AN
ACT Relating to verification of income eligibility for the basic health plan;
reenacting and amending RCW 70.47.060; and prescribing penalties.
BE IT
ENACTED BY THE LEGISLATURE OF THE STATE OF WASHINGTON:
Sec.
1. RCW
70.47.060 and 1997 c 337 s 2, 1997 c 335 s 2, 1997 c 245 s 6, and 1997 c 231 s
206 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 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)) 48.47.030, 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.
(d)
To develop, as an offering by every health carrier providing coverage identical
to the basic health plan, as configured on January 1, 1996, a basic health plan
model plan 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. 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, 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.
