BILL REQ. #: H-2182.2
State of Washington | 58th Legislature | 2003 Regular Session |
READ FIRST TIME 03/04/03.
AN ACT Relating to access to health insurance for small employers and their employees; amending RCW 48.21.045, 48.44.023, 48.46.066, 48.43.035, and 70.47.020; adding a new section to chapter 48.43 RCW; adding a new section to chapter 70.47 RCW; creating a new section; and providing an effective date.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF WASHINGTON:
Sec. 1 RCW 48.21.045 and 1995 c 265 s 14 are each amended to read
as follows:
(1)(a) An insurer offering any health benefit plan to a small
employer shall offer and actively market to the small employer a health
benefit plan ((providing benefits identical to the schedule of covered
health services that are required to be delivered to an individual
enrolled in the basic health plan)) featuring a limited schedule of
covered health services. Nothing in this subsection shall preclude an
insurer from offering, or a small employer from purchasing, other
health benefit plans that may have more ((or less)) comprehensive
benefits than ((the basic health plan, provided such plans are in
accordance with this chapter)) those included in the product offered
under this subsection. An insurer offering a health benefit plan
((that does not include benefits in the basic health plan)) under this
subsection shall clearly disclose ((these differences)) all covered
benefits to the small employer in a brochure approved by the
commissioner.
(b) A health benefit plan offered under this subsection shall
provide coverage for hospital expenses and services rendered by a
((physician)) health care professionals licensed under ((chapter 18.57
or 18.71)) Title 18 RCW but is not subject to the requirements of RCW
48.21.130, 48.21.140, ((48.21.141,)) 48.21.142, 48.21.144, 48.21.146,
48.21.160 through 48.21.197, 48.21.200, 48.21.220, 48.21.225,
48.21.230, 48.21.235, 48.21.240, 48.21.244, 48.21.250, ((48.21.300,))
48.21.310, or 48.21.320 if ((: (i) The health benefit plan is the
mandatory offering under (a) of this subsection that provides benefits
identical to the basic health plan, to the extent these requirements
differ from the basic health plan; or (ii))) the health benefit plan is
offered to employers with not more than twenty-five employees.
(2) Nothing in this section shall prohibit an insurer from
offering, or a purchaser from seeking, health benefit plans with
benefits in excess of the ((basic health plan services)) health benefit
plan offered under subsection (1) of this section. All forms,
policies, and contracts shall be submitted for approval to the
commissioner, and the rates of any plan offered under this section
shall be reasonable in relation to the benefits thereto.
(3) Premium rates for health benefit plans for small employers as
defined in this section shall be subject to the following provisions:
(a) The insurer shall develop its rates based on an adjusted
community rate and may only vary the adjusted community rate for:
(i) Geographic area;
(ii) Family size;
(iii) Age; and
(iv) Wellness activities.
(b) The adjustment for age in (a)(iii) of this subsection may not
use age brackets smaller than five-year increments, which shall begin
with age twenty and end with age sixty-five. Employees under the age
of twenty shall be treated as those age twenty.
(c) The insurer shall be permitted to develop separate rates for
individuals age sixty-five or older for coverage for which medicare is
the primary payer and coverage for which medicare is not the primary
payer. Both rates shall be subject to the requirements of this
subsection (3).
(d) The permitted rates for any age group shall be no more than
((four hundred twenty-five percent of the lowest rate for all age
groups on January 1, 1996, four hundred percent on January 1, 1997,
and)) three hundred seventy-five percent of the lowest rate for all age
groups on January 1, 2000, and five hundred percent on January 1, 2004,
and thereafter.
(e) A discount for wellness activities shall be permitted to
reflect actuarially justified differences in utilization or cost
attributed to such programs ((not to exceed twenty percent)).
(f) The rate charged for a health benefit plan offered under this
section may not be adjusted more frequently than annually except that
the premium may be changed to reflect:
(i) Changes to the enrollment of the small employer;
(ii) Changes to the family composition of the employee;
(iii) Changes to the health benefit plan requested by the small
employer; or
(iv) Changes in government requirements affecting the health
benefit plan.
(g) Rating factors shall produce premiums for identical groups that
differ only by the amounts attributable to plan design, with the
exception of discounts for health improvement programs.
(h) For the purposes of this section, a health benefit plan that
contains a restricted network provision shall not be considered similar
coverage to a health benefit plan that does not contain such a
provision, provided that the restrictions of benefits to network
providers result in substantial differences in claims costs. This
subsection does not restrict or enhance the portability of benefits as
provided in RCW 48.43.015.
(i) Adjusted community rates established under this section shall
pool the medical experience of all small groups purchasing coverage.
(4) ((The health benefit plans authorized by this section that are
lower than the required offering shall not supplant or supersede any
existing policy for the benefit of employees in this state.)) Nothing
in this section shall restrict the right of employees to collectively
bargain for insurance providing benefits in excess of those provided
herein.
(5)(a) Except as provided in this subsection, requirements used by
an insurer in determining whether to provide coverage to a small
employer shall be applied uniformly among all small employers applying
for coverage or receiving coverage from the carrier.
(b) An insurer shall not require a minimum participation level
greater than:
(i) One hundred percent of eligible employees working for groups
with three or less employees; and
(ii) Seventy-five percent of eligible employees working for groups
with more than three employees.
(c) In applying minimum participation requirements with respect to
a small employer, a small employer shall not consider employees or
dependents who have similar existing coverage in determining whether
the applicable percentage of participation is met.
(d) An insurer may not increase any requirement for minimum
employee participation or modify any requirement for minimum employer
contribution applicable to a small employer at any time after the small
employer has been accepted for coverage.
(6) An insurer must offer coverage to all eligible employees of a
small employer and their dependents. An insurer may not offer coverage
to only certain individuals or dependents in a small employer group or
to only part of the group. An insurer may not modify a health plan
with respect to a small employer or any eligible employee or dependent,
through riders, endorsements or otherwise, to restrict or exclude
coverage or benefits for specific diseases, medical conditions, or
services otherwise covered by the plan.
(7) As used in this section, "health benefit plan," "small
employer," "basic health plan," "adjusted community rate," and
"wellness activities" mean the same as defined in RCW 48.43.005.
Sec. 2 RCW 48.44.023 and 1995 c 265 s 16 are each amended to read
as follows:
(1)(a) A health care services contractor offering any health
benefit plan to a small employer shall offer and actively market to the
small employer a health benefit plan ((providing benefits identical to
the schedule of covered health services that are required to be
delivered to an individual enrolled in the basic health plan))
featuring a limited schedule of covered health services. Nothing in
this subsection shall preclude a contractor from offering, or a small
employer from purchasing, other health benefit plans that may have more
((or less)) comprehensive benefits than ((the basic health plan,
provided such plans are in accordance with this chapter)) those
included in the product offered under this subsection. A contractor
offering a health benefit plan ((that does not include benefits in the
basic health plan)) under this subsection shall clearly disclose
((these differences)) all covered benefits to the small employer in a
brochure approved by the commissioner.
(b) A health benefit plan offered under this subsection shall
provide coverage for hospital expenses and services rendered by a
((physician)) health care professionals licensed under ((chapter 18.57
or 18.71)) Title 18 RCW but is not subject to the requirements of RCW
((48.44.225,)) 48.44.240, 48.44.245, ((48.44.290, 48.44.300,))
48.44.310, 48.44.320, 48.44.325, 48.44.330, 48.44.335, 48.44.340,
48.44.344, 48.44.360, 48.44.400, ((48.44.440,)) 48.44.450, and
48.44.460 if ((: (i) The health benefit plan is the mandatory offering
under (a) of this subsection that provides benefits identical to the
basic health plan, to the extent these requirements differ from the
basic health plan; or (ii))) the health benefit plan is offered to
employers with not more than twenty-five employees.
(2) Nothing in this section shall prohibit a health care service
contractor from offering, or a purchaser from seeking, health benefits
plans with benefits in excess of the ((basic health plan services))
health benefit plan offered under subsection (1) of this section. All
forms, policies, and contracts shall be submitted for approval to the
commissioner, and the rates of any plan offered under this section
shall be reasonable in relation to the benefits thereto.
(3) Premium rates for health benefit plans for small employers as
defined in this section shall be subject to the following provisions:
(a) The contractor shall develop its rates based on an adjusted
community rate and may only vary the adjusted community rate for:
(i) Geographic area;
(ii) Family size;
(iii) Age; and
(iv) Wellness activities.
(b) The adjustment for age in (a)(iii) of this subsection may not
use age brackets smaller than five-year increments, which shall begin
with age twenty and end with age sixty-five. Employees under the age
of twenty shall be treated as those age twenty.
(c) The contractor shall be permitted to develop separate rates for
individuals age sixty-five or older for coverage for which medicare is
the primary payer and coverage for which medicare is not the primary
payer. Both rates shall be subject to the requirements of this
subsection (3).
(d) The permitted rates for any age group shall be no more than
((four hundred twenty-five percent of the lowest rate for all age
groups on January 1, 1996, four hundred percent on January 1, 1997,
and)) three hundred seventy-five percent of the lowest rate for all age
groups on January 1, 2000, and five hundred percent on January 1, 2004,
and thereafter.
(e) A discount for wellness activities shall be permitted to
reflect actuarially justified differences in utilization or cost
attributed to such programs ((not to exceed twenty percent)).
(f) The rate charged for a health benefit plan offered under this
section may not be adjusted more frequently than annually except that
the premium may be changed to reflect:
(i) Changes to the enrollment of the small employer;
(ii) Changes to the family composition of the employee;
(iii) Changes to the health benefit plan requested by the small
employer; or
(iv) Changes in government requirements affecting the health
benefit plan.
(g) Rating factors shall produce premiums for identical groups that
differ only by the amounts attributable to plan design, with the
exception of discounts for health improvement programs.
(h) For the purposes of this section, a health benefit plan that
contains a restricted network provision shall not be considered similar
coverage to a health benefit plan that does not contain such a
provision, provided that the restrictions of benefits to network
providers result in substantial differences in claims costs. This
subsection does not restrict or enhance the portability of benefits as
provided in RCW 48.43.015.
(i) Adjusted community rates established under this section shall
pool the medical experience of all groups purchasing coverage.
(4) ((The health benefit plans authorized by this section that are
lower than the required offering shall not supplant or supersede any
existing policy for the benefit of employees in this state.)) Nothing
in this section shall restrict the right of employees to collectively
bargain for insurance providing benefits in excess of those provided
herein.
(5)(a) Except as provided in this subsection, requirements used by
a contractor in determining whether to provide coverage to a small
employer shall be applied uniformly among all small employers applying
for coverage or receiving coverage from the carrier.
(b) A contractor shall not require a minimum participation level
greater than:
(i) One hundred percent of eligible employees working for groups
with three or less employees; and
(ii) Seventy-five percent of eligible employees working for groups
with more than three employees.
(c) In applying minimum participation requirements with respect to
a small employer, a small employer shall not consider employees or
dependents who have similar existing coverage in determining whether
the applicable percentage of participation is met.
(d) A contractor may not increase any requirement for minimum
employee participation or modify any requirement for minimum employer
contribution applicable to a small employer at any time after the small
employer has been accepted for coverage.
(6) A contractor must offer coverage to all eligible employees of
a small employer and their dependents. A contractor may not offer
coverage to only certain individuals or dependents in a small employer
group or to only part of the group. A contractor may not modify a
health plan with respect to a small employer or any eligible employee
or dependent, through riders, endorsements or otherwise, to restrict or
exclude coverage or benefits for specific diseases, medical conditions,
or services otherwise covered by the plan.
Sec. 3 RCW 48.46.066 and 1995 c 265 s 18 are each amended to read
as follows:
(1)(a) A health maintenance organization offering any health
benefit plan to a small employer shall offer and actively market to the
small employer a health benefit plan ((providing benefits identical to
the schedule of covered health services that are required to be
delivered to an individual enrolled in the basic health plan))
featuring a limited schedule of covered health services. Nothing in
this subsection shall preclude a health maintenance organization from
offering, or a small employer from purchasing, other health benefit
plans that may have more ((or less)) comprehensive benefits than ((the
basic health plan, provided such plans are in accordance with this
chapter)) those included in the product offered under this subsection.
A health maintenance organization offering a health benefit plan ((that
does not include benefits in the basic health plan)) under this
subsection shall clearly disclose ((these differences)) all covered
benefits to the small employer in a brochure approved by the
commissioner.
(b) A health benefit plan offered under this subsection shall
provide coverage for hospital expenses and services rendered by a
((physician)) health care professionals licensed under ((chapter 18.57
or 18.71)) Title 18 RCW but is not subject to the requirements of RCW
48.46.275, 48.46.280, 48.46.285, 48.46.290, 48.46.350, 48.46.355,
48.46.375, 48.46.440, 48.46.480, ((48.46.510,)) 48.46.520, and
48.46.530 if ((: (i) The health benefit plan is the mandatory offering
under (a) of this subsection that provides benefits identical to the
basic health plan, to the extent these requirements differ from the
basic health plan; or (ii))) the health benefit plan is offered to
employers with not more than twenty-five employees.
(2) Nothing in this section shall prohibit a health maintenance
organization from offering, or a purchaser from seeking, health benefit
plans with benefits in excess of the ((basic health plan services))
health benefit plan offered under subsection (1) of this section. All
forms, policies, and contracts shall be submitted for approval to the
commissioner, and the rates of any plan offered under this section
shall be reasonable in relation to the benefits thereto.
(3) Premium rates for health benefit plans for small employers as
defined in this section shall be subject to the following provisions:
(a) The health maintenance organization shall develop its rates
based on an adjusted community rate and may only vary the adjusted
community rate for:
(i) Geographic area;
(ii) Family size;
(iii) Age; and
(iv) Wellness activities.
(b) The adjustment for age in (a)(iii) of this subsection may not
use age brackets smaller than five-year increments, which shall begin
with age twenty and end with age sixty-five. Employees under the age
of twenty shall be treated as those age twenty.
(c) The health maintenance organization shall be permitted to
develop separate rates for individuals age sixty-five or older for
coverage for which medicare is the primary payer and coverage for which
medicare is not the primary payer. Both rates shall be subject to the
requirements of this subsection (3).
(d) The permitted rates for any age group shall be no more than
((four hundred twenty-five percent of the lowest rate for all age
groups on January 1, 1996, four hundred percent on January 1, 1997,
and)) three hundred seventy-five percent of the lowest rate for all age
groups on January 1, 2000, and five hundred percent on January 1, 2004,
and thereafter.
(e) A discount for wellness activities shall be permitted to
reflect actuarially justified differences in utilization or cost
attributed to such programs ((not to exceed twenty percent)).
(f) The rate charged for a health benefit plan offered under this
section may not be adjusted more frequently than annually except that
the premium may be changed to reflect:
(i) Changes to the enrollment of the small employer;
(ii) Changes to the family composition of the employee;
(iii) Changes to the health benefit plan requested by the small
employer; or
(iv) Changes in government requirements affecting the health
benefit plan.
(g) Rating factors shall produce premiums for identical groups that
differ only by the amounts attributable to plan design, with the
exception of discounts for health improvement programs.
(h) For the purposes of this section, a health benefit plan that
contains a restricted network provision shall not be considered similar
coverage to a health benefit plan that does not contain such a
provision, provided that the restrictions of benefits to network
providers result in substantial differences in claims costs. This
subsection does not restrict or enhance the portability of benefits as
provided in RCW 48.43.015.
(i) Adjusted community rates established under this section shall
pool the medical experience of all groups purchasing coverage.
(4) ((The health benefit plans authorized by this section that are
lower than the required offering shall not supplant or supersede any
existing policy for the benefit of employees in this state.)) Nothing
in this section shall restrict the right of employees to collectively
bargain for insurance providing benefits in excess of those provided
herein.
(5)(a) Except as provided in this subsection, requirements used by
a health maintenance organization in determining whether to provide
coverage to a small employer shall be applied uniformly among all small
employers applying for coverage or receiving coverage from the carrier.
(b) A health maintenance organization shall not require a minimum
participation level greater than:
(i) One hundred percent of eligible employees working for groups
with three or less employees; and
(ii) Seventy-five percent of eligible employees working for groups
with more than three employees.
(c) In applying minimum participation requirements with respect to
a small employer, a small employer shall not consider employees or
dependents who have similar existing coverage in determining whether
the applicable percentage of participation is met.
(d) A health maintenance organization may not increase any
requirement for minimum employee participation or modify any
requirement for minimum employer contribution applicable to a small
employer at any time after the small employer has been accepted for
coverage.
(6) A health maintenance organization must offer coverage to all
eligible employees of a small employer and their dependents. A health
maintenance organization may not offer coverage to only certain
individuals or dependents in a small employer group or to only part of
the group. A health maintenance organization may not modify a health
plan with respect to a small employer or any eligible employee or
dependent, through riders, endorsements or otherwise, to restrict or
exclude coverage or benefits for specific diseases, medical conditions,
or services otherwise covered by the plan.
Sec. 4 RCW 48.43.035 and 2000 c 79 s 24 are each amended to read
as follows:
For group health benefit plans, the following shall apply:
(1) All health carriers shall accept for enrollment any state
resident within the group to whom the plan is offered and 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 (5) 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. 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; or
(g) Change or implementation of federal or state laws that no
longer permit the continued offering of such coverage.
(4) ((The provisions of)) This section ((do)) does not apply in the
following cases:
(a) A carrier has zero enrollment on a product; or
(b) For group health plans sold to groups other than small employer
groups, 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) For group health plans offered to small employer groups, no
sooner than October 1, 2003, a carrier discontinues offering a
particular type of health benefit plan if: (i) The carrier provides
notice to each group provided coverage of this type of the
discontinuation at least ninety days prior to the date of the
discontinuation; (ii) the carrier offers to each group provided
coverage of this type the option to enroll in any other small employer
group health benefit plan currently being offered by the carrier; and
(iii) in exercising the option to discontinue coverage of this type and
in offering the option of coverage under (c)(ii) of this subsection,
the carrier acts uniformly without regard to any health status-related
factor of individuals enrolled through the small employer group,
individuals who may become eligible for such coverage, or the
collective health status of groups enrolled in coverage of this type;
or
(d) A carrier discontinues offering all small employer group health
coverage in the state and discontinues coverage under all existing
small employer group health benefit plans if: (i) The carrier provides
notice to the commissioner of its intent to discontinue offering all
small employer group health coverage in the state and its intent to
discontinue coverage under all existing health benefit plans at least
one hundred eighty days prior to the date of the discontinuation of
coverage under all existing health benefit plans; and (ii) the carrier
provides notice to each covered small employer group of the intent to
discontinue his or her existing health benefit plan at least one
hundred eighty days prior to the date of the discontinuation and
includes information in the notice that can help the small employer
group identify alternative sources of coverage. In the case of
discontinuation under this subsection, the carrier may not issue any
small employer group health coverage in this state for a five-year
period beginning on the date of the discontinuation of the last health
plan not so renewed. Nothing in this subsection (3) may be construed
to require a carrier to provide notice to the commissioner of its
intent to discontinue offering a health benefit plan to new applicants
where the carrier does not discontinue coverage of existing enrollees
under that health benefit plan; or
(e) 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) 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.
NEW SECTION. Sec. 5 A new section is added to chapter 48.43 RCW
to read as follows:
Beginning January 1, 2004, any carrier offering health benefit
plans to small employers in addition to the benefit plan authorized
under RCW 48.21.045(1), 48.44.023(1), and 48.46.066(1) must offer and
actively market to small employers at least three other plans of the
carrier's choosing. Nothing in this section limits the ability of a
carrier to offer small employer group health benefit plans in addition
to those that must be offered under this section.
NEW SECTION. Sec. 6 A new section is added to chapter 70.47 RCW
to read as follows:
(1) In coordination with the department of social and health
services medical assistance administration and interested entities, the
administrator will identify and design pilot projects to improve health
care coverage access, including review of proposals by entities that
have received funding through the federal health resources and services
administration community access program. The administrator may approve
pilot projects that are found to be feasible. Pilot projects may
include applying basic health plan or medical assistance subsidy
payments toward employer-sponsored health insurance or other health
insurance premium shares, rather than as direct payments to managed
health care systems participating in the basic health plan or medical
assistance program.
(2) The schedule of benefits for persons enrolled through an
approved pilot project may differ from the benefits offered through the
basic health plan, but shall be reasonably comparable in value to those
benefits.
(3) By November 1, 2003, the administrator and the secretary of the
department of social and health services shall jointly report to the
health care committees of the senate and the house of representatives
on their progress in developing the pilot projects authorized in this
act, the anticipated implementation date of any pilot project under
development, and the resources needed to implement the pilot project.
Sec. 7 RCW 70.47.020 and 2000 c 79 s 43 are each amended to read
as follows:
As used in this chapter:
(1) "Washington basic health plan" or "plan" means the system of
enrollment and payment for basic health care services, administered by
the plan administrator through participating managed health care
systems, created by this chapter.
(2) "Administrator" means the Washington basic health plan
administrator, who also holds the position of administrator of the
Washington state health care authority.
(3) "Managed health care system" means: (a) Any health care
organization, including health care providers, insurers, health care
service contractors, health maintenance organizations, or any
combination thereof, that provides directly or by contract basic health
care services, as defined by the administrator and rendered by duly
licensed providers, to a defined patient population enrolled in the
plan and in the managed health care system; or (b) a self-funded or
self-insured method of providing insurance coverage to subsidized
enrollees provided under RCW 41.05.140 and subject to the limitations
under RCW 70.47.100(7).
(4) "Subsidized enrollee" means an individual, or an individual
plus the individual's spouse or dependent children: (a) Who is not
eligible for medicare; (b) who is not confined or residing in a
government-operated institution, unless he or she meets eligibility
criteria adopted by the administrator; (c) who resides in an area of
the state served by a managed health care system participating in the
plan; (d) whose gross family income at the time of enrollment does not
exceed two hundred percent of the federal poverty level as adjusted for
family size and determined annually by the federal department of health
and human services; and (e) who chooses to obtain basic health care
coverage from a particular managed health care system in return for
periodic payments to the plan. To the extent that state funds are
specifically appropriated for this purpose, with a corresponding
federal match, "subsidized enrollee" also means an individual, or an
individual's spouse or dependent children, who meets the requirements
in (a) through (c) and (e) of this subsection and whose gross family
income at the time of enrollment is more than two hundred percent, but
less than two hundred fifty-one percent, of the federal poverty level
as adjusted for family size and determined annually by the federal
department of health and human services. Upon approval of a pilot
project under section 6 of this act, "subsidized enrollee" also means
an individual, or an individual's spouse or dependent children, who
meets the requirements of (a), (b), and (d) of this subsection, who
resides within the state of Washington, and who qualifies for a premium
subsidy under a pilot project approved under section 6 of this act.
(5) "Nonsubsidized enrollee" means an individual, or an individual
plus the individual's spouse or dependent children: (a) Who is not
eligible for medicare; (b) who is not confined or residing in a
government-operated institution, unless he or she meets eligibility
criteria adopted by the administrator; (c) who resides in an area of
the state served by a managed health care system participating in the
plan; (d) who chooses to obtain basic health care coverage from a
particular managed health care system; and (e) who pays or on whose
behalf is paid the full costs for participation in the plan, without
any subsidy from the plan.
(6) "Subsidy" means the difference between the amount of periodic
payment the administrator makes to a managed health care system or
through payments developed as part of a pilot project approved under
section 6 of this act on behalf of a subsidized enrollee plus the
administrative cost to the plan of providing the plan to that
subsidized enrollee, and the amount determined to be the subsidized
enrollee's responsibility under RCW 70.47.060(2).
(7) "Premium" means a periodic payment, based upon gross family
income which an individual, their employer or another financial sponsor
makes to the plan as consideration for enrollment in the plan as a
subsidized enrollee or a nonsubsidized enrollee.
(8) "Rate" means the amount, negotiated by the administrator with
and paid to a participating managed health care system, that is based
upon the enrollment of subsidized and nonsubsidized enrollees in the
plan and in that system.
NEW SECTION. Sec. 8 The insurance commissioner shall submit a
report to the legislature by December 2006 on the extent to which the
health benefits plans authorized under RCW 48.21.045(1), 48.44.023(1),
and 48.46.066(1) have been marketed and sold, and the extent to which
those plans are being offered by carriers that are new entrants into
the small group market, and the impact of those plans, RCW 48.43.035,
and section 5 of this act on the small group health insurance market.
NEW SECTION. Sec. 9 Section 4 of this act takes effect January
1, 2004.