AN
ACT Relating to technical corrections to chapters 79 and 80, Laws of 2000;
amending RCW 48.20.025, 48.41.030, 48.41.100, 48.41.110, 48.43.005, 48.43.012,
48.43.015, 48.43.018, 48.43.025, 48.44.017, 48.46.062, and 70.47.060; adding a
new section to chapter 48.43 RCW; and declaring an emergency.
BE IT
ENACTED BY THE LEGISLATURE OF THE STATE OF WASHINGTON:
Sec.
1. RCW
48.20.025 and 2000 c 79 s 3 are each amended to read as follows:
(1)
The definitions in this subsection apply throughout this section unless the
context clearly requires otherwise.
(a)
"Claims" means the cost to the insurer of health care services, as
defined in RCW 48.43.005, provided to a policyholder or paid to or on behalf of
the policyholder in accordance with the terms of a health benefit plan, as
defined in RCW 48.43.005. This includes capitation payments or other similar
payments made to providers for the purpose of paying for health care services
for a policyholder.
(b)
"Claims reserves" means: (i) The liability for claims which have
been reported but not paid; (ii) the liability for claims which have not been
reported but which may reasonably be expected; (iii) active life reserves; and
(iv) additional claims reserves whether for a specific liability purpose or
not.
(c)
"Earned premiums" means premiums, as defined in RCW 48.43.005, plus
any rate credits or recoupments less any refunds, for the applicable period,
whether received before, during, or after the applicable period.
(d)
"Incurred claims expense" means claims paid during the applicable
period plus any increase, or less any decrease, in the claims reserves.
(e)
"Loss ratio" means incurred claims expense as a percentage of earned
premiums.
(f)
"Reserves" means: (i) Active life reserves; and (ii) additional
reserves whether for a specific liability purpose or not.
(2)
An insurer shall file, for informational purposes only, a notice of its
schedule of rates for its individual health benefit plans with the commissioner
prior to use.
(3)
An insurer shall file with the notice required under subsection (2) of this
section supporting documentation of its method of determining the rates
charged. The commissioner may request only the following supporting
documentation:
(a)
A description of the insurer's rate-making methodology;
(b)
An actuarially determined estimate of incurred claims which includes the
experience data, assumptions, and justifications of the insurer's projection;
(c)
The percentage of premium attributable in aggregate for nonclaims expenses used
to determine the adjusted community rates charged; and
(d)
A certification by a member of the American academy of actuaries, or other
person approved by the commissioner, that the adjusted community rate charged
can be reasonably expected to result in a loss ratio that meets or exceeds the
loss ratio standard established in subsection (7) of this section.
(4)
The commissioner may not disapprove or otherwise impede the implementation of
the filed rates.
(5)
By the last day of May each year any insurer ((providing)) issuing or
renewing individual health benefit plans in this state during the
preceding calendar year shall file for review by the commissioner
supporting documentation of its actual loss ratio for its individual health
benefit plans offered or renewed in the state in aggregate for the
preceding calendar year. The filing shall include aggregate earned
premiums, aggregate incurred claims, and a certification by a member of the
American academy of actuaries, or other person approved by the commissioner,
that the actual loss ratio has been calculated in accordance with accepted
actuarial principles.
(a)
At the expiration of a thirty-day period beginning with the date the filing is
((delivered to)) received by the commissioner, the filing shall
be deemed approved unless prior thereto the commissioner contests the
calculation of the actual loss ratio.
(b)
If the commissioner contests the calculation of the actual loss ratio, the
commissioner shall state in writing the grounds for contesting the calculation
to the insurer.
(c)
Any dispute regarding the calculation of the actual loss ratio shall, upon written
demand of either the commissioner or the insurer, be submitted to hearing under
chapters 48.04 and 34.05 RCW.
(6)
If the actual loss ratio for the preceding calendar year is less than the loss
ratio established in subsection (7) of this section, a remittance is due and
the following shall apply:
(a)
The insurer shall calculate a percentage of premium to be remitted to the
Washington state health insurance pool by subtracting the actual loss ratio for
the preceding year from the loss ratio established in subsection (7) of this
section.
(b)
The remittance to the Washington state health insurance pool is the percentage
calculated in (a) of ((the [this])) this subsection, multiplied
by the premium earned from each enrollee in the previous calendar year.
Interest shall be added to the remittance due at a five percent annual rate
calculated from the end of the calendar year for which the remittance is due to
the date the remittance is made.
(c)
All remittances shall be aggregated and such amounts shall be remitted to the
Washington state high risk pool to be used as directed by the pool board of
directors.
(d)
Any remittance required to be issued under this section shall be issued within
thirty days after the actual loss ratio is deemed approved under subsection
(5)(a) of this section or the determination by an administrative law judge
under subsection (5)(c) of this section.
(7)
The loss ratio applicable to this section shall be seventy-four percent minus
the premium tax rate applicable to the insurer's individual health benefit
plans under RCW 48.14.0201.
Sec.
2. RCW
48.41.030 and 2000 c 79 s 6 are each amended to read as follows:
The
definitions in this section apply throughout this chapter unless the context
clearly 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.
(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.
(8)
"Health care services" means services for the purpose of preventing,
alleviating, curing, or healing human illness or injury.
(9)
"Health carrier" or "carrier" has the same meaning as in
RCW 48.43.005.
(10)
"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.
(11)
"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 (10) of this
section.
(12)
"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.
(13)
"Medicare" means coverage under Title XVIII of the Social Security
Act, (42 U.S.C. Sec. 1395 et seq., as amended).
(14)
"Member" means any commercial insurer which provides disability
insurance or stop loss insurance, any health care service contractor, and any
health maintenance organization licensed under Title 48 RCW.
"Member" also means the Washington state health care authority as
issuer of the state uniform medical plan. "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 (10) of this section.
(15)
"Network provider" means a health care provider who has contracted in
writing with the pool administrator or a health carrier contracting with the
pool administrator to offer pool coverage to accept payment from and to look
solely to the pool or health carrier according to the terms of the pool health
plans.
(16)
"Plan of operation" means the pool, including articles, by-laws, and
operating rules, adopted by the board pursuant to RCW 48.41.050.
(17)
"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.
(18)
"Pool" means the Washington state health insurance pool as created in
RCW 48.41.040.
Sec.
3. RCW
48.41.100 and 2000 c 79 s 12 are each amended to read as follows:
(1)
The following persons who are residents of this state are eligible for pool
coverage:
(a)
Any person who provides evidence of a carrier's decision not to accept him or
her for enrollment in an individual health benefit plan as defined in RCW
48.43.005 based upon, and within ninety days of the receipt of, the results of
the standard health questionnaire designated by the board and administered by
health carriers under RCW 48.43.018;
(b)
Any person who continues to be eligible for pool coverage based upon the
results of the standard health questionnaire designated by the board and
administered by the pool administrator pursuant to subsection (3) of this
section;
(c)
Any person who resides in a county of the state where no carrier or insurer ((regulated))
eligible under chapter 48.15 RCW offers to the public an individual
health benefit plan other than a catastrophic health plan as defined in RCW
48.43.005 at the time of application to the pool, and who makes direct
application to the pool; and
(d)
Any medicare eligible person upon providing evidence of rejection for medical
reasons, a requirement of restrictive riders, an up-rated premium, or a
preexisting conditions limitation on a medicare supplemental insurance policy
under chapter 48.66 RCW, the effect of which is to substantially reduce
coverage from that received by a person considered a standard risk by at least
one member within six months of the date of application.
(2)
The following persons are not eligible for coverage by the pool:
(a)
Any person having terminated coverage in the pool unless (i) twelve months have
lapsed since termination, or (ii) that person can show continuous other
coverage which has been involuntarily terminated for any reason other than
nonpayment of premiums. However, these exclusions do not apply to eligible
individuals as defined in section 2741(b) of the federal health insurance
portability and accountability act of 1996 (42 U.S.C. Sec. 300gg-41(b));
(b)
Any person on whose behalf the pool has paid out one million dollars in
benefits;
(c)
Inmates of public institutions and persons whose benefits are duplicated under
public programs. However, these exclusions do not apply to eligible
individuals as defined in section 2741(b) of the federal health insurance
portability and accountability act of 1996 (42 U.S.C. Sec. 300gg-41(b));
(d)
Any person who resides in a county of the state where any carrier or insurer
regulated under chapter 48.15 RCW offers to the public an individual health
benefit plan other than a catastrophic health plan as defined in RCW 48.43.005
at the time of application to the pool and who does not qualify for pool
coverage based upon the results of the standard health questionnaire, or
pursuant to subsection (1)(d) of this section.
(3)
When a carrier or insurer regulated under chapter 48.15 RCW begins to offer an
individual health benefit plan in a county where no carrier had been offering
an individual health benefit plan:
(a)
If the health benefit plan offered is other than a catastrophic health plan as
defined in RCW 48.43.005, any person enrolled in a pool plan pursuant to
subsection (1)(c) of this section in that county shall no longer be eligible
for coverage under that plan pursuant to subsection (1)(c) of this section, but
may continue to be eligible for pool coverage based upon the results of the
standard health questionnaire designated by the board and administered by the
pool administrator. The pool administrator shall offer to administer the
questionnaire to each person no longer eligible for coverage under subsection
(1)(c) of this section within thirty days of determining that he or she is no
longer eligible;
(b)
Losing eligibility for pool coverage under this subsection (3) does not affect
a person's eligibility for pool coverage under subsection (1)(a), (b), or (d)
of this section; and
(c)
The pool administrator shall provide written notice to any person who is no
longer eligible for coverage under a pool plan under this subsection (3) within
thirty days of the administrator's determination that the person is no longer
eligible. The notice shall: (i) Indicate that coverage under the plan will
cease ninety days from the date that the notice is dated; (ii) describe any
other coverage options, either in or outside of the pool, available to the
person; (iii) describe the procedures for the administration of the standard
health questionnaire to determine the person's continued eligibility for
coverage under subsection (1)(b) of this section; and (iv) describe the enrollment
process for the available options outside of the pool.
Sec.
4. RCW
48.41.110 and 2000 c 80 s 2 are each amended to read as follows:
(1)
The pool shall offer one or more care management plans of coverage. Such plans
may, but are not required to, include point of service features that permit
participants to receive in-network benefits or out-of-network benefits subject
to differential cost shares. Covered persons enrolled in the pool on January
1, 2001, may continue coverage under the pool plan in which they are enrolled
on that date. However, the pool may incorporate managed care features into
such existing plans.
(2)
The administrator shall prepare a brochure outlining the benefits and
exclusions of the pool policy in plain language. After approval by the board,
such brochure shall be made reasonably available to participants or potential
participants.
(3)
The health insurance policy issued by the pool shall pay only reasonable
amounts for medically necessary eligible health care services rendered or
furnished for the diagnosis or treatment of illnesses, injuries, and conditions
which are not otherwise limited or excluded. Eligible expenses are the
reasonable amounts for the health care services and items for which benefits
are extended under the pool policy. Such benefits shall at minimum include,
but not be limited to, the following services or related items:
(a)
Hospital services, including charges for the most common semiprivate room, for
the most common private room if semiprivate rooms do not exist in the health
care facility, or for the private room if medically necessary, but limited to a
total of one hundred eighty inpatient days in a calendar year, and limited to
thirty days inpatient care for mental and nervous conditions, or alcohol, drug,
or chemical dependency or abuse per calendar year;
(b)
Professional services including surgery for the treatment of injuries, illnesses,
or conditions, other than dental, which are rendered by a health care provider,
or at the direction of a health care provider, by a staff of registered or
licensed practical nurses, or other health care providers;
(c)
The first twenty outpatient professional visits for the diagnosis or treatment
of one or more mental or nervous conditions or alcohol, drug, or chemical
dependency or abuse rendered during a calendar year by one or more physicians,
psychologists, or community mental health professionals, or, at the direction
of a physician, by other qualified licensed health care practitioners, in the
case of mental or nervous conditions, and rendered by a state certified
chemical dependency program approved under chapter 70.96A RCW, in the case of
alcohol, drug, or chemical dependency or abuse;
(d)
Drugs and contraceptive devices requiring a prescription;
(e)
Services of a skilled nursing facility, excluding custodial and convalescent
care, for not more than one hundred days in a calendar year as prescribed by a
physician;
(f)
Services of a home health agency;
(g)
Chemotherapy, radioisotope, radiation, and nuclear medicine therapy;
(h)
Oxygen;
(i)
Anesthesia services;
(j)
Prostheses, other than dental;
(k)
Durable medical equipment which has no personal use in the absence of the
condition for which prescribed;
(l)
Diagnostic x-rays and laboratory tests;
(m)
Oral surgery limited to the following: Fractures of facial bones; excisions of
mandibular joints, lesions of the mouth, lip, or tongue, tumors, or cysts
excluding treatment for temporomandibular joints; incision of accessory
sinuses, mouth salivary glands or ducts; dislocations of the jaw; plastic
reconstruction or repair of traumatic injuries occurring while covered under
the pool; and excision of impacted wisdom teeth;
(n)
Maternity care services;
(o)
Services of a physical therapist and services of a speech therapist;
(p)
Hospice services;
(q)
Professional ambulance service to the nearest health care facility qualified to
treat the illness or injury; and
(r)
Other medical equipment, services, or supplies required by physician's orders
and medically necessary and consistent with the diagnosis, treatment, and
condition.
(4)
The board shall design and employ cost containment measures and requirements
such as, but not limited to, care coordination, provider network limitations,
preadmission certification, and concurrent inpatient review which may make the
pool more cost-effective.
(5)
The pool benefit policy may contain benefit limitations, exceptions, and cost
shares such as copayments, coinsurance, and deductibles that are consistent
with managed care products, except that differential cost shares may be adopted
by the board for nonnetwork providers under point of service plans. The pool benefit
policy cost shares and limitations must be consistent with those that are
generally included in health plans approved by the insurance commissioner;
however, no limitation, exception, or reduction may be used that would exclude
coverage for any disease, illness, or injury.
(6)
The pool may not reject an individual for health plan coverage based upon
preexisting conditions of the individual or deny, exclude, or otherwise limit
coverage for an individual's preexisting health conditions; except that it shall
impose a six-month benefit waiting period for preexisting conditions for which
medical advice was given, for which a health care provider recommended or
provided treatment, or for which a prudent layperson would have sought advice
or treatment, within six months before the effective date of coverage. The
preexisting condition waiting period shall not apply to prenatal care
services. The pool may not avoid the requirements of this section through the
creation of a new rate classification or the modification of an existing rate
classification. Credit against the waiting period shall be as provided in
subsection (7) of this section.
(7)(a)
Except as provided in (b) of this subsection, the pool shall credit any
preexisting condition waiting period in its plans for a person who was enrolled
at any time during the sixty-three day period immediately preceding the date of
application for the new pool plan ((in a group health benefit plan or an
individual health benefit plan other than a catastrophic health plan. The pool
must credit the period of coverage the person was continuously covered under
the immediately preceding health plan)). For the person previously
enrolled in a group health benefit plan, the pool must credit the aggregate of
all periods of preceding coverage not separated by more than sixty-three days
toward the waiting period of the new health plan. For the person previously
enrolled in an individual health benefit plan other than a catastrophic health
plan, the pool must credit the period of coverage the person was continuously
covered under the immediately preceding health plan toward the waiting
period of the new health plan. For the purposes of this subsection, a
preceding health plan includes an employer-provided self-funded health plan.
(b)
The pool shall waive any preexisting condition waiting period for a person who
is an eligible individual as defined in section 2741(b) of the federal health
insurance portability and accountability act of 1996 (42 U.S.C. 300gg-41(b)).
(8)
If an application is made for the pool policy as a result of rejection by a
carrier, then the date of application to the carrier, rather than to the pool,
should govern for purposes of determining preexisting condition credit.
Sec.
5. RCW
48.43.005 and 2000 c 79 s 18 are each amended to read as follows:
Unless
otherwise specifically provided, the definitions in this section apply
throughout this chapter.
(1)
"Adjusted community rate" means the rating method used to establish
the premium for health plans adjusted to reflect actuarially demonstrated
differences in utilization or cost attributable to geographic region, age,
family size, and use of wellness activities.
(2)
"Basic health plan" means the plan described under chapter 70.47 RCW,
as revised from time to time.
(3)
"Basic health plan model plan" means a health plan as required in
RCW 70.47.060(2)(d).
(4)
"Basic health plan services" means that schedule of covered health
services, including the description of how those benefits are to be
administered, that are required to be delivered to an enrollee under the basic
health plan, as revised from time to time.
(((4)))
(5) "Catastrophic health plan" means:
(a)
In the case of a contract, agreement, or policy covering a single enrollee, a
health benefit plan requiring a calendar year deductible of, at a minimum, one
thousand five hundred dollars and an annual out-of-pocket expense required to
be paid under the plan (other than for premiums) for covered benefits of at
least three thousand dollars; and
(b)
In the case of a contract, agreement, or policy covering more than one
enrollee, a health benefit plan requiring a calendar year deductible of, at a
minimum, three thousand dollars and an annual out-of-pocket expense required to
be paid under the plan (other than for premiums) for covered benefits of at
least five thousand five hundred dollars; or
(c)
Any health benefit plan that provides benefits for hospital inpatient and
outpatient services, professional and prescription drugs provided in
conjunction with such hospital inpatient and outpatient services, and excludes
or substantially limits outpatient physician services and those services
usually provided in an office setting.
(((5)))
(6) "Certification" means a determination by a review
organization that an admission, extension of stay, or other health care service
or procedure has been reviewed and, based on the information provided, meets
the clinical requirements for medical necessity, appropriateness, level of
care, or effectiveness under the auspices of the applicable health benefit
plan.
(((6)))
(7) "Concurrent review" means utilization review conducted
during a patient's hospital stay or course of treatment.
(((7)))
(8) "Covered person" or "enrollee" means a person
covered by a health plan including an enrollee, subscriber, policyholder,
beneficiary of a group plan, or individual covered by any other health plan.
(((8)))
(9) "Dependent" means, at a minimum, the enrollee's legal
spouse and unmarried dependent children who qualify for coverage under the
enrollee's health benefit plan.
(((9)))
(10) "Eligible employee" means an employee who works on a
full-time basis with a normal work week of thirty or more hours. The term
includes a self-employed individual, including a sole proprietor, a partner of
a partnership, and may include an independent contractor, if the self-employed
individual, sole proprietor, partner, or independent contractor is included as
an employee under a health benefit plan of a small employer, but does not work
less than thirty hours per week and derives at least seventy-five percent of
his or her income from a trade or business through which he or she has
attempted to earn taxable income and for which he or she has filed the
appropriate internal revenue service form. Persons covered under a health
benefit plan pursuant to the consolidated omnibus budget reconciliation act of
1986 shall not be considered eligible employees for purposes of minimum
participation requirements of chapter 265, Laws of 1995.
(((10)))
(11) "Emergency medical condition" means the emergent and
acute onset of a symptom or symptoms, including severe pain, that would lead a
prudent layperson acting reasonably to believe that a health condition exists
that requires immediate medical attention, if failure to provide medical
attention would result in serious impairment to bodily functions or serious
dysfunction of a bodily organ or part, or would place the person's health in
serious jeopardy.
(((11)))
(12) "Emergency services" means otherwise covered health care
services medically necessary to evaluate and treat an emergency medical
condition, provided in a hospital emergency department.
(((12)))
(13) "Enrollee point-of-service cost-sharing" means amounts
paid to health carriers directly providing services, health care providers, or
health care facilities by enrollees and may include copayments, coinsurance, or
deductibles.
(((13)))
(14) "Grievance" means a written complaint submitted by or on
behalf of a covered person regarding: (a) Denial of payment for medical
services or nonprovision of medical services included in the covered person's
health benefit plan, or (b) service delivery issues other than denial of
payment for medical services or nonprovision of medical services, including
dissatisfaction with medical care, waiting time for medical services, provider
or staff attitude or demeanor, or dissatisfaction with service provided by the
health carrier.
(((14)))
(15) "Health care facility" or "facility" means
hospices licensed under chapter 70.127 RCW, hospitals licensed under chapter
70.41 RCW, rural health care facilities as defined in RCW 70.175.020,
psychiatric hospitals licensed under chapter 71.12 RCW, nursing homes licensed
under chapter 18.51 RCW, community mental health centers licensed under chapter
71.05 or 71.24 RCW, kidney disease treatment centers licensed under chapter
70.41 RCW, ambulatory diagnostic, treatment, or surgical facilities licensed
under chapter 70.41 RCW, drug and alcohol treatment facilities licensed under
chapter 70.96A RCW, and home health agencies licensed under chapter 70.127 RCW,
and includes such facilities if owned and operated by a political subdivision
or instrumentality of the state and such other facilities as required by
federal law and implementing regulations.
(((15)))
(16) "Health care provider" or "provider" means:
(a)
A person regulated under Title 18 or chapter 70.127 RCW, to practice health or
health-related services or otherwise practicing health care services in this
state consistent with state law; or
(b)
An employee or agent of a person described in (a) of this subsection, acting in
the course and scope of his or her employment.
(((16)))
(17) "Health care service" means that service offered or
provided by health care facilities and health care providers relating to the
prevention, cure, or treatment of illness, injury, or disease.
(((17)))
(18) "Health carrier" or "carrier" means a
disability insurer regulated under chapter 48.20 or 48.21 RCW, a health care
service contractor as defined in RCW 48.44.010, or a health maintenance
organization as defined in RCW 48.46.020.
(((18)))
(19) "Health plan" or "health benefit plan" means
any policy, contract, or agreement offered by a health carrier to provide,
arrange, reimburse, or pay for health care services except the following:
(a)
Long-term care insurance governed by chapter 48.84 RCW;
(b)
Medicare supplemental health insurance governed by chapter 48.66 RCW;
(c)
Limited health care services offered by limited health care service contractors
in accordance with RCW 48.44.035;
(d)
Disability income;
(e)
Coverage incidental to a property/casualty liability insurance policy such as
automobile personal injury protection coverage and homeowner guest medical;
(f)
Workers' compensation coverage;
(g)
Accident only coverage;
(h)
Specified disease and hospital confinement indemnity when marketed solely as a
supplement to a health plan;
(i)
Employer-sponsored self-funded health plans;
(j)
Dental only and vision only coverage; and
(k)
Plans deemed by the insurance commissioner to have a short-term limited purpose
or duration, or to be a student-only plan that is guaranteed renewable while
the covered person is enrolled as a regular full-time undergraduate or graduate
student at an accredited higher education institution, after a written request
for such classification by the carrier and subsequent written approval by the
insurance commissioner.
(((19)))
(20) "Material modification" means a change in the actuarial
value of the health plan as modified of more than five percent but less than
fifteen percent.
(((20)))
(21) "Preexisting condition" means any medical condition,
illness, or injury that existed any time prior to the effective date of
coverage.
(((21)))
(22) "Premium" means all sums charged, received, or deposited
by a health carrier as consideration for a health plan or the continuance of a
health plan. Any assessment or any "membership," "policy,"
"contract," "service," or similar fee or charge made by a
health carrier in consideration for a health plan is deemed part of the
premium. "Premium" shall not include amounts paid as enrollee point-of-service
cost-sharing.
(((22)))
(23) "Review organization" means a disability insurer
regulated under chapter 48.20 or 48.21 RCW, health care service contractor as
defined in RCW 48.44.010, or health maintenance organization as defined in RCW
48.46.020, and entities affiliated with, under contract with, or acting on
behalf of a health carrier to perform a utilization review.
(((23)))
(24) "Small employer" or "small group" means any
person, firm, corporation, partnership, association, political subdivision
except school districts, or self-employed individual that is actively engaged
in business that, on at least fifty percent of its working days during the
preceding calendar quarter, employed no more than fifty eligible employees,
with a normal work week of thirty or more hours, the majority of whom were
employed within this state, and is not formed primarily for purposes of buying
health insurance and in which a bona fide employer-employee relationship
exists. In determining the number of eligible employees, companies that are
affiliated companies, or that are eligible to file a combined tax return for
purposes of taxation by this state, shall be considered an employer.
Subsequent to the issuance of a health plan to a small employer and for the
purpose of determining eligibility, the size of a small employer shall be
determined annually. Except as otherwise specifically provided, a small
employer shall continue to be considered a small employer until the plan
anniversary following the date the small employer no longer meets the
requirements of this definition. The term "small employer" includes
a self-employed individual or sole proprietor. The term "small
employer" also includes a self-employed individual or sole proprietor who
derives at least seventy-five percent of his or her income from a trade or
business through which the individual or sole proprietor has attempted to earn
taxable income and for which he or she has filed the appropriate internal
revenue service form 1040, schedule C or F, for the previous taxable year.
(((24)))
(25) "Utilization review" means the prospective, concurrent,
or retrospective assessment of the necessity and appropriateness of the
allocation of health care resources and services of a provider or facility,
given or proposed to be given to an enrollee or group of enrollees.
(((25)))
(26) "Wellness activity" means an explicit program of an
activity consistent with department of health guidelines, such as, smoking
cessation, injury and accident prevention, reduction of alcohol misuse,
appropriate weight reduction, exercise, automobile and motorcycle safety, blood
cholesterol reduction, and nutrition education for the purpose of improving
enrollee health status and reducing health service costs.
Sec.
6. RCW
48.43.012 and 2000 c 79 s 19 are each amended to read as follows:
(1)
No carrier may reject an individual for an individual health benefit plan based
upon preexisting conditions of the individual except as provided in RCW
48.43.018.
(2)
No carrier may deny, exclude, or otherwise limit coverage for an individual's
preexisting health conditions except as provided in this section.
(3)
For an individual health benefit plan originally issued on or after March 23,
2000, preexisting condition waiting periods imposed upon a person enrolling in
an individual health benefit plan shall be no more than nine months for a
preexisting condition for which medical advice was given, for which a health
care provider recommended or provided treatment, or for which a prudent
layperson would have sought advice or treatment, within six months prior to the
effective date of the plan. No carrier may impose a preexisting condition
waiting period on an individual health benefit plan issued to an eligible
individual as defined in section 2741(b) of the federal health insurance
portability and accountability act of 1996 (42 U.S.C. 300gg-41(b)).
(4)
Individual health benefit plan preexisting condition waiting periods shall not
apply to prenatal care services.
(5)
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 who
are higher than average health risks. These provisions apply only to
individuals who are Washington residents.
Sec.
7. RCW
48.43.015 and 2000 c 80 s 3 are each amended to read as follows:
(1)
((For a health benefit plan offered to a group other than a small group,
every health carrier shall reduce any preexisting condition exclusion or
limitation for persons or groups who had similar health coverage under a
different health plan at any time during the three-month period immediately
preceding the date of application for the new health plan if such person was
continuously covered under the immediately preceding health plan. If the person
was continuously covered for at least three months under the immediately
preceding health plan, the carrier may not impose a waiting period for coverage
of preexisting conditions. If the person was continuously covered for less than
three months under the immediately preceding health plan, the carrier must
credit any waiting period under the immediately preceding health plan toward
the new health plan. For the purposes of this subsection, a preceding health
plan includes an employer-provided self-funded health plan and plans of the
Washington state health insurance pool.
(2)
For a health benefit plan offered to a small group, every health carrier shall
reduce any preexisting condition exclusion or limitation for persons or groups
who had similar health coverage under a different health plan at any time
during the three-month period immediately preceding the date of application for
the new health plan if such person was continuously covered under the
immediately preceding health plan. If the person was continuously covered for
at least nine months under the immediately preceding health plan, the carrier
may not impose a waiting period for coverage of preexisting conditions. If the
person was continuously covered for less than nine months under the immediately
preceding health plan, the carrier must credit any waiting period under the
immediately preceding health plan toward the new health plan. For the purposes
of this subsection, a preceding health plan includes an employer‑provided
self-funded health plan and plans of the Washington state health insurance
pool.
(3))) For
a health benefit plan offered to a group, every health carrier shall reduce any
preexisting condition exclusion, limitation, or waiting period in the group
health plan in accordance with the provisions of section 2701 of the federal
health insurance portability and accountability act of 1996 (42 U.S.C. Sec.
300gg).
(2)
For a health benefit plan offered to a group other than a small group:
(a)
If the individual applicant's immediately preceding health plan coverage
terminated during the period beginning ninety days and ending sixty-four days
before the date of application for the new plan and such coverage was similar
and continuous for at least three months, then the carrier shall not impose a
waiting period for coverage of preexisting conditions under the new health
plan.
(b)
If the individual applicant's immediately preceding health plan coverage
terminated during the period beginning ninety days and ending sixty-four days
before the date of application for the new plan and such coverage was similar
and continuous for less than three months, then the carrier shall credit the
time covered under the immediately preceding health plan toward any preexisting
condition waiting period under the new health plan.
(c)
For the purposes of this subsection, a preceding health plan includes an
employer-provided self-funded health plan and plans of the Washington state
health insurance pool.
(3)
For a health benefit plan offered to a small group:
(a)
If the individual applicant's immediately preceding health plan coverage
terminated during the period beginning ninety days and ending sixty-four days
before the date of application for the new plan and such coverage was similar
and continuous for at least nine months, then the carrier shall not impose a
waiting period for coverage of preexisting conditions under the new health
plan.
(b)
If the individual applicant's immediately preceding health plan coverage
terminated during the period beginning ninety days and ending sixty-four days
before the date of application for the new plan and such coverage was similar
and continuous for less than nine months, then the carrier shall credit the
time covered under the immediately preceding health plan toward any preexisting
condition waiting period under the new health plan.
(c)
For the purpose of this subsection, a preceding health plan includes an
employer-provided self-funded health plan and plans of the Washington state
health insurance pool.
(4)
For a health benefit plan offered to an individual, other than an individual to
whom subsection (((4))) (5) of this section applies, every health
carrier shall credit any preexisting condition waiting period in that plan for
a person who was enrolled at any time during the sixty-three day period
immediately preceding the date of application for the new health plan in a
group health benefit plan or an individual health benefit plan, other than a
catastrophic health plan, and (a) the benefits under the previous plan provide
equivalent or greater overall benefit coverage than that provided in the health
benefit plan the individual seeks to purchase; or (b) the person is seeking an
individual health benefit plan due to his or her change of residence from one
geographic area in Washington state to another geographic area in Washington
state where his or her current health plan is not offered, if application for
coverage is made within ninety days of relocation; or (c) the person is seeking
an individual health benefit plan: (i) Because a health care provider with
whom he or she has an established care relationship and from whom he or she has
received treatment within the past twelve months is no longer part of the
carrier's provider network under his or her existing Washington individual
health benefit plan; and (ii) his or her health care provider is part of
another carrier's provider network; and (iii) application for a health benefit
plan under that carrier's provider network individual coverage is made within
ninety days of his or her provider leaving the previous carrier's provider
network. The carrier must credit the period of coverage the person was continuously
covered under the immediately preceding health plan toward the waiting period
of the new health plan. For the purposes of this subsection (((3))) (4),
a preceding health plan includes an employer-provided self-funded health plan
and plans of the Washington state health insurance pool.
(((4)))
(5) Every health carrier shall waive any preexisting condition waiting
period in its individual plans for a person who is an eligible individual as
defined in section 2741(b) of the federal health insurance portability and
accountability act of 1996 (42 U.S.C. Sec. 300gg-41(b)).
(((5)))
(6) Subject to the provisions of subsections (1) through (((4))) (5)
of this section, nothing contained in this section requires a health carrier to
amend a health plan to provide new benefits in its existing health plans. In
addition, nothing in this section requires a carrier to waive benefit
limitations not related to an individual or group's preexisting conditions or
health history.
Sec.
8. RCW
48.43.018 and 2000 c 80 s 4 are each amended to read as follows:
(1)
Except as provided in (a) through (c) of this subsection, a health carrier may
require any person applying for an individual health benefit plan to complete
the standard health questionnaire designated under chapter 48.41 RCW.
(a)
If a person is seeking an individual health benefit plan due to his or her
change of residence from one geographic area in Washington state to another
geographic area in Washington state where his or her current health plan is not
offered, completion of the standard health questionnaire shall not be a
condition of coverage if application for coverage is made within ninety days of
relocation.
(b)
If a person is seeking an individual health benefit plan:
(i)
Because a health care provider with whom he or she has an established care
relationship and from whom he or she has received treatment within the past
twelve months is no longer part of the carrier's provider network under his or
her existing Washington individual health benefit plan; and
(ii)
His or her health care provider is part of another carrier's provider network;
and
(iii)
Application for a health benefit plan under that carrier's provider network
individual coverage is made within ninety days of his or her provider leaving
the previous carrier's provider network; then completion of the standard health
questionnaire shall not be a condition of coverage.
(c)
If a person is seeking an individual health benefit plan due to his or her
having exhausted continuation coverage provided under 29 U.S.C. Sec. 1161 et
seq., completion of the standard health questionnaire shall not be a condition
of coverage if application for coverage is made within ninety days of
exhaustion of continuation coverage. A health carrier shall accept an
application without a standard health questionnaire from a person currently
covered by such continuation coverage if application is made within ninety days
prior to the date the continuation coverage would be exhausted and the effective
date of the individual coverage applied for is the date the continuation
coverage would be exhausted, or within ninety days thereafter.
(2)
If, based upon the results of the standard health questionnaire, the person
qualifies for coverage under the Washington state health insurance pool, the
following shall apply:
(a)
The carrier may decide not to accept the person's application for enrollment in
its individual health benefit plan; and
(b)
Within fifteen business days of receipt of a completed application, the carrier
shall provide written notice of the decision not to accept the person's
application for enrollment to both the person and the administrator of the
Washington state health insurance pool. The notice to the person shall state
that the person is eligible for health insurance provided by the Washington
state health insurance pool, and shall include information about the Washington
state health insurance pool and an application for such coverage. If the
carrier does not provide or postmark such notice within fifteen business days,
the application is deemed approved.
(3)
If the person applying for an individual health benefit plan: (a) Does not
qualify for coverage under the Washington state health insurance pool based
upon the results of the standard health questionnaire; (b) does qualify for
coverage under the Washington state health insurance pool based upon the
results of the standard health questionnaire and the carrier elects to accept
the person for enrollment; or (c) is not required to complete the standard
health questionnaire designated under this chapter under subsection (1)(a) or
(b) of this section, the carrier shall accept the person for enrollment if he
or she resides 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 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.
Sec.
9. RCW
48.43.025 and 2000 c 79 s 23 are each amended to read as follows:
(1)
For group health benefit plans for groups other than small groups, no carrier may
reject an individual for health plan coverage based upon preexisting conditions
of the individual and 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((, or for which a prudent layperson would have sought
advice or treatment,)) within three months before the effective date of
coverage. Any preexisting condition waiting period or limitation relating to
pregnancy as a preexisting condition shall be imposed only to the extent
allowed in the federal health insurance portability and accountability act of
1996.
(2)
For group health benefit plans for small groups, no carrier may reject an
individual for health plan coverage based upon preexisting conditions of the
individual and no carrier may deny, exclude, or otherwise limit coverage for an
individual's preexisting health conditions. Except that a carrier may impose a
nine-month benefit waiting period for preexisting conditions for which medical
advice was given, or for which a health care provider recommended or provided
treatment((, or for which a prudent layperson would have sought advice or
treatment,)) within six months before the effective date of coverage. Any
preexisting condition waiting period or limitation relating to pregnancy as a
preexisting condition shall be imposed only to the extent allowed in the
federal health insurance portability and accountability act of 1996.
(3)
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. These provisions apply only to
individuals who are Washington residents.
NEW
SECTION. Sec. 10. A
new section is added to chapter 48.43 RCW to read as follows:
To
the extent required of the federal health insurance portability and
accountability act of 1996, the eligibility of an employer or group to purchase
a health benefit plan set forth in RCW 48.21.045(1)(b), 48.44.023(1)(b), and
48.46.066(1)(b) must be extended to all small employers and small groups as
defined in RCW 48.43.005.
Sec.
11. RCW
48.44.017 and 2000 c 79 s 29 are each amended to read as follows:
(1)
The definitions in this subsection apply throughout this section unless the
context clearly requires otherwise.
(a)
"Claims" means the cost to the health care service contractor of
health care services, as defined in RCW 48.43.005, provided to a contract
holder or paid to or on behalf of a contract holder in accordance with the
terms of a health benefit plan, as defined in RCW 48.43.005. This includes
capitation payments or other similar payments made to providers for the purpose
of paying for health care services for an enrollee.
(b)
"Claims reserves" means: (i) The liability for claims which have
been reported but not paid; (ii) the liability for claims which have not been
reported but which may reasonably be expected; (iii) active life reserves; and
(iv) additional claims reserves whether for a specific liability purpose or
not.
(c)
"Earned premiums" means premiums, as defined in RCW 48.43.005, plus
any rate credits or recoupments less any refunds, for the applicable period,
whether received before, during, or after the applicable period.
(d)
"Incurred claims expense" means claims paid during the applicable
period plus any increase, or less any decrease, in the claims reserves.
(e)
"Loss ratio" means incurred claims expense as a percentage of earned
premiums.
(f)
"Reserves" means: (i) Active life reserves; and (ii) additional
reserves whether for a specific liability purpose or not.
(2)
A health care service contractor shall file, for informational purposes only, a
notice of its schedule of rates for its individual contracts with the
commissioner prior to use.
(3)
A health care service contractor shall file with the notice required under
subsection (2) of this section supporting documentation of its method of
determining the rates charged. The commissioner may request only the following
supporting documentation:
(a)
A description of the health care service contractor's rate-making methodology;
(b)
An actuarially determined estimate of incurred claims which includes the
experience data, assumptions, and justifications of the health care service
contractor's projection;
(c)
The percentage of premium attributable in aggregate for nonclaims expenses used
to determine the adjusted community rates charged; and
(d)
A certification by a member of the American academy of actuaries, or other
person approved by the commissioner, that the adjusted community rate charged
can be reasonably expected to result in a loss ratio that meets or exceeds the
loss ratio standard established in subsection (7) of this section.
(4)
The commissioner may not disapprove or otherwise impede the implementation of
the filed rates.
(5)
By the last day of May each year any health care service contractor ((providing))
issuing or renewing individual health benefit plans in this state during
the preceding calendar year shall file for review by the commissioner
supporting documentation of its actual loss ratio for its individual health
benefit plans offered or renewed in this state in aggregate for the
preceding calendar year. The filing shall include aggregate earned premiums,
aggregate incurred claims, and a certification by a member of the American
academy of actuaries, or other person approved by the commissioner, that the
actual loss ratio has been calculated in accordance with accepted actuarial
principles.
(a)
At the expiration of a thirty-day period beginning with the date the filing is
((delivered to)) received by the commissioner, the filing shall
be deemed approved unless prior thereto the commissioner contests the
calculation of the actual loss ratio.
(b)
If the commissioner contests the calculation of the actual loss ratio, the
commissioner shall state in writing the grounds for contesting the calculation
to the health care service contractor.
(c)
Any dispute regarding the calculation of the actual loss ratio shall upon
written demand of either the commissioner or the health care service contractor
be submitted to hearing under chapters 48.04 and 34.05 RCW.
(6)
If the actual loss ratio for the preceding calendar year is less than the loss
ratio standard established in subsection (7) of this section, a remittance is
due and the following shall apply:
(a)
The health care service contractor shall calculate a percentage of premium to
be remitted to the Washington state health insurance pool by subtracting the actual
loss ratio for the preceding year from the loss ratio established in subsection
(7) of this section.
(b)
The remittance to the Washington state health insurance pool is the percentage
calculated in (a) of this subsection, multiplied by the premium earned from
each enrollee in the previous calendar year. Interest shall be added to the
remittance due at a five percent annual rate calculated from the end of the
calendar year for which the remittance is due to the date the remittance is
made.
(c)
All remittances shall be aggregated and such amounts shall be remitted to the
Washington state high risk pool to be used as directed by the pool board of
directors.
(d)
Any remittance required to be issued under this section shall be issued within
thirty days after the actual loss ratio is deemed approved under subsection
(5)(a) of this section or the determination by an administrative law judge
under subsection (5)(c) of this section.
(7)
The loss ratio applicable to this section shall be seventy-four percent minus
the premium tax rate applicable to the health care service contractor's
individual health benefit plans under RCW 48.14.0201.
Sec.
12. RCW
48.46.062 and 2000 c 79 s 32 are each amended to read as follows:
(1)
The definitions in this subsection apply throughout this section unless the
context clearly requires otherwise.
(a)
"Claims" means the cost to the health maintenance organization of
health care services, as defined in RCW 48.43.005, provided to an enrollee or
paid to or on behalf of the enrollee in accordance with the terms of a health
benefit plan, as defined in RCW 48.43.005. This includes capitation payments
or other similar payments made to providers for the purpose of paying for
health care services for an enrollee.
(b)
"Claims reserves" means: (i) The liability for claims which have
been reported but not paid; (ii) the liability for claims which have not been
reported but which may reasonably be expected; (iii) active life reserves; and
(iv) additional claims reserves whether for a specific liability purpose or
not.
(c)
"Earned premiums" means premiums, as defined in RCW 48.43.005, plus
any rate credits or recoupments less any refunds, for the applicable period,
whether received before, during, or after the applicable period.
(d)
"Incurred claims expense" means claims paid during the applicable
period plus any increase, or less any decrease, in the claims reserves.
(e)
"Loss ratio" means incurred claims expense as a percentage of earned
premiums.
(f)
"Reserves" means: (i) Active life reserves; and (ii) additional
reserves whether for a specific liability purpose or not.
(2)
A health maintenance organization shall file, for informational purposes only,
a notice of its schedule of rates for its individual agreements with the
commissioner prior to use.
(3)
A health maintenance organization shall file with the notice required under
subsection (2) of this section supporting documentation of its method of
determining the rates charged. The commissioner may request only the following
supporting documentation:
(a)
A description of the health maintenance organization's rate-making methodology;
(b)
An actuarially determined estimate of incurred claims which includes the
experience data, assumptions, and justifications of the health maintenance
organization's projection;
(c)
The percentage of premium attributable in aggregate for nonclaims expenses used
to determine the adjusted community rates charged; and
(d)
A certification by a member of the American academy of actuaries, or other
person approved by the commissioner, that the adjusted community rate charged
can be reasonably expected to result in a loss ratio that meets or exceeds the
loss ratio standard established in subsection (7) of this section.
(4)
The commissioner may not disapprove or otherwise impede the implementation of
the filed rates.
(5)
By the last day of May each year any health maintenance organization ((providing))
issuing or renewing individual health benefit plans in this state during
the preceding calendar year shall file for review by the commissioner
supporting documentation of its actual loss ratio for its individual health
benefit plans offered or renewed in the state in aggregate for the
preceding calendar year. The filing shall include aggregate earned
premiums, aggregate incurred claims, and a certification by a member of the
American academy of actuaries, or other person approved by the commissioner,
that the actual loss ratio has been calculated in accordance with accepted
actuarial principles.
(a)
At the expiration of a thirty-day period beginning with the date the filing is
((delivered to)) received by the commissioner, the filing shall
be deemed approved unless prior thereto the commissioner contests the
calculation of the actual loss ratio.
(b)
If the commissioner contests the calculation of the actual loss ratio, the
commissioner shall state in writing the grounds for contesting the calculation
to the health maintenance organization.
(c)
Any dispute regarding the calculation of the actual loss ratio shall, upon
written demand of either the commissioner or the health maintenance
organization, be submitted to hearing under chapters 48.04 and 34.05 RCW.
(6)
If the actual loss ratio for the preceding calendar year is less than the loss
ratio standard established in subsection (7) of this section, a remittance is
due and the following shall apply:
(a)
The health maintenance organization shall calculate a percentage of premium to
be remitted to the Washington state health insurance pool by subtracting the
actual loss ratio for the preceding year from the loss ratio established in
subsection (7) of this section.
(b)
The remittance to the Washington state health insurance pool is the percentage
calculated in (a) of this subsection, multiplied by the premium earned from
each enrollee in the previous calendar year. Interest shall be added to the
remittance due at a five percent annual rate calculated from the end of the
calendar year for which the remittance is due to the date the remittance is
made.
(c)
All remittances shall be aggregated and such amounts shall be remitted to the
Washington state high risk pool to be used as directed by the pool board of
directors.
(d)
Any remittance required to be issued under this section shall be issued within
thirty days after the actual loss ratio is deemed approved under subsection
(5)(a) of this section or the determination by an administrative law judge
under subsection (5)(c) of this section.
(7)
The loss ratio applicable to this section shall be seventy-four percent minus
the premium tax rate applicable to the health maintenance organization's
individual health benefit plans under RCW 48.14.0201.
Sec.
13. RCW
70.47.060 and 2000 c 79 s 34 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 (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, 2001, 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 for either subsidized enrollees, or nonsubsidized enrollees, or both.
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.
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.
(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 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.
(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.
(17)
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.
NEW
SECTION. Sec. 14. This
act is necessary for the immediate preservation of the public peace, health, or
safety, or support of the state government and its existing public
institutions, and takes effect immediately.
