BILL REQ. #:  S-1831.1 

READ FIRST TIME 02/14/07.   

     AN ACT Relating to health care services for children; amending RCW 74.09.402; adding new sections to chapter 74.09 RCW; adding a new section to chapter 28A.210 RCW; adding a new section to chapter 48.43 RCW; creating a new section; and repealing RCW 74.09.405, 74.09.415, 74.09.425, 74.09.435, and 74.09.450.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF WASHINGTON:

Sec. 1   RCW 74.09.402 and 2005 c 279 s 1 are each amended to read as follows:
     (1) The legislature finds that:
     (a) Improving the health of children in Washington state is an investment in a productive and successful next generation. The health of ((the)) children ((of Washington state)) is critical to their success in school and throughout their lives((.));
     (b) Healthy children are ready to learn. In order to provide students with the opportunity to become responsible citizens, to contribute to their own economic well-being and to that of their families and communities, and to enjoy productive and satisfying lives, the state recognizes the importance that access to appropriate health services and improved health brings to the children of Washington state. In addition, fully immunized children are themselves protected, and in turn protect others, from contracting communicable diseases;
     (c) Children with health insurance coverage have better health outcomes than those who lack coverage. Children without health insurance coverage are more likely to be in poor health and more likely to delay receiving, or go without, needed health care services;
     (((b) Access to preventive and well-child health services for children is a cost-effective investment of both public and private dollars that improves the health of children and of our communities at large; and
     (c))) (d) Health care coverage for children in Washington state is the product of critical efforts in both the private and public sectors to help children succeed. Private health insurance coverage is complemented by public programs that meet needs of low-income children whose parents are not offered health insurance coverage through their employer or who cannot otherwise afford the costs of coverage. In ((2004)) 2006, thirty-five percent of children in Washington state had some form of public health coverage. Washington state is making progress in its efforts to increase the number of children with health care coverage. Yet, even with ((the)) these efforts of both ((the)) private and public sectors, ((too)) many children in Washington state continue to lack health insurance coverage. ((In 2004, almost one hundred)) In 2006, over seventy thousand children were uninsured. Almost two-thirds of these children are ((low income)) in families whose income is under two hundred fifty percent of the federal poverty level; and
     (e) Improved health outcomes for the children of Washington state are the expected result of improved access to health care coverage. Linking children with a medical home that provides preventive and well child health services and referral to needed specialty services, linking children with needed behavioral health and dental services, more effectively managing childhood diseases, improving nutrition, and increasing physical activity are key to improving children's health. Care should be provided in appropriate settings by efficient providers, consistent with high quality care and at an appropriate stage, soon enough to avert the need for overly expensive treatment.
     (2) It is therefore the intent of the legislature that:
     (a) All children in the state of Washington have health care coverage by 2010. This should be accomplished by building upon and strengthening the successes of private health insurance coverage and publicly supported children's health insurance programs in Washington state. Access to coverage should be streamlined and efficient, with reductions in unnecessary administrative costs and mechanisms to expeditiously link children with a medical home;
     (b) The state, in collaboration with parents, schools, communities, health plans, and providers, take steps to improve health outcomes for the children of Washington state by linking children with a medical home, identifying health improvement goals for children, and linking innovative purchasing strategies to those goals.

NEW SECTION.  Sec. 2   A new section is added to chapter 74.09 RCW to read as follows:
     (1) Consistent with the goals established in RCW 74.09.402, through the program authorized in this section, the department shall provide affordable health care coverage to children under the age of nineteen who reside in Washington state and whose family income at the time of enrollment is not greater than two hundred fifty percent of the federal poverty level as adjusted for family size and determined annually by the federal department of health and human services, and effective January 1, 2009, and only to the extent that funds are specifically appropriated therefor, to children whose family income is not greater than three hundred percent of the federal poverty level. In administering the program, the department shall take such actions as may be necessary to ensure the receipt of federal financial participation under the medical assistance program, as codified at Title XIX of the federal social security act, the state children's health insurance program, as codified at Title XXI of the federal social security act, and any other federal funding sources that are now available or may become available in the future. The department and the caseload forecast council shall estimate the anticipated caseload and costs of the program established in this section.
     (2) The department shall accept applications for enrollment for children's health care coverage; establish appropriate minimum-enrollment periods, as may be necessary; and determine eligibility based on current family income. The department shall make eligibility determinations within the time frames for establishing eligibility for children on medical assistance, as defined by RCW 74.09.510. The application and annual renewal processes shall be designed to minimize administrative barriers for applicants and enrolled clients, and to minimize gaps in eligibility for families who are eligible for coverage. If a change in family income results in a change in program eligibility, the department shall transfer the family members to the appropriate programs and notify the family with respect to any change in premium obligation, without a break in eligibility. The department shall use the same eligibility redetermination and appeals procedures as those provided for children on medical assistance programs. The department shall modify its eligibility renewal procedures to lower the percentage of children failing to annually renew. The department shall report to the appropriate committees of the legislature on its progress in this regard by December 2007.
     (3) To ensure continuity of care and ease of understanding for families and health care providers, and to maximize the efficiency of the program, the amount, scope, and duration of health care services provided to children under this section shall be the same as that provided to children under medical assistance, as defined in RCW 74.09.520.
     (4) The primary mechanism for purchasing health care coverage under this section shall be through contracts with managed health care systems as defined in RCW 74.09.522 except when utilization patterns suggest that fee-for-service purchasing could produce equally effective and cost-efficient care. However, the department shall make every effort within available resources to purchase health care coverage for uninsured children whose families have access to dependent coverage through an employer-sponsored health plan or another source when it is cost-effective for the state to do so, and the purchase is consistent with requirements of Title XIX and Title XXI of the federal social security act. To the extent allowable under federal law, the department shall require families to enroll in available employer-sponsored coverage, as a condition of participating in the program established under this act, when it is cost-effective for the state to do so. Families who enroll in available employer-sponsored coverage under this act shall be accounted for separately in the annual report required by RCW 74.09.053.
     (5)(a) To reflect appropriate parental responsibility, the department shall develop and implement a schedule of premiums for children's health care coverage due to the department from families with income greater than two hundred percent of the federal poverty level. For families with income greater than two hundred fifty percent of the federal poverty level, the premiums shall be established in consultation with the senate majority and minority leaders and the speaker and minority leader of the house of representatives. Premiums shall be set at a reasonable level that does not pose a barrier to enrollment. The amount of the premium shall be based upon family income and shall not exceed the premium limitations in Title XXI of the federal social security act. Premiums shall not be imposed on children in households at or below two hundred percent of the federal poverty level as articulated in RCW 74.09.055.
     (b) Beginning January 1, 2009, the department shall offer families whose income is greater than three hundred percent of the federal poverty level the opportunity to purchase health care coverage for their children through the programs administered under this section without a premium subsidy from the state. The amount paid by the family shall be in an amount equal to the rate paid by the state to the managed health care system for coverage of the child, including any associated and administrative costs to the state of providing coverage for the child.
     (6) The department shall undertake a proactive, targeted outreach and education effort with the goal of enrolling children in health coverage and improving the health literacy of youth and parents. The department shall collaborate with the department of health, local public health jurisdictions, the office of superintendent of public instruction, the department of early learning, health educators, health care providers, health carriers, and parents in the design and development of this effort. The outreach and education effort shall include the following components:
     (a) Broad dissemination of information about the availability of coverage, including media campaigns;
     (b) Assistance with completing applications, and community-based outreach efforts to help people apply for coverage. Community-based outreach efforts should be targeted to the populations least likely to be covered;
     (c) Use of existing systems, such as enrollment information from the free and reduced price lunch program, the department of early learning child care subsidy program, the department of health's women, infants, and children program, and the early childhood education and assistance program, to identify children who may be eligible but not enrolled in coverage;
     (d) Contracting with community-based organizations and government entities to support community-based outreach efforts to help families apply for coverage. These efforts should be targeted to the populations least likely to be covered. The department shall provide informational materials for use by government entities and community-based organizations in their outreach activities, and should identify any available federal matching funds to support these efforts;
     (e) Development and dissemination of materials to engage and inform parents and families statewide on issues such as: The benefits of health insurance coverage; the appropriate use of health services, including primary care provided by health care practitioners licensed under chapters 18.71, 18.57, 18.36A, and 18.79 RCW, and emergency services; the value of a medical home, well-child services and immunization, and other preventive health services with linkages to department of health child profile efforts; identifying and managing chronic conditions such as asthma and diabetes; and the value of good nutrition and physical activity;
     (f) An evaluation of the outreach and education efforts, based upon clear outcome measures that are included in contracts with entities that undertake components of the outreach and education effort;
     (g) A feasibility study and implementation plan to develop online application capability that is integrated with the department's automated client eligibility system, and to develop data linkages with the office of superintendent of public instruction for free and reduced price lunch enrollment information and the department of early learning for child care subsidy program enrollment information. The department shall submit a feasibility study on the implementation of the requirements in this subsection to the governor and legislature by July 2008.
     (7) The department shall take action to increase the number of primary care physicians providing dental disease preventive services including oral health screenings, risk assessment, family education, the application of fluoride varnish, and referral to a dentist as needed.
     (8) The department shall monitor the rates of substitution between private-sector health care coverage and the coverage provided under this section and shall report to appropriate committees of the legislature by December 2010.

NEW SECTION.  Sec. 3   A new section is added to chapter 74.09 RCW to read as follows:
     (1) The legislature finds that parents have a responsibility to:
     (a) Enroll their children in affordable health coverage;
     (b) Ensure that their children receive appropriate well-child preventive care;
     (c) Link their child with a medical home; and
     (d) Understand and act upon the health benefits of good nutrition and physical activity.
     (2) The legislature intends that the programs and outreach and education efforts established in section 2(6) of this act, as well as partnerships with the public and private sectors, provide the support and information needed by parents to meet the responsibilities set forth in this section.

NEW SECTION.  Sec. 4   A new section is added to chapter 74.09 RCW to read as follows:
     (1) The department, in collaboration with the department of health, health carriers, local public health jurisdictions, children's health care providers including pediatricians, family practitioners, and pediatric subspecialists, parents, and other purchasers, shall identify explicit performance measures that indicate that a child has an established and effective medical home, such as:
     (a) Childhood immunization rates;
     (b) Well child care utilization rates, including the use of validated, structured developmental assessment tools that include behavioral and oral health screening;
     (c) Care management for children with chronic illnesses;
     (d) Emergency room utilization; and
     (e) Preventive oral health service utilization.
     Performance measures and targets for each performance measure must be reported to the appropriate committees of the senate and house of representatives by December 1, 2007.
     (2) Beginning in calendar year 2009, targeted provider rate increases shall be linked to quality improvement measures established under this section. The department, in conjunction with those groups identified in subsection (1) of this section, shall develop parameters for determining criteria for increased payment or other incentives for those practices and health plans that incorporate evidence-based practice and improve and achieve sustained improvement with respect to the measures in both fee for service and managed care.
     (3) The department shall provide an annual report to the governor and the legislature related to provider performance on these measures, beginning in September 2010 and annually thereafter.

NEW SECTION.  Sec. 5   A new section is added to chapter 28A.210 RCW to read as follows:
     It is the goal of Washington state to ensure that:
     (1) By 2010, all K-12 districts have school health advisory committees that advise school administration and school board members on policies, environmental changes, and programs needed to support healthy food choice and physical activity and childhood fitness. Districts shall include school nurses or other school personnel as advisory committee members.
     (2) By 2010, only healthy food and beverages provided by schools during school hours or for school-sponsored activities shall be available on school campuses. Minimum standards for available food and beverages, except food served as part of a United States department of agriculture meal program, are:
     (a) Not more than thirty-five percent of its total calories shall be from fat. This restriction does not apply to nuts, nut butters, seeds, eggs, fresh or dried fruits, vegetables that have not been deep-fried, legumes, reduced-fat cheese, part-skim cheese, nonfat dairy products, or low-fat dairy products;
     (b) Not more than ten percent of its total calories shall be from saturated fat. This restriction does not apply to eggs, reduced-fat cheese, part-skim cheese, nonfat dairy products, or low-fat dairy products;
     (c) Not more than thirty-five percent of its total weight or fifteen grams per food item shall be composed of sugar, including naturally occurring and added sugar. This restriction does not apply to the availability of fresh or dried fruits and vegetables that have not been deep-fried; and
     (d) The standards for food and beverages in this subsection do not apply to:
     (i) Low-fat and nonfat flavored milk with up to thirty grams of sugar per serving;
     (ii) Nonfat or low-fat rice or soy beverages; or
     (iii) One hundred percent fruit or vegetable juice.
     (3) By 2010, all students in grades one through eight should have at least one hundred fifty minutes of quality physical education every week.
     (4) By 2010, all student health and fitness instruction shall be conducted by appropriately certified instructors.
     (5) Beginning with the 2011-2012 school year, any district waiver or exemption policy from physical education requirements for high school students should be based upon meeting both health and fitness curricula concepts as well as alternative means of engaging in physical activity, but should acknowledge students' interest in pursuing their academic interests.

NEW SECTION.  Sec. 6   (1) There is hereby established a select interim legislative task force on comprehensive school health reform. The task force shall consist of two members of each caucus of the senate, and two members of each caucus of the house of representatives. The task force shall review and make recommendations on policies, environmental changes, and programs needed to support healthy schools, including but not limited to food choice, physical activity, and childhood fitness. The task force shall also review the delivery of health care services in the schools by school personnel providing health services. The task force may establish technical advisory committees related to nutrition, fitness, and child health.
     (2) The task force shall submit its findings and recommendations to the appropriate committees of the senate and house of representatives by October 1, 2008.

NEW SECTION.  Sec. 7   A new section is added to chapter 48.43 RCW to read as follows:
     When the department of social and health services has determined that it is cost-effective to enroll a child participating in a medical assistance program under chapter 74.09 RCW in an employer-sponsored health plan, the carrier shall permit the enrollment of the participant who is otherwise eligible for coverage in the health plan without regard to any open enrollment restrictions. The request for special enrollment shall be made by the department or participant within sixty days of the department's determination that the enrollment would be cost-effective.

NEW SECTION.  Sec. 8   The following acts or parts of acts are each repealed:
     (1) RCW 74.09.405 (Children's health program -- Purpose) and 1990 c 296 s 1;
     (2) RCW 74.09.415 (Children's health program established) and 2005 c 279 s 2, 2002 c 366 s 2, 1998 c 245 s 144, & 1990 c 296 s 2;
     (3) RCW 74.09.425 (Children's health care accessibility -- Community action) and 1990 c 296 s 4;
     (4) RCW 74.09.435 (Children's health program -- Biennial evaluation) and 1990 c 296 s 5; and
     (5) RCW 74.09.450 (Children's health insurance program -- Intent--Department duties) and 1999 c 370 s 1.