2)
No carrier may avoid the requirements of this section through the creation of a
new rate classification or the modification of an existing rate
classification. A new or changed rate classification will be deemed an attempt
to avoid the provisions of this section if the new or changed classification
would substantially discourage applications for coverage from individuals or
groups who are higher than average health risks. The provisions of this
section apply only to individuals who are Washington residents.
*Sec. 3 was vetoed. See message at end of chapter.
*Sec.
4.
RCW 48.43.035 and 1997 c . . . s 204 (Engrossed Substitute House Bill
No. 2018) are each amended to read as follows:
(1)
Except as permitted in RCW 48.43.025 or otherwise specified in this
section ((and in RCW 48.43.025)), every health carrier shall accept for
enrollment any state resident within the carrier's service area and provide or
assure the provision of all covered services regardless of age, sex, family
structure, ethnicity, race, health condition, geographic location, employment
status, socioeconomic status, other condition or situation, or the provisions
of RCW 49.60.174(2). The insurance commissioner may grant a temporary
exemption from this subsection, if, upon application by a health carrier the
commissioner finds that the clinical, financial, or administrative capacity to
serve existing enrollees will be impaired if a health carrier is required to
continue enrollment of additional eligible individuals.
(2)
Except as provided in subsection (6) of this section, all health plans shall
contain or incorporate by endorsement a guarantee of the continuity of coverage
of the plan. For the purposes of this section, a plan is "renewed"
when it is continued beyond the earliest date upon which, at the carrier's sole
option, the plan could have been terminated for other than nonpayment of
premium. In the case of group plans, the carrier may consider the group's
anniversary date as the renewal date for purposes of complying with the
provisions of this section.
(3)
The guarantee of continuity of coverage required in health plans shall not
prevent a carrier from canceling or nonrenewing a health plan for:
(a)
Nonpayment of premium;
(b)
Violation of published policies of the carrier approved by the insurance
commissioner;
(c)
Covered persons entitled to become eligible for medicare benefits by reason of
age who fail to apply for a medicare supplement plan or medicare cost, risk, or
other plan offered by the carrier pursuant to federal laws and regulations;
(d)
Covered persons who fail to pay any deductible or copayment amount owed to the
carrier and not the provider of health care services;
(e)
Covered persons committing fraudulent acts as to the carrier;
(f)
Covered persons who materially breach the health plan;
(g)
Change or implementation of federal or state laws that no longer permit the
continued offering of such coverage; or
(h)
Cessation of a plan in accordance with subsection (5) or (7) of this section.
(4)
The provisions of this section do not apply in the following cases:
(a)
A carrier has zero enrollment on a product;
(b)
A carrier replaces a product and the replacement product is provided to all
covered persons within that class or line of business, includes all of the
services covered under the replaced product, and does not significantly limit
access to the kind of services covered under the replaced product. The health
plan may also allow unrestricted conversion to a fully comparable product; or
(c)
A carrier is withdrawing from a service area or from a segment of its service
area because the carrier has demonstrated to the insurance commissioner that
the carrier's clinical, financial, or administrative capacity to serve
enrollees would be exceeded.
(5)
A health carrier may discontinue or materially modify a particular health plan,
only if:
(a)
The health carrier provides notice to each covered person or group provided
coverage of this type of such discontinuation or modification at least ninety
days prior to the date of the discontinuation or modification of coverage;
(b)
The health carrier offers to each covered person or group provided
coverage of this type the option to purchase any other health plan currently
being offered by the health carrier to similar covered persons in the market
category and geographic area; and
(c)
In exercising the option to discontinue or modify a particular health plan and
in offering the option of coverage under (b) of this subsection, the health
carrier acts uniformly without regard to any health-status related factor of
covered persons or persons who may become eligible for coverage.
(6)
The provisions of this section do not apply to health plans deemed by the
insurance commissioner to be unique or limited or have a short-term purpose,
after a written request for such classification by the carrier and subsequent
written approval by the insurance commissioner.
(7)
A health carrier may discontinue all health plan coverage in one or more of the
following lines of business:
(a)(i)
Individual; or
(ii)(A)
Small group (1-50 eligible employees); and
(B)
Large group (51+ eligible employees);
(b)
Only if:
(i)
The health carrier provides notice to the office of the insurance commissioner
and to each person covered by a plan within the line of business of such
discontinuation at least one hundred eighty days prior to the expiration of
coverage; and
(ii)
All plans issued or delivered in the state by the health carrier in such line
of business are discontinued, and coverage under such plans in such line of
business is not renewed; and
(iii)
The health carrier may not issue any health plan coverage in the line of
business and state involved during the five-year period beginning on the date
of the discontinuation of the last health plan not so renewed.
(8)
The portability provisions of RCW 48.43.015 continue to apply to all enrollees
whose health insurance coverage is modified or discontinued pursuant to this
section.
(9)
Nothing in this section modifies a health carrier's responsibility to offer the
basic health plan model plan as required by RCW 70.47.060(2)(d).
*Sec. 4 was vetoed. See message at end of chapter.
Sec.
5. RCW
48.41.060 and 1997 c . . . s 211 (Engrossed Substitute House Bill No.
2018) are each amended to read as follows:
The
board shall have the general powers and authority granted under the laws of
this state to insurance companies, health care service contractors, and health
maintenance organizations, licensed or registered to offer or provide the kinds
of health coverage defined under this title. In addition thereto, the board
may:
(1)
Enter into contracts as are necessary or proper to carry out the provisions and
purposes of this chapter including the authority, with the approval of the
commissioner, to enter into contracts with similar pools of other states for
the joint performance of common administrative functions, or with persons or
other organizations for the performance of administrative functions;
(2)
Sue or be sued, including taking any legal action as necessary to avoid the
payment of improper claims against the pool or the coverage provided by or
through the pool;
(3)
Establish appropriate rates, rate schedules, rate adjustments, expense
allowances, agent referral fees, claim reserve formulas and any other actuarial
functions appropriate to the operation of the pool. Rates shall not be
unreasonable in relation to the coverage provided, the risk experience, and
expenses of providing the coverage. Rates and rate schedules may be adjusted
for appropriate risk factors such as age and area variation in claim costs and
shall take into consideration appropriate risk factors in accordance with
established actuarial underwriting practices consistent with Washington state
small group plan rating requirements under RCW ((48.20.028, 48.44.022, and
48.46.064)) 48.44.023 and 48.46.066;
(4)
Assess members of the pool in accordance with the provisions of this chapter,
and make advance interim assessments as may be reasonable and necessary for the
organizational or interim operating expenses. Any interim assessments will be
credited as offsets against any regular assessments due following the close of
the year;
(5)
Issue policies of health coverage in accordance with the requirements of this
chapter;
(6)
Appoint appropriate legal, actuarial and other committees as necessary to
provide technical assistance in the operation of the pool, policy, and other
contract design, and any other function within the authority of the pool; and
(7)
Conduct periodic audits to assure the general accuracy of the financial data
submitted to the pool, and the board shall cause the pool to have an annual
audit of its operations by an independent certified public accountant.
Sec.
6. RCW
48.41.030 and 1997 c . . . (Engrossed Substitute House Bill No. 2018)
s 210 are each amended to read as follows:
HEALTH
INSURANCE POOL‑-DEFINITIONS. As
used in this chapter, the following terms have the meaning indicated, unless
the context requires otherwise:
(1)
"Accounting year" means a twelve-month period determined by the board
for purposes of record-keeping and accounting. The first accounting year may
be more or less than twelve months and, from time to time in subsequent years,
the board may order an accounting year of other than twelve months as may be
required for orderly management and accounting of the pool.
(2)
"Administrator" means the entity chosen by the board to administer
the pool under RCW 48.41.080.
(3)
"Board" means the board of directors of the pool.
(4)
"Commissioner" means the insurance commissioner.
(5)
"Covered Person" means any individual resident of this state who
is eligible to receive benefits from any member, or other health plan.
(6)
"Health care facility" has the same meaning as in RCW 70.38.025.
(((6)))
(7) "Health care provider" means any physician, facility, or
health care professional, who is licensed in Washington state and entitled to
reimbursement for health care services.
(((7)))
(8) "Health care services" means services for the purpose of
preventing, alleviating, curing, or healing human illness or injury.
(((8)))
(9) "Health coverage" means any group or individual disability
insurance policy, health care service contract, and health maintenance
agreement, except those contracts entered into for the provision of health care
services pursuant to Title XVIII of the Social Security Act, 42 U.S.C. Sec. 1395
et seq. The term does not include short-term care, long-term care, dental,
vision, accident, fixed indemnity, disability income contracts, civilian health
and medical program for the uniform services (CHAMPUS), 10 U.S.C. 55, limited
benefit or credit insurance, coverage issued as a supplement to liability
insurance, insurance arising out of the worker's compensation or similar law,
automobile medical payment insurance, or insurance under which benefits are
payable with or without regard to fault and which is statutorily required to be
contained in any liability insurance policy or equivalent self-insurance.
(((9)))
(10) "Health plan" means any arrangement by which persons,
including dependents or spouses, covered or making application to be covered
under this pool, have access to hospital and medical benefits or reimbursement
including any group or individual disability insurance policy; health care
service contract; health maintenance agreement; uninsured arrangements of group
or group-type contracts including employer self-insured, cost-plus, or other
benefit methodologies not involving insurance or not governed by Title 48 RCW;
coverage under group-type contracts which are not available to the general
public and can be obtained only because of connection with a particular
organization or group; and coverage by medicare or other governmental
benefits. This term includes coverage through "health coverage" as
defined under this section, and specifically excludes those types of programs
excluded under the definition of "health coverage" in subsection (((8)))
(9) of this section.
(((10)))
(11) "Medical assistance" means coverage under Title XIX of
the federal Social Security Act (42 U.S.C., Sec. 1396 et seq.) and chapter
74.09 RCW.
(((11)))
(12) "Medicare" means coverage under Title XVIII of the Social
Security Act, (42 U.S.C. Sec. 1395 et seq., as amended).
(((12)))
(13) "Member" means any commercial insurer which provides
disability insurance, any health care service contractor, and any health
maintenance organization licensed under Title 48 RCW. "Member" shall
also mean, as soon as authorized by federal law, employers and other entities,
including a self-funding entity and employee welfare benefit plans that provide
health plan benefits in this state on or after May 18, 1987.
"Member" does not include any insurer, health care service
contractor, or health maintenance organization whose products are exclusively
dental products or those products excluded from the definition of "health
coverage" set forth in subsection (((8))) (9) of this
section.
(((13)))
(14) "Network provider" means a health care provider who has
contracted in writing with the pool administrator to accept payment from and to
look solely to the pool according to the terms of the pool health plans.
(((14)))
(15) "Plan of operation" means the pool, including articles,
by-laws, and operating rules, adopted by the board pursuant to RCW 48.41.050.
(((15)))
(16) "Point of service plan" means a benefit plan offered by
the pool under which a covered person may elect to receive covered services
from network providers, or nonnetwork providers at a reduced rate of benefits.
(((16)))
(17) "Pool" means the Washington state health insurance pool
as created in RCW 48.41.040.
(((17)))
(18) "Substantially equivalent health plan" means a
"health plan" as defined in subsection (((9))) (10) of
this section which, in the judgment of the board or the administrator, offers
persons including dependents or spouses covered or making application to be
covered by this pool an overall level of benefits deemed approximately
equivalent to the minimum benefits available under this pool.
Sec.
7. RCW
70.47.120 and 1987 1st ex.s. c 5 s 14 are each amended to read as follows:
In
addition to the powers and duties specified in RCW 70.47.040 and 70.47.060, the
administrator has the power to enter into contracts for the following functions
and services:
(1)
With public or private agencies, to assist the administrator in her or his
duties to design or revise the schedule of covered basic health care services,
and/or to monitor or evaluate the performance of participating managed health
care systems.
(2)
With public or private agencies, to provide technical or professional
assistance to health care providers, particularly public or private nonprofit
organizations and providers serving rural areas, who show serious intent and
apparent capability to participate in the plan as managed health care systems.
(3)
With public or private agencies, including health care service contractors
registered under RCW 48.44.015, and doing business in the state, for marketing
and administrative services in connection with participation of managed health
care systems, enrollment of enrollees, billing and collection services to the
administrator, and other administrative functions ordinarily performed by
health care service contractors, other than insurance. Any activities of a
health care service contractor pursuant to a contract with the administrator
under this section shall be exempt from the provisions and requirements of
Title 48 RCW except that persons appointed or authorized to solicit
applications for enrollment in the basic health plan shall comply with chapter
48.17 RCW.
Sec.
8. RCW
70.47.130 and 1994 c 309 s 6 are each amended to read as follows:
(1)
The activities and operations of the Washington basic health plan under this
chapter, including those of managed health care systems to the extent of their
participation in the plan, are exempt from the provisions and requirements of
Title 48 RCW((, except as provided in RCW 70.47.070 and that the premium and
prepayment tax imposed under RCW 48.14.0201 shall apply to amounts paid to a
managed health care system by the basic health plan for participating in the
basic health plan and providing health care services for nonsubsidized
enrollees in the basic health plan)) except:
(a)
Benefits as provided in RCW 70.47.070;
(b)
Persons appointed or authorized to solicit applications for enrollment in the
basic health plan, including employees of the health care authority, must
comply with chapter 48.17 RCW. For purposes of this subsection (1)(b),
"solicit" does not include distributing information and applications
for the basic health plan and responding to questions; and
(c)
Amounts paid to a managed health care system by the basic health plan for
participating in the basic health plan and providing health care services for
nonsubsidized enrollees in the basic health plan must comply with RCW
48.14.0201.
(2)
The purpose of the 1994 amendatory language to this section in chapter 309,
Laws of 1994 is to clarify the intent of the legislature that premiums paid on
behalf of nonsubsidized enrollees in the basic health plan are subject to the
premium and prepayment tax. The legislature does not consider this clarifying
language to either raise existing taxes nor to impose a tax that did not exist
previously.
NEW
SECTION. Sec. 9.
Sections 1 and 2 of this act are necessary for the immediate preservation of
the public peace, health, or safety, or support of the state government and its
existing public institutions, and take effect July 1, 1997.
