| Passed by the Senate April 21, 2007 YEAS 31 BRAD OWEN ________________________________________ President of the Senate Passed by the House April 20, 2007 YEAS 63 FRANK CHOPP ________________________________________ Speaker of the House of Representatives | I, Thomas Hoemann, Secretary of the Senate of the State of Washington, do hereby certify that the attached is ENGROSSED SECOND SUBSTITUTE SENATE BILL 5930 as passed by the Senate and the House of Representatives on the dates hereon set forth. THOMAS HOEMANN ________________________________________ Secretary | |
| Approved May 2, 2007, 10:36 a.m., with
the exception of sections 59 and 74
which are vetoed. CHRISTINE GREGOIRE ________________________________________ Governor of the State of Washington | May 3, 2007 Secretary of State State of Washington |
| State of Washington | 60th Legislature | 2007 Regular Session |
READ FIRST TIME 03/05/07.
AN ACT Relating to providing high quality, affordable health care to Washingtonians based on the recommendations of the blue ribbon commission on health care costs and access; amending RCW 7.70.060, 70.83.040, 43.70.110, 70.56.030, 48.41.110, 48.41.160, 48.41.200, 48.41.037, 48.41.100, 48.41.120, 48.43.005, 48.41.190, 41.05.075, 70.47.020, 70.47.060, 48.43.018, 43.70.670, 41.05.540, 70.38.015, 70.38.135, 70.47A.030, 43.70.520, and 70.48.130; reenacting and amending RCW 42.56.360; adding new sections to chapter 41.05 RCW; adding new sections to chapter 74.09 RCW; adding new sections to chapter 43.70 RCW; adding a new section to chapter 70.83 RCW; adding a new section to chapter 48.20 RCW; adding a new section to chapter 48.21 RCW; adding a new section to chapter 48.44 RCW; adding a new section to chapter 48.46 RCW; adding a new section to chapter 48.43 RCW; adding a new section to chapter 70.47A RCW; adding a new chapter to Title 70 RCW; adding a new chapter to Title 43 RCW; repealing RCW 70.38.919; repealing 2006 c 255 s 10 (uncodified); prescribing penalties; providing effective dates; providing expiration dates; and declaring an emergency.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF WASHINGTON:
NEW SECTION. Sec. 1 (1) The health care authority and the
department of social and health services shall, by September 1, 2007,
develop a five-year plan to change reimbursement within their health
care programs to:
(a) Reward quality health outcomes rather than simply paying for
the receipt of particular services or procedures;
(b) Pay for care that reflects patient preference and is of proven
value;
(c) Require the use of evidence-based standards of care where
available;
(d) Tie provider rate increases to measurable improvements in
access to quality care;
(e) Direct enrollees to quality care systems;
(f) Better support primary care and provide a medical home to all
enrollees through reimbursement policies that create incentives for
providers to enter and remain in primary care practice and that address
disparities in payment between specialty procedures and primary care
services; and
(g) Pay for e-mail consultations, telemedicine, and telehealth
where doing so reduces the overall cost of care.
(2) In developing any component of the plan that links payment to
health care provider performance, the authority and the department
shall work in collaboration with the department of health, health
carriers, local public health jurisdictions, physicians and other
health care providers, the Puget Sound health alliance, and other
purchasers.
(3) The plan shall (a) identify any existing barriers and
opportunities to support implementation, including needed changes to
state or federal law; (b) identify the goals the plan is intended to
achieve and how progress toward those goals will be measured; and (c)
be submitted to the governor and the legislature upon completion. The
agencies shall report to the legislature by September 1, 2007. Any
component of the plan that links payment to health care provider
performance must be submitted to the legislature for consideration
prior to implementation by the department or the authority.
NEW
SECTION. Sec. 2 A new section is added to chapter 41.05 RCW
to read as follows:
(1) The legislature finds that there is growing evidence that, for
preference-sensitive care involving elective surgery, patient-practitioner communication is improved through the use of high-quality
decision aids that detail the benefits, harms, and uncertainty of
available treatment options. Improved communication leads to more
fully informed patient decisions. The legislature intends to increase
the extent to which patients make genuinely informed, preference-based
treatment decisions, by promoting public/private collaborative efforts
to broaden the development, certification, use, and evaluation of
effective decision aids and by recognition of shared decision making
and patient decision aids in the state's laws on informed consent.
(2) The health care authority shall implement a shared
decision-making demonstration project. The demonstration project shall
be conducted at one or more multispecialty group practice sites
providing state purchased health care in the state of Washington, and
may include other practice sites providing state purchased health care.
The demonstration project shall include the following elements:
(a) Incorporation into clinical practice of one or more decision
aids for one or more identified preference-sensitive care areas
combined with ongoing training and support of involved practitioners
and practice teams, preferably at sites with necessary supportive
health information technology;
(b) An evaluation of the impact of the use of shared decision
making with decision aids, including the use of preference-sensitive
health care services selected for the demonstration project and
expenditures for those services, the impact on patients, including
patient understanding of the treatment options presented and
concordance between patient values and the care received, and patient
and practitioner satisfaction with the shared decision-making process;
and
(c) As a condition of participating in the demonstration project,
a participating practice site must bear the cost of selecting,
purchasing, and incorporating the chosen decision aids into clinical
practice.
(3) The health care authority may solicit and accept funding and
in-kind contributions to support the demonstration and evaluation, and
may scale the evaluation to fall within resulting resource parameters.
Sec. 3 RCW 7.70.060 and 1975-'76 2nd ex.s. c 56 s 11 are each
amended to read as follows:
(1) If a patient while legally competent, or his or her
representative if he or she is not competent, signs a consent form
which sets forth the following, the signed consent form shall
constitute prima facie evidence that the patient gave his or her
informed consent to the treatment administered and the patient has the
burden of rebutting this by a preponderance of the evidence:
(((1))) (a) A description, in language the patient could reasonably
be expected to understand, of:
(((a))) (i) The nature and character of the proposed treatment;
(((b))) (ii) The anticipated results of the proposed treatment;
(((c))) (iii) The recognized possible alternative forms of
treatment; and
(((d))) (iv) The recognized serious possible risks, complications,
and anticipated benefits involved in the treatment and in the
recognized possible alternative forms of treatment, including
nontreatment;
(((2))) (b) Or as an alternative, a statement that the patient
elects not to be informed of the elements set forth in (a) of this
subsection (((1) of this section)).
(2) If a patient while legally competent, or his or her
representative if he or she is not competent, signs an acknowledgement
of shared decision making as described in this section, such
acknowledgement shall constitute prima facie evidence that the patient
gave his or her informed consent to the treatment administered and the
patient has the burden of rebutting this by clear and convincing
evidence. An acknowledgement of shared decision making shall include:
(a) A statement that the patient, or his or her representative, and
the health care provider have engaged in shared decision making as an
alternative means of meeting the informed consent requirements set
forth by laws, accreditation standards, and other mandates;
(b) A brief description of the services that the patient and
provider jointly have agreed will be furnished;
(c) A brief description of the patient decision aid or aids that
have been used by the patient and provider to address the needs for (i)
high-quality, up-to-date information about the condition, including
risk and benefits of available options and, if appropriate, a
discussion of the limits of scientific knowledge about outcomes; (ii)
values clarification to help patients sort out their values and
preferences; and (iii) guidance or coaching in deliberation, designed
to improve the patient's involvement in the decision process;
(d) A statement that the patient or his or her representative
understands: The risk or seriousness of the disease or condition to be
prevented or treated; the available treatment alternatives, including
nontreatment; and the risks, benefits, and uncertainties of the
treatment alternatives, including nontreatment; and
(e) A statement certifying that the patient or his or her
representative has had the opportunity to ask the provider questions,
and to have any questions answered to the patient's satisfaction, and
indicating the patient's intent to receive the identified services.
(3) As used in this section, "shared decision making" means a
process in which the physician or other health care practitioner
discusses with the patient or his or her representative the information
specified in subsection (2) of this section with the use of a patient
decision aid and the patient shares with the provider such relevant
personal information as might make one treatment or side effect more or
less tolerable than others.
(4) As used in this section, "patient decision aid" means a
written, audio-visual, or online tool that provides a balanced
presentation of the condition and treatment options, benefits, and
harms, including, if appropriate, a discussion of the limits of
scientific knowledge about outcomes, and that is certified by one or
more national certifying organizations.
(5) Failure to use a form or to engage in shared decision making,
with or without the use of a patient decision aid, shall not be
admissible as evidence of failure to obtain informed consent. There
shall be no liability, civil or otherwise, resulting from a health care
provider choosing either the signed consent form set forth in
subsection (1)(a) of this section or the signed acknowledgement of
shared decision making as set forth in subsection (2) of this section.
NEW SECTION. Sec. 4 A new section is added to chapter 74.09 RCW
to read as follows:
(1) The department of social and health services, in collaboration
with the department of health, shall:
(a) Design and implement medical homes for its aged, blind, and
disabled clients in conjunction with chronic care management programs
to improve health outcomes, access, and cost-effectiveness. Programs
must be evidence based, facilitating the use of information technology
to improve quality of care, must acknowledge the role of primary care
providers and include financial and other supports to enable these
providers to effectively carry out their role in chronic care
management, and must improve coordination of primary, acute, and long-term care for those clients with multiple chronic conditions. The
department shall consider expansion of existing medical home and
chronic care management programs and build on the Washington state
collaborative initiative. The department shall use best practices in
identifying those clients best served under a chronic care management
model using predictive modeling through claims or other health risk
information; and
(b) Evaluate the effectiveness of current chronic care management
efforts in the health and recovery services administration and the
aging and disability services administration, comparison to best
practices, and recommendations for future efforts and organizational
structure to improve chronic care management.
(2) For purposes of this section:
(a) "Medical home" means a site of care that provides comprehensive
preventive and coordinated care centered on the patient needs and
assures high quality, accessible, and efficient care.
(b) "Chronic care management" means the department's program that
provides care management and coordination activities for medical
assistance clients determined to be at risk for high medical costs.
"Chronic care management" provides education and training and/or
coordination that assist program participants in improving self-management skills to improve health outcomes and reduce medical costs
by educating clients to better utilize services.
NEW SECTION. Sec.5 A new section is added to chapter 43.70 RCW
to read as follows:
(1) The department shall conduct a program of training and
technical assistance regarding care of people with chronic conditions
for providers of primary care. The program shall emphasize evidence-based high quality preventive and chronic disease care. The department
may designate one or more chronic conditions to be the subject of the
program.
(2) The training and technical assistance program shall include the
following elements:
(a) Clinical information systems and sharing and organization of
patient data;
(b) Decision support to promote evidence-based care;
(c) Clinical delivery system design;
(d) Support for patients managing their own conditions; and
(e) Identification and use of community resources that are
available in the community for patients and their families.
(3) In selecting primary care providers to participate in the
program, the department shall consider the number and type of patients
with chronic conditions the provider serves, and the provider's
participation in the medicaid program, the basic health plan, and
health plans offered through the public employees' benefits board.
NEW SECTION. Sec. 6 (1) The health care authority, in
collaboration with the department of health, shall design and implement
a chronic care management program for state employees enrolled in the
state's self-insured uniform medical plan. Programs must be evidence
based, facilitating the use of information technology to improve
quality of care and must improve coordination of primary, acute, and
long-term care for those enrollees with multiple chronic conditions.
The authority shall consider expansion of existing medical home and
chronic care management programs. The authority shall use best
practices in identifying those employees best served under a chronic
care management model using predictive modeling through claims or other
health risk information.
(2) For purposes of this section:
(a) "Medical home" means a site of care that provides comprehensive
preventive and coordinated care centered on the patient needs and
assures high-quality, accessible, and efficient care.
(b) "Chronic care management" means the authority's program that
provides care management and coordination activities for health plan
enrollees determined to be at risk for high medical costs. "Chronic
care management" provides education and training and/or coordination
that assist program participants in improving self-management skills to
improve health outcomes and reduce medical costs by educating clients
to better utilize services.
Sec. 7 RCW 70.83.040 and 2005 c 518 s 938 are each amended to
read as follows:
When notified of positive screening tests, the state department of
health shall offer the use of its services and facilities, designed to
prevent mental retardation or physical defects in such children, to the
attending physician, or the parents of the newborn child if no
attending physician can be identified.
The services and facilities of the department, and other state and
local agencies cooperating with the department in carrying out programs
of detection and prevention of mental retardation and physical defects
shall be made available to the family and physician to the extent
required in order to carry out the intent of this chapter and within
the availability of funds. ((The department has the authority to
collect a reasonable fee, from the parents or other responsible party
of each infant screened to fund specialty clinics that provide
treatment services for hemoglobin diseases, phenylketonuria, congenital
adrenal hyperplasia, congenital hypothyroidism, and, during the 2005-07
fiscal biennium, other disorders defined by the board of health under
RCW 70.83.020. The fee may be collected through the facility where the
screening specimen is obtained.))
NEW SECTION. Sec. 8 A new section is added to chapter 70.83 RCW
to read as follows:
The department has the authority to collect a fee of three dollars
and fifty cents from the parents or other responsible party of each
infant screened for congenital disorders as defined by the state board
of health under RCW 70.83.020 to fund specialty clinics that provide
treatment services for those with the defined disorders. The fee may
be collected through the facility where a screening specimen is
obtained.
NEW SECTION. Sec. 9 A new section is added to chapter 41.05 RCW
to read as follows:
The Washington state quality forum is established within the
authority. In collaboration with the Puget Sound health alliance and
other local organizations, the forum shall:
(1) Collect and disseminate research regarding health care quality,
evidence-based medicine, and patient safety to promote best practices,
in collaboration with the technology assessment program and the
prescription drug program;
(2) Coordinate the collection of health care quality data among
state health care purchasing agencies;
(3) Adopt a set of measures to evaluate and compare health care
cost and quality and provider performance;
(4) Identify and disseminate information regarding variations in
clinical practice patterns across the state; and
(5) Produce an annual quality report detailing clinical practice
patterns for purchasers, providers, insurers, and policy makers. The
agencies shall report to the legislature by September 1, 2007.
NEW SECTION. Sec. 10 A new section is added to chapter 41.05 RCW
to read as follows:
(1) The administrator shall design and pilot a consumer-centric
health information infrastructure and the first health record banks
that will facilitate the secure exchange of health information when and
where needed and shall:
(a) Complete the plan of initial implementation, including but not
limited to determining the technical infrastructure for health record
banks and the account locator service, setting criteria and standards
for health record banks, and determining oversight of health record
banks;
(b) Implement the first health record banks in pilot sites as
funding allows;
(c) Involve health care consumers in meaningful ways in the design,
implementation, oversight, and dissemination of information on the
health record bank system; and
(d) Promote adoption of electronic medical records and health
information exchange through continuation of the Washington health
information collaborative, and by working with private payors and other
organizations in restructuring reimbursement to provide incentives for
providers to adopt electronic medical records in their practices.
(2) The administrator may establish an advisory board, a
stakeholder committee, and subcommittees to assist in carrying out the
duties under this section. The administrator may reappoint health
information infrastructure advisory board members to assure continuity
and shall appoint any additional representatives that may be required
for their expertise and experience.
(a) The administrator shall appoint the chair of the advisory
board, chairs, and cochairs of the stakeholder committee, if formed;
(b) Meetings of the board, stakeholder committee, and any advisory
group are subject to chapter 42.30 RCW, the open public meetings act,
including RCW 42.30.110(1)(l), which authorizes an executive session
during a regular or special meeting to consider proprietary or
confidential nonpublished information; and
(c) The members of the board, stakeholder committee, and any
advisory group:
(i) Shall agree to the terms and conditions imposed by the
administrator regarding conflicts of interest as a condition of
appointment;
(ii) Are immune from civil liability for any official acts
performed in good faith as members of the board, stakeholder committee,
or any advisory group.
(3) Members of the board may be compensated for participation in
accordance with a personal services contract to be executed after
appointment and before commencement of activities related to the work
of the board. Members of the stakeholder committee shall not receive
compensation but shall be reimbursed under RCW 43.03.050 and 43.03.060.
(4) The administrator may work with public and private entities to
develop and encourage the use of personal health records which are
portable, interoperable, secure, and respectful of patients' privacy.
(5) The administrator may enter into contracts to issue,
distribute, and administer grants that are necessary or proper to carry
out this section.
Sec. 11 RCW 43.70.110 and 2006 c 72 s 3 are each amended to read
as follows:
(1) The secretary shall charge fees to the licensee for obtaining
a license. After June 30, 1995, municipal corporations providing
emergency medical care and transportation services pursuant to chapter
18.73 RCW shall be exempt from such fees, provided that such other
emergency services shall only be charged for their pro rata share of
the cost of licensure and inspection, if appropriate. The secretary
may waive the fees when, in the discretion of the secretary, the fees
would not be in the best interest of public health and safety, or when
the fees would be to the financial disadvantage of the state.
(2) Except as provided in ((RCW 18.79.202, until June 30, 2013, and
except for the cost of regulating retired volunteer medical workers in
accordance with RCW 18.130.360)) subsection (3) of this section, fees
charged shall be based on, but shall not exceed, the cost to the
department for the licensure of the activity or class of activities and
may include costs of necessary inspection.
(3) License fees shall include amounts in addition to the cost of
licensure activities in the following circumstances:
(a) For registered nurses and licensed practical nurses licensed
under chapter 18.79 RCW, support of a central nursing resource center
as provided in RCW 18.79.202, until June 30, 2013;
(b) For all health care providers licensed under RCW 18.130.040,
the cost of regulatory activities for retired volunteer medical worker
licensees as provided in RCW 18.130.360; and
(c) For physicians licensed under chapter 18.71 RCW, physician
assistants licensed under chapter 18.71A RCW, osteopathic physicians
licensed under chapter 18.57 RCW, osteopathic physicians' assistants
licensed under chapter 18.57A RCW, naturopaths licensed under chapter
18.36A RCW, podiatrists licensed under chapter 18.22 RCW, chiropractors
licensed under chapter 18.25 RCW, psychologists licensed under chapter
18.83 RCW, registered nurses licensed under chapter 18.79 RCW,
optometrists licensed under chapter 18.53 RCW, mental health counselors
licensed under chapter 18.225 RCW, massage therapists licensed under
chapter 18.108 RCW, clinical social workers licensed under chapter
18.225 RCW, and acupuncturists licensed under chapter 18.06 RCW, the
license fees shall include up to an additional twenty-five dollars to
be transferred by the department to the University of Washington for
the purposes of section 12 of this act.
(4) Department of health advisory committees may review fees
established by the secretary for licenses and comment upon the
appropriateness of the level of such fees.
NEW SECTION. Sec. 12 A new section is added to chapter 43.70 RCW
to read as follows:
Within the amounts transferred from the department of health under
RCW 43.70.110(3), the University of Washington shall, through the
health sciences library, provide online access to selected vital
clinical resources, medical journals, decision support tools, and
evidence-based reviews of procedures, drugs, and devices to the health
professionals listed in RCW 43.70.110(3)(c). Online access shall be
available no later than January 1, 2009.
Sec. 13 RCW 70.56.030 and 2006 c 8 s 107 are each amended to read
as follows:
(1) The department shall:
(a) Receive and investigate, where necessary, notifications and
reports of adverse events, including root cause analyses and corrective
action plans submitted as part of reports, and communicate to
individual facilities the department's conclusions, if any, regarding
an adverse event reported by a facility; ((and))
(b) Provide to the Washington state quality forum established in
section 9 of this act such information from the adverse health events
and incidents reports made under this chapter as the department and the
Washington state quality forum determine will assist in the Washington
state quality forum's research regarding health care quality, evidence-based medicine, and patient safety. Any shared information must be
aggregated and not identify an individual medical facility. As
determined by the department and the Washington state quality forum,
selected shared information may be disseminated on the Washington state
quality forum's web site and through other appropriate means; and
(c) Adopt rules as necessary to implement this chapter.
(2) The department may enforce the reporting requirements of RCW
70.56.020 using ((their)) its existing enforcement authority provided
in chapter 18.46 RCW for childbirth centers, chapter 70.41 RCW for
hospitals, and chapter 71.12 RCW for psychiatric hospitals.
NEW SECTION. Sec. 14 The Washington state health care authority
and the department of social and health services shall report to the
legislature by December 1, 2007, on recent trends in unnecessary
emergency room use by enrollees in state purchased health care programs
that they administer and the uninsured, and then partner with community
organizations and local health care providers to develop reimbursement
incentive strategies and design a demonstration pilot to reduce such
unnecessary visits.
NEW SECTION. Sec. 15 A new section is added to chapter 41.05 RCW
to read as follows:
To the extent that sufficient funding is provided specifically for
this purpose, the administrator, in collaboration with the department
of social and health services, shall provide all persons enrolled in
health plans under this chapter and chapter 70.47 RCW with access to a
twenty-four hour, seven day a week nurse hotline.
NEW SECTION. Sec. 16 A new section is added to chapter 74.09 RCW
to read as follows:
To the extent that sufficient funding is provided specifically for
this purpose, the department, in collaboration with the health care
authority, shall provide all persons receiving services under this
chapter with access to a twenty-four hour, seven day a week nurse
hotline. The health care authority and the department of social and
health services shall determine the most appropriate way to provide the
nurse hotline under section 15 of this act and this section, which may
include use of the 211 system established in chapter 43.211 RCW.
NEW SECTION. Sec. 17 By December 1, 2007, the insurance
commissioner shall provide a report to the governor and the legislature
that identifies the key contributors to health care administrative
costs and evaluates opportunities to reduce them, including suggested
changes to state law. The report shall be completed in collaboration
with health care providers, hospitals, carriers, state health
purchasing agencies, the Washington healthcare forum, and other
interested parties.
NEW SECTION. Sec. 18 A new section is added to chapter 41.05 RCW
to read as follows:
(1) Any plan offered to employees under this chapter must offer
each employee the option of covering any unmarried dependent of the
employee under the age of twenty-five.
(2) Any employee choosing under subsection (1) of this section to
cover a dependent who is: (a) Age twenty through twenty-three and not
a registered student at an accredited secondary school, college,
university, vocational school, or school of nursing; or (b) age twenty-four, shall be required to pay the full cost of such coverage.
(3) Any employee choosing under subsection (1) of this section to
cover a dependent with disabilities, developmental disabilities, mental
illness, or mental retardation, who is incapable of self-support, may
continue covering that dependent under the same premium and payment
structure as for dependents under the age of twenty, irrespective of
age.
NEW SECTION. Sec. 19 A new section is added to chapter 48.20 RCW
to read as follows:
Any disability insurance contract that provides coverage for a
subscriber's dependent must offer the option of covering any unmarried
dependent under the age of twenty-five.
NEW SECTION. Sec. 20 A new section is added to chapter 48.21 RCW
to read as follows:
Any group disability insurance contract or blanket disability
insurance contract that provides coverage for a participating member's
dependent must offer each participating member the option of covering
any unmarried dependent under the age of twenty-five.
NEW SECTION. Sec. 21 A new section is added to chapter 48.44 RCW
to read as follows:
(1) Any individual health care service plan contract that provides
coverage for a subscriber's dependent must offer the option of covering
any unmarried dependent under the age of twenty-five.
(2) Any group health care service plan contract that provides
coverage for a participating member's dependent must offer each
participating member the option of covering any unmarried dependent
under the age of twenty-five.
NEW SECTION. Sec. 22 A new section is added to chapter 48.46 RCW
to read as follows:
(1) Any individual health maintenance agreement that provides
coverage for a subscriber's dependent must offer the option of covering
any unmarried dependent under the age of twenty-five.
(2) Any group health maintenance agreement that provides coverage
for a participating member's dependent must offer each participating
member the option of covering any unmarried dependent under the age of
twenty-five.
NEW SECTION. Sec. 23 (1) The department of social and health
services shall develop a series of options that require federal waivers
and state plan amendments to expand coverage and leverage federal and
state resources for the state's basic health program, for the medical
assistance program, as codified at Title XIX of the federal social
security act, and the state's children's health insurance program, as
codified at Title XXI of the federal social security act. The
department shall propose options including but not limited to:
(a) Offering alternative benefit designs to promote high quality
care, improve health outcomes, and encourage cost-effective treatment
options and redirect savings to finance additional coverage;
(b) Creation of a health opportunity account demonstration program
for individuals eligible for transitional medical benefits. When a
participant in the health opportunity account demonstration program
satisfies his or her deductible, the benefits provided shall be those
included in the medicaid benefit package in effect during the period of
the demonstration program; and
(c) Promoting private health insurance plans and premium subsidies
to purchase employer-sponsored insurance wherever possible, including
federal approval to expand the department's employer-sponsored
insurance premium assistance program to enrollees covered through the
state's children's health insurance program.
(2) Prior to submitting requests for federal waivers or state plan
amendments, the department shall consult with and seek input from
stakeholders and other interested parties.
(3) The department of social and health services, in collaboration
with the Washington state health care authority, shall ensure that
enrollees are not simultaneously enrolled in the state's basic health
program and the medical assistance program or the state's children's
health insurance program to ensure coverage for the maximum number of
people within available funds.
NEW SECTION. Sec. 24 A new section is added to chapter 48.43 RCW
to read as follows:
When the department of social and health services determines that
it is cost-effective to enroll a person eligible for medical assistance
under chapter 74.09 RCW in an employer-sponsored health plan, a carrier
shall permit the enrollment of the person in the health plan for which
he or she is otherwise eligible without regard to any open enrollment
period restrictions.
NEW SECTION. Sec. 25 (1) The office of financial management, in
collaboration with the office of the insurance commissioner, shall
evaluate options and design a state-supported reinsurance program to
address the impact of high cost enrollees in the individual and small
group health insurance markets, and submit an interim report to the
governor and the legislature by December 1, 2007, and a final report,
including implementing legislation and supporting information,
including financing options, by September 1, 2008. In designing the
program, the office of financial management shall:
(a) Estimate the quantitative impact on premium savings, premium
stability over time and across groups of enrollees, individual and
employer take-up, number of uninsured, and government costs associated
with a government-funded stop-loss insurance program, including
distinguishing between one-time premium savings and savings in
subsequent years. In evaluating the various reinsurance models,
evaluate and consider (i) the reduction in total health care costs to
the state and private sector, and (ii) the reduction in individual
premiums paid by employers, employees, and individuals;
(b) Identify all relevant design issues and alternative options for
each issue. At a minimum, the evaluation shall examine (i) a
reinsurance corridor of ten thousand dollars to ninety thousand
dollars, and a reimbursement of ninety percent; (ii) the impacts of
providing reinsurance for all small group products or a subset of
products; and (iii) the applicability of a chronic care program such as
the approach used by the department of labor and industries with the
centers of occupational health and education. Where quantitative
impacts cannot be estimated, the office of financial management shall
assess qualitative impacts of design issues and their options,
including potential disincentives for reducing premiums, achieving
premium stability, sustaining/increasing take-up, decreasing the number
of uninsured, and managing government's stop-loss insurance costs;
(c) Identify market and regulatory changes needed to maximize the
chance of the program achieving its policy goals, including how the
program will relate to other coverage programs and markets. Design
efforts shall coordinate with other design efforts targeting small
group programs that may be directed by the legislature, as well as
other approaches examining alternatives to managing risk;
(d) Address conditions under which overall expenditures could
increase as a result of a government-funded stop-loss program and
options to mitigate those conditions, such as passive versus aggressive
use of disease and care management programs by insurers;
(e) Determine whether the Washington state health insurance pool
should be retained, and if so, develop options for additional sources
of funding;
(f) Evaluate, and quantify where possible, the behavioral responses
of insurers to the program including impacts on insurer premiums and
practices for settling legal disputes around large claims; and
(g) Provide alternatives for transitioning from the status quo and,
where applicable, alternatives for phasing in some design elements,
such as threshold or corridor levels, to balance government costs and
premium savings.
(2) Within funds specifically appropriated for this purpose, the
office of financial management may contract with actuaries and other
experts as necessary to meet the requirements of this section.
Sec. 26 RCW 48.41.110 and 2001 c 196 s 4 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)) policies 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)) policies 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 covered 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)) a pool policy. ((Such benefits
shall at minimum include, but not be limited to, the following services
or related items:))
(4) The pool shall offer at least two policies, one of which will
be a comprehensive policy that must comply with RCW 48.41.120 and must
at a minimum include 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)) including no less than a total
of one hundred eighty inpatient days in a calendar year, and ((limited
to)) no less than 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)) No less than 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)) less 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)) including at least 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))) (5) 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))) (6) 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))) (7) 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))) (8) of this section.
(((7))) (8)(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. 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))) (9) 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.
(10) The pool shall contract with organizations that provide care
management that has been demonstrated to be effective and shall
encourage enrollees who are eligible for care management services to
participate. The pool may encourage the use of shared decision making
and certified decision aids for preference-sensitive care areas.
Sec. 27 RCW 48.41.160 and 1987 c 431 s 16 are each amended to
read as follows:
(1) ((A pool policy offered under this chapter shall contain
provisions under which the pool is obligated to renew the policy until
the day on which the individual in whose name the policy is issued
first becomes eligible for medicare coverage. At that time, coverage
of dependents shall terminate if such dependents are eligible for
coverage under a different health plan. Dependents who become eligible
for medicare prior to the individual in whose name the policy is
issued, shall receive benefits in accordance with RCW 48.41.150)) On or
before December 31, 2007, the pool shall cancel all existing pool
policies and replace them with policies that are identical to the
existing policies except for the inclusion of a provision providing for
a guarantee of the continuity of coverage consistent with this section.
As a means to minimize the number of policy changes for enrollees,
replacement policies provided under this subsection also may include
the plan modifications authorized in RCW 48.41.100, 48.41.110, and
48.41.120.
(2) A pool policy shall contain a guarantee of the individual's
right to continued coverage, subject to the provisions of subsections
(4) and (5) of this section.
(3) The guarantee of continuity of coverage required by this
section shall not prevent the pool from canceling or nonrenewing a
policy for:
(a) Nonpayment of premium;
(b) Violation of published policies of the pool;
(c) Failure of a covered person who becomes eligible for medicare
benefits by reason of age to apply for a pool medical supplement plan,
or a medicare supplement plan or other similar plan offered by a
carrier pursuant to federal laws and regulations;
(d) Failure of a covered person to pay any deductible or copayment
amount owed to the pool and not the provider of health care services;
(e) Covered persons committing fraudulent acts as to the pool;
(f) Covered persons materially breaching the pool policy; or
(g) Changes adopted to federal or state laws when such changes no
longer permit the continued offering of such coverage.
(4)(a) The guarantee of continuity of coverage provided by this
section requires that if the pool replaces a plan, it must make the
replacement plan available to all individuals in the plan being
replaced. The replacement plan must include all of the services
covered under the replaced plan, and must not significantly limit
access to the kind of services covered under the replacement plan
through unreasonable cost-sharing requirements or otherwise. The pool
may also allow individuals who are covered by a plan that is being
replaced an unrestricted right to transfer to a fully comparable plan.
(b) The guarantee of continuity of coverage provided by this
section requires that if the pool discontinues offering a plan: (i)
The pool must provide notice to each individual of the discontinuation
at least ninety days prior to the date of the discontinuation; (ii) the
pool must offer to each individual provided coverage under the
discontinued plan the option to enroll in any other plan currently
offered by the pool for which the individual is otherwise eligible; and
(iii) in exercising the option to discontinue a plan and in offering
the option of coverage under (b)(ii) of this subsection, the pool must
act uniformly without regard to any health status-related factor of
enrolled individuals or individuals who may become eligible for this
coverage.
(c) The pool cannot replace or discontinue a plan under this
subsection (4) until it has completed an evaluation of the impact of
replacing the plan upon:
(i) The cost and quality of care to pool enrollees;
(ii) Pool financing and enrollment;
(iii) The board's ability to offer comprehensive and other plans to
its enrollees;
(iv) Other items identified by the board.
In its evaluation, the board must request input from the
constituents represented by the board members.
(d) The guarantee of continuity of coverage provided by this
section does not apply if the pool has zero enrollment in a plan.
(5) The pool may not change the rates for pool policies except on
a class basis, with a clear disclosure in the policy of the pool's
right to do so.
(((3))) (6) A pool policy offered under this chapter shall provide
that, upon the death of the individual in whose name the policy is
issued, every other individual then covered under the policy may elect,
within a period specified in the policy, to continue coverage under the
same or a different policy.
Sec. 28 RCW 48.41.200 and 2000 c 79 s 17 are each amended to read
as follows:
(1) The pool shall determine the standard risk rate by calculating
the average individual standard rate charged for coverage comparable to
pool coverage by the five largest members, measured in terms of
individual market enrollment, offering such coverages in the state. In
the event five members do not offer comparable coverage, the standard
risk rate shall be established using reasonable actuarial techniques
and shall reflect anticipated experience and expenses for such coverage
in the individual market.
(2) Subject to subsection (3) of this section, maximum rates for
pool coverage shall be as follows:
(a) Maximum rates for a pool indemnity health plan shall be one
hundred fifty percent of the rate calculated under subsection (1) of
this section;
(b) Maximum rates for a pool care management plan shall be one
hundred twenty-five percent of the rate calculated under subsection (1)
of this section; and
(c) Maximum rates for a person eligible for pool coverage pursuant
to RCW 48.41.100(1)(a) who was enrolled at any time during the sixty-three day period immediately prior to the date of application for pool
coverage in a group health benefit plan or an individual health benefit
plan other than a catastrophic health plan as defined in RCW 48.43.005,
where such coverage was continuous for at least eighteen months, shall
be:
(i) For a pool indemnity health plan, one hundred twenty-five
percent of the rate calculated under subsection (1) of this section;
and
(ii) For a pool care management plan, one hundred ten percent of
the rate calculated under subsection (1) of this section.
(3)(a) Subject to (b) and (c) of this subsection:
(i) The rate for any person ((aged fifty to sixty-four)) whose
current gross family income is less than two hundred fifty-one percent
of the federal poverty level shall be reduced by thirty percent from
what it would otherwise be;
(ii) The rate for any person ((aged fifty to sixty-four)) whose
current gross family income is more than two hundred fifty but less
than three hundred one percent of the federal poverty level shall be
reduced by fifteen percent from what it would otherwise be;
(iii) The rate for any person who has been enrolled in the pool for
more than thirty-six months shall be reduced by five percent from what
it would otherwise be.
(b) In no event shall the rate for any person be less than one
hundred ten percent of the rate calculated under subsection (1) of this
section.
(c) Rate reductions under (a)(i) and (ii) of this subsection shall
be available only to the extent that funds are specifically
appropriated for this purpose in the omnibus appropriations act.
Sec. 29 RCW 48.41.037 and 2000 c 79 s 36 are each amended to read
as follows:
The Washington state health insurance pool account is created in
the custody of the state treasurer. All receipts from moneys
specifically appropriated to the account must be deposited in the
account. Expenditures from this account shall be used to cover
deficits incurred by the Washington state health insurance pool under
this chapter in excess of the threshold established in this section.
To the extent funds are available in the account, funds shall be
expended from the account to offset that portion of the deficit that
would otherwise have to be recovered by imposing an assessment on
members in excess of a threshold of seventy cents per insured person
per month. The commissioner shall authorize expenditures from the
account, to the extent that funds are available in the account, upon
certification by the pool board that assessments will exceed the
threshold level established in this section. The account is subject to
the allotment procedures under chapter 43.88 RCW, but an appropriation
is not required for expenditures.
Whether the assessment has reached the threshold of seventy cents
per insured person per month shall be determined by dividing the total
aggregate amount of assessment by the proportion of total assessed
members. Thus, stop loss members shall be counted as one-tenth of a
whole member in the denominator given that is the amount they are
assessed proportionately relative to a fully insured medical member.
Sec. 30 RCW 48.41.100 and 2001 c 196 s 3 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 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)) two
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.
(4) The board shall ensure that an independent analysis of the
eligibility standards for the pool coverage is conducted, including
examining the eight percent eligibility threshold, eligibility for
medicaid enrollees and other publicly sponsored enrollees, and the
impacts on the pool and the state budget. The board shall report the
findings to the legislature by December 1, 2007.
Sec. 31 RCW 48.41.120 and 2000 c 79 s 14 are each amended to read
as follows:
(1) Subject to the limitation provided in subsection (3) of this
section, ((a)) the comprehensive pool policy offered ((in accordance
with)) under RCW 48.41.110(((3))) (4) shall impose a deductible as
provided in this subsection. Deductibles of five hundred dollars and
one thousand dollars on a per person per calendar year basis shall
initially be offered. The board may authorize deductibles in other
amounts. The deductible shall be applied to the first five hundred
dollars, one thousand dollars, or other authorized amount of eligible
expenses incurred by the covered person.
(2) Subject to the limitations provided in subsection (3) of this
section, a mandatory coinsurance requirement shall be imposed at
((the)) a rate ((of)) not to exceed twenty percent of eligible expenses
in excess of the mandatory deductible and which supports the efficient
delivery of high quality health care services for the medical
conditions of pool enrollees.
(3) The maximum aggregate out of pocket payments for eligible
expenses by the insured in the form of deductibles and coinsurance
under ((a)) the comprehensive pool policy offered ((in accordance
with)) under RCW 48.41.110(((3))) (4) shall not exceed in a calendar
year:
(a) One thousand five hundred dollars per individual, or three
thousand dollars per family, per calendar year for the five hundred
dollar deductible policy;
(b) Two thousand five hundred dollars per individual, or five
thousand dollars per family per calendar year for the one thousand
dollar deductible policy; or
(c) An amount authorized by the board for any other deductible
policy.
(4) Except for those enrolled in a high deductible health plan
qualified under federal law for use with a health savings account,
eligible expenses incurred by a covered person in the last three months
of a calendar year, and applied toward a deductible, shall also be
applied toward the deductible amount in the next calendar year.
(5) The board may modify cost-sharing as an incentive for enrollees
to participate in care management services and other cost-effective
programs and policies.
Sec. 32 RCW 48.43.005 and 2006 c 25 s 16 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)(e).
(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.
(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)) seven hundred fifty
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 five hundred dollars, both amounts to be adjusted
annually by the insurance commissioner; 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 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 ((five)) six
thousand ((five hundred)) dollars, both amounts to be adjusted annually
by the insurance commissioner; 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.
In July, 2008, and in each July thereafter, the insurance
commissioner shall adjust the minimum deductible and out-of-pocket
expense required for a plan to qualify as a catastrophic plan to
reflect the percentage change in the consumer price index for medical
care for a preceding twelve months, as determined by the United States
department of labor. The adjusted amount shall apply on the following
January 1st.
(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.
(7) "Concurrent review" means utilization review conducted during
a patient's hospital stay or course of treatment.
(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.
(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.
(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.
(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.
(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.
(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.
(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.
(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.
(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.
(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.
(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.
(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) Coverage supplemental to the coverage provided under chapter
55, Title 10, United States Code;
(d) Limited health care services offered by limited health care
service contractors in accordance with RCW 48.44.035;
(e) Disability income;
(f) Coverage incidental to a property/casualty liability insurance
policy such as automobile personal injury protection coverage and
homeowner guest medical;
(g) Workers' compensation coverage;
(h) Accident only coverage;
(i) Specified disease and hospital confinement indemnity when
marketed solely as a supplement to a health plan;
(j) Employer-sponsored self-funded health plans;
(k) Dental only and vision only coverage; and
(l) 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.
(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.
(21) "Preexisting condition" means any medical condition, illness,
or injury that existed any time prior to the effective date of
coverage.
(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.
(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.
(24) "Small employer" or "small group" means any person, firm,
corporation, partnership, association, political subdivision, sole
proprietor, 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 at least two but 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. A self-employed individual
or sole proprietor must derive 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 except for a self-employed individual or sole proprietor in an agricultural trade or
business, who must derive at least fifty-one percent of his or her
income from the 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, for the
previous taxable year. A self-employed individual or sole proprietor
who is covered as a group of one on the day prior to June 10, 2004,
shall also be considered a "small employer" to the extent that
individual or group of one is entitled to have his or her coverage
renewed as provided in RCW 48.43.035(6).
(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.
(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. 33 RCW 48.41.190 and 1989 c 121 s 10 are each amended to
read as follows:
((Neither the participation by members, the establishment of rates,
forms, or procedures for coverages issued by the pool, nor any other
joint or collective action required by this chapter or the state of
Washington shall be the basis of any legal action, civil or criminal
liability or penalty against the pool, any member of the board of
directors, or members of the pool either jointly or separately.)) The
pool, members of the pool, board directors of the pool, officers of the
pool, employees of the pool, the commissioner, the commissioner's
representatives, and the commissioner's employees shall not be civilly
or criminally liable and shall not have any penalty or cause of action
of any nature arise against them for any action taken or not taken,
including any discretionary decision or failure to make a discretionary
decision, when the action or inaction is done in good faith and in the
performance of the powers and duties under this chapter. Nothing in
this section prohibits legal actions against the pool to enforce the
pool's statutory or contractual duties or obligations.
Sec. 34 RCW 41.05.075 and 2006 c 103 s 3 are each amended to read
as follows:
(1) The administrator shall provide benefit plans designed by the
board through a contract or contracts with insuring entities, through
self-funding, self-insurance, or other methods of providing insurance
coverage authorized by RCW 41.05.140.
(2) The administrator shall establish a contract bidding process
that:
(a) Encourages competition among insuring entities;
(b) Maintains an equitable relationship between premiums charged
for similar benefits and between risk pools including premiums charged
for retired state and school district employees under the separate risk
pools established by RCW 41.05.022 and 41.05.080 such that insuring
entities may not avoid risk when establishing the premium rates for
retirees eligible for medicare;
(c) Is timely to the state budgetary process; and
(d) Sets conditions for awarding contracts to any insuring entity.
(3) The administrator shall establish a requirement for review of
utilization and financial data from participating insuring entities on
a quarterly basis.
(4) The administrator shall centralize the enrollment files for all
employee and retired or disabled school employee health plans offered
under chapter 41.05 RCW and develop enrollment demographics on a plan-specific basis.
(5) All claims data shall be the property of the state. The
administrator may require of any insuring entity that submits a bid to
contract for coverage all information deemed necessary including:
(a) Subscriber or member demographic and claims data necessary for
risk assessment and adjustment calculations in order to fulfill the
administrator's duties as set forth in this chapter; and
(b) Subscriber or member demographic and claims data necessary to
implement performance measures or financial incentives related to
performance under subsection (7) of this section.
(6) All contracts with insuring entities for the provision of
health care benefits shall provide that the beneficiaries of such
benefit plans may use on an equal participation basis the services of
practitioners licensed pursuant to chapters 18.22, 18.25, 18.32, 18.53,
18.57, 18.71, 18.74, 18.83, and 18.79 RCW, as it applies to registered
nurses and advanced registered nurse practitioners. However, nothing
in this subsection may preclude the administrator from establishing
appropriate utilization controls approved pursuant to RCW 41.05.065(2)
(a), (b), and (d).
(7) The administrator shall, in collaboration with other state
agencies that administer state purchased health care programs, private
health care purchasers, health care facilities, providers, and
carriers:
(a) Use evidence-based medicine principles to develop common
performance measures and implement financial incentives in contracts
with insuring entities, health care facilities, and providers that:
(i) Reward improvements in health outcomes for individuals with
chronic diseases, increased utilization of appropriate preventive
health services, and reductions in medical errors; and
(ii) Increase, through appropriate incentives to insuring entities,
health care facilities, and providers, the adoption and use of
information technology that contributes to improved health outcomes,
better coordination of care, and decreased medical errors;
(b) Through state health purchasing, reimbursement, or pilot
strategies, promote and increase the adoption of health information
technology systems, including electronic medical records, by hospitals
as defined in RCW 70.41.020(4), integrated delivery systems, and
providers that:
(i) Facilitate diagnosis or treatment;
(ii) Reduce unnecessary duplication of medical tests;
(iii) Promote efficient electronic physician order entry;
(iv) Increase access to health information for consumers and their
providers; and
(v) Improve health outcomes;
(c) Coordinate a strategy for the adoption of health information
technology systems using the final health information technology report
and recommendations developed under chapter 261, Laws of 2005.
(8) The administrator may permit the Washington state health
insurance pool to contract to utilize any network maintained by the
authority or any network under contract with the authority.
Sec. 35 RCW 70.47.020 and 2005 c 188 s 2 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) "Health coverage tax credit program" means the program created
by the Trade Act of 2002 (P.L. 107-210) that provides a federal tax
credit that subsidizes private health insurance coverage for displaced
workers certified to receive certain trade adjustment assistance
benefits and for individuals receiving benefits from the pension
benefit guaranty corporation.
(4) "Health coverage tax credit eligible enrollee" means individual
workers and their qualified family members who lose their jobs due to
the effects of international trade and are eligible for certain trade
adjustment assistance benefits; or are eligible for benefits under the
alternative trade adjustment assistance program; or are people who
receive benefits from the pension benefit guaranty corporation and are
at least fifty-five years old.
(5) "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).
(6) "Subsidized enrollee" means:
(a) An individual, or an individual plus the individual's spouse or
dependent children:
(((a))) (i) Who is not eligible for medicare;
(((b))) (ii) Who is not confined or residing in a government-operated institution, unless he or she meets eligibility criteria
adopted by the administrator;
(((c))) (iii) Who is not a full-time student who has received a
temporary visa to study in the United States;
(((d))) (iv) Who resides in an area of the state served by a
managed health care system participating in the plan;
(((e))) (v) 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
(((f))) (vi) Who chooses to obtain basic health care coverage from
a particular managed health care system in return for periodic payments
to the plan((.));
(b) An individual who meets the requirements in (a)(i) through (iv)
and (vi) of this subsection and who is a foster parent licensed under
chapter 74.15 RCW and whose gross family income at the time of
enrollment does not exceed three 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
(c) 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)(i) through
(((d))) (iv) and (((f))) (vi) 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.
(7) "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 is accepted for
enrollment by the administrator as provided in RCW 48.43.018, either
because the potential enrollee cannot be required to complete the
standard health questionnaire under RCW 48.43.018, or, based upon the
results of the standard health questionnaire, the potential enrollee
would not qualify for coverage under the Washington state health
insurance pool; (d) who resides in an area of the state served by a
managed health care system participating in the plan; (((d))) (e) who
chooses to obtain basic health care coverage from a particular managed
health care system; and (((e))) (f) who pays or on whose behalf is paid
the full costs for participation in the plan, without any subsidy from
the plan.
(8) "Subsidy" means the difference between the amount of periodic
payment the administrator makes to a managed health care system 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).
(9) "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, a nonsubsidized enrollee, or a health
coverage tax credit eligible enrollee.
(10) "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, nonsubsidized, and health coverage
tax credit eligible enrollees in the plan and in that system.
Sec. 36 RCW 70.47.060 and 2006 c 343 s 9 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 (11) 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 (12) of this section.
(b) To determine the periodic premiums due the administrator from
subsidized enrollees under RCW 70.47.020(6)(b). Premiums due for
foster parents with gross family income up to two hundred percent of
the federal poverty level shall be set at the minimum premium amount
charged to enrollees with income below sixty-five percent of the
federal poverty level. Premiums due for foster parents with gross
family income between two hundred percent and three hundred percent of
the federal poverty level shall not exceed one hundred dollars per
month.
(c) 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))) (d) To determine the periodic premiums due the
administrator from health coverage tax credit eligible enrollees.
Premiums due from health coverage tax credit eligible enrollees must 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. The administrator will consider the impact of eligibility
determination by the appropriate federal agency designated by the Trade
Act of 2002 (P.L. 107-210) as well as the premium collection and
remittance activities by the United States internal revenue service
when determining the administrative cost charged for health coverage
tax credit eligible enrollees.
(((d))) (e) 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. The administrator shall establish a mechanism for
receiving premium payments from the United States internal revenue
service for health coverage tax credit eligible enrollees.
(((e))) (f) 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 evaluate, with the cooperation of participating managed
health care system providers, the impact on the basic health plan of
enrolling health coverage tax credit eligible enrollees. The
administrator shall issue to the appropriate committees of the
legislature preliminary evaluations on June 1, 2005, and January 1,
2006, and a final evaluation by June 1, 2006. The evaluation shall
address the number of persons enrolled, the duration of their
enrollment, their utilization of covered services relative to other
basic health plan enrollees, and the extent to which their enrollment
contributed to any change in the cost of the basic health plan.
(4) To end the participation of health coverage tax credit eligible
enrollees in the basic health plan if the federal government reduces or
terminates premium payments on their behalf through the United States
internal revenue service.
(5) To design and implement a structure of enrollee cost-sharing
due a managed health care system from subsidized, nonsubsidized, and
health coverage tax credit eligible 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.
(6) 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. Such a closure does
not apply to health coverage tax credit eligible enrollees who receive
a premium subsidy from the United States internal revenue service as
long as the enrollees qualify for the health coverage tax credit
program.
(7) 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.
(8) 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.
(9) 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 subsidized enrollees,
nonsubsidized enrollees, or health coverage tax credit eligible
enrollees. 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.
(10) To receive periodic premiums from or on behalf of subsidized,
nonsubsidized, and health coverage tax credit eligible 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.
(11) 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, nonsubsidized, or health coverage tax credit eligible
enrollees, to give priority to members of the Washington national guard
and reserves who served in Operation Enduring Freedom, Operation Iraqi
Freedom, or Operation Noble Eagle, and their spouses and dependents,
for enrollment in the Washington basic health plan, 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.
(12) 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.
(13) 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.
(14) 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.
(15) 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.
(16) To develop a program of proven preventive health measures and
to integrate it into the plan wherever possible and consistent with
this chapter.
(17) To provide, consistent with available funding, assistance for
rural residents, underserved populations, and persons of color.
(18) In consultation with appropriate state and local government
agencies, to establish criteria defining eligibility for persons
confined or residing in government-operated institutions.
(19) 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.
(20) To give priority in enrollment to persons who disenrolled from
the program in order to enroll in medicaid, and subsequently became
ineligible for medicaid coverage.
Sec. 37 RCW 48.43.018 and 2004 c 244 s 3 are each amended to read
as follows:
(1) Except as provided in (a) through (e) of this subsection, a
health carrier may require any person applying for an individual health
benefit plan and the health care authority shall require any person
applying for nonsubsidized enrollment in the basic health plan to
complete the standard health questionnaire designated under chapter
48.41 RCW.
(a) If a person is seeking an individual health benefit plan or
enrollment in the basic health plan as a nonsubsidized enrollee 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 or
enrollment in the basic health plan as a nonsubsidized enrollee:
(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
or a basic health plan managed care system's provider network; and
(iii) Application for a health benefit plan under that carrier's
provider network individual coverage or for basic health plan
nonsubsidized enrollment 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 or
enrollment in the basic health plan as a nonsubsidized enrollee 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 or the health care authority as
administrator of basic health plan nonsubsidized coverage 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.
(d) If a person is seeking an individual health benefit plan or
enrollment in the basic health plan as a nonsubsidized enrollee due to
his or her receiving notice that his or her coverage under a conversion
contract is discontinued, completion of the standard health
questionnaire shall not be a condition of coverage if application for
coverage is made within ninety days of discontinuation of eligibility
under the conversion contract. A health carrier or the health care
authority as administrator of basic health plan nonsubsidized coverage
shall accept an application without a standard health questionnaire
from a person currently covered by such conversion contract if
application is made within ninety days prior to the date eligibility
under the conversion contract would be discontinued and the effective
date of the individual coverage applied for is the date eligibility
under the conversion contract would be discontinued, or within ninety
days thereafter.
(e) If a person is seeking an individual health benefit plan ((and,
but for the number of persons employed by his or her employer, would
have qualified for)) or enrollment in the basic health plan as a
nonsubsidized enrollee following disenrollment from a health plan that
is exempt from 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: (i) ((Application for coverage is made
within ninety days of a qualifying event as defined in 29 U.S.C. Sec.
1163; and (ii))) The person had at least twenty-four months of
continuous group coverage including church plans immediately prior to
((the qualifying event. A health carrier shall accept an application
without a standard health questionnaire from a person with at least
twenty-four months of continuous group coverage if)) disenrollment;
(ii) application is made no more than ninety days prior to the date of
((a qualifying event)) disenrollment; and (iii) the effective date of
the individual coverage applied for is the date of ((the qualifying
event)) disenrollment, or within ninety days thereafter.
(f) If a person is seeking an individual health benefit plan,
completion of the standard health questionnaire shall not be a
condition of coverage if: (i) The person had at least twenty-four
months of continuous basic health plan coverage under chapter 70.47 RCW
immediately prior to disenrollment; and (ii) application for coverage
is made within ninety days of disenrollment from the basic health plan.
A health carrier shall accept an application without a standard health
questionnaire from a person with at least twenty-four months of
continuous basic health plan coverage if application is made no more
than ninety days prior to the date of disenrollment and the effective
date of the individual coverage applied for is the date of
disenrollment, 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 the health
care authority, as administrator of basic health plan nonsubsidized
coverage, shall not accept the person's application for enrollment as
a nonsubsidized enrollee; and
(b) Within fifteen business days of receipt of a completed
application, the carrier or the health care authority as administrator
of basic health plan nonsubsidized coverage 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 or the health care authority as administrator
of basic health plan nonsubsidized coverage 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 or the health care authority as
administrator of basic health plan nonsubsidized coverage, whichever
entity administered the standard health questionnaire, shall accept the
person for enrollment if he or she resides within the carrier's or the
basic health plan'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. 38 RCW 43.70.670 and 2003 c 274 s 2 are each amended to read
as follows:
(1) "Human immunodeficiency virus insurance program," as used in
this section, means a program that provides health insurance coverage
for individuals with human immunodeficiency virus, as defined in RCW
70.24.017(7), who are not eligible for medical assistance programs from
the department of social and health services as defined in RCW
74.09.010(8) and meet eligibility requirements established by the
department of health.
(2) The department of health may pay for health insurance coverage
on behalf of persons with human immunodeficiency virus, who meet
department eligibility requirements, and who are eligible for
"continuation coverage" as provided by the federal consolidated omnibus
budget reconciliation act of 1985, group health insurance policies, or
individual policies. ((The number of insurance policies supported by
this program in the Washington state health insurance pool as defined
in RCW 48.41.030(18) shall not grow beyond the July 1, 2003, level.))
NEW SECTION. Sec. 39 (1) The Washington state health care
authority, the department of social and health services, the department
of labor and industries, and the department of health shall, by
September 1, 2007, develop a five-year plan to integrate disease and
accident prevention and health promotion into state purchased health
programs that they administer by:
(a) Structuring benefits and reimbursements to promote healthy
choices and disease and accident prevention;
(b) Encouraging enrollees in state health programs to complete a
health assessment, and providing appropriate follow up;
(c) Reimbursing for cost-effective prevention activities; and
(d) Developing prevention and health promotion contracting
standards for state programs that contract with health carriers.
(2) The plan shall: (a) Identify any existing barriers and
opportunities to support implementation, including needed changes to
state or federal law; (b) identify the goals the plan is intended to
achieve and how progress towards those goals will be measured and
reported; and (c) be submitted to the governor and the legislature upon
completion.
Sec. 40 RCW 41.05.540 and 2005 c 360 s 8 are each amended to read
as follows:
(1) The health care authority, in coordination with ((the
department of personnel,)) the department of health, health plans
participating in public employees' benefits board programs, and the
University of Washington's center for health promotion, ((may create a
worksite health promotion program to develop and implement initiatives
designed to increase physical activity and promote improved self-care
and engagement in health care decision-making among state employees.))
shall establish and maintain a state employee health program focused on
reducing the health risks and improving the health status of state
employees, dependents, and retirees enrolled in the public employees'
benefits board. The program shall use public and private sector best
practices to achieve goals of measurable health outcomes, measurable
productivity improvements, positive impact on the cost of medical care,
and positive return on investment. The program shall establish
standards for health promotion and disease prevention activities, and
develop a mechanism to update standards as evidence-based research
brings new information and best practices forward.
(2) The health care authority shall report to the governor and the
legislature by December 1, 2006, on progress in implementing, and
evaluating the results of, the worksite health promotion program
(2) The state employee health program shall:
(a) Provide technical assistance and other services as needed to
wellness staff in all state agencies and institutions of higher
education;
(b) Develop effective communication tools and ongoing training for
wellness staff;
(c) Contract with outside vendors for evaluation of program goals;
(d) Strongly encourage the widespread completion of online health
assessment tools for all state employees, dependents, and retirees.
The health assessment tool must be voluntary and confidential. Health
assessment data and claims data shall be used to:
(i) Engage state agencies and institutions of higher education in
providing evidence-based programs targeted at reducing identified
health risks;
(ii) Guide contracting with third-party vendors to implement
behavior change tools for targeted high-risk populations; and
(iii) Guide the benefit structure for state employees, dependents,
and retirees to include covered services and medications known to
manage and reduce health risks.
(3) The health care authority shall report to the legislature in
December 2008 and December 2010 on outcome goals for the employee
health program.
NEW SECTION. Sec. 41 A new section is added
to chapter 41.05 RCW
to read as follows:
(1) The health care authority through the state employee health
program shall implement a state employee health demonstration project.
The agencies selected must: (a) Show a high rate of health risk
assessment completion; (b) document an infrastructure capable of
implementing employee health programs using current and emerging best
practices; (c) show evidence of senior management support; and (d)
together employ a total of no more than eight thousand employees who
are enrolled in health plans of the public employees' benefits board.
Demonstration project agencies shall operate employee health programs
for their employees in collaboration with the state employee health
program.
(2) Agency demonstration project employee health programs:
(a) Shall include but are not limited to the following key
elements: Outreach to all staff with efforts made to reach the largest
percentage of employees possible; awareness-building information that
promotes health; motivational opportunities that encourage employees to
improve their health; behavior change opportunities that demonstrate
and support behavior change; and tools to improve employee health care
decisions;
(b) Must have wellness staff with direct accountability to agency
senior management;
(c) Shall initiate and maintain employee health programs using
current and emerging best practices in the field of health promotion;
(d) May offer employees such incentives as cash for completing
health risk assessments, free preventive screenings, training in
behavior change tools, improved nutritional standards on agency
campuses, bike racks, walking maps, on-site weight reduction programs,
and regular communication to promote personal health awareness.
(3) The state employee health program shall evaluate each of the
four programs separately and compare outcomes for each of them with the
entire state employee population to assess effectiveness of the
programs. Specifically, the program shall measure at least the
following outcomes in the demonstration population: The reduction in
the percent of the population that is overweight or obese, the
reduction in risk factors related to diabetes, the reduction in risk
factors related to absenteeism, the reduction in tobacco consumption,
the reduction in high blood pressure and high cholesterol, and the
increase in appropriate use of preventive health services. The state
employee health program shall report to the legislature in December
2008 and December 2010 on the demonstration project.
(4) This section expires June 30, 2011.
NEW SECTION. Sec. 42 The definitions in this section apply
throughout this chapter unless the context clearly requires otherwise.
(1) "Controlled substance" has the meaning provided in RCW
69.50.101.
(2) "Department" means the department of health.
(3) "Patient" means the person or animal who is the ultimate user
of a drug for whom a prescription is issued or for whom a drug is
dispensed.
(4) "Dispenser" means a practitioner or pharmacy that delivers a
Schedule II, III, IV, or V controlled substance to the ultimate user,
but does not include:
(a) A practitioner or other authorized person who administers, as
defined in RCW 69.41.010, a controlled substance; or
(b) A licensed wholesale distributor or manufacturer, as defined in
chapter 18.64 RCW, of a controlled substance.
NEW SECTION. Sec. 43 (1) When sufficient funding is provided for
such purpose through federal or private grants, or is appropriated by
the legislature, the department shall establish and maintain a
prescription monitoring program to monitor the prescribing and
dispensing of all Schedules II, III, IV, and V controlled substances
and any additional drugs identified by the board of pharmacy as
demonstrating a potential for abuse by all professionals licensed to
prescribe or dispense such substances in this state. The program shall
be designed to improve health care quality and effectiveness by
reducing abuse of controlled substances, reducing duplicative
prescribing and over-prescribing of controlled substances, and
improving controlled substance prescribing practices with the intent of
eventually establishing an electronic database available in real time
to dispensers and prescribers of control substances. As much as
possible, the department should establish a common database with other
states.
(2) Except as provided in subsection (4) of this section, each
dispenser shall submit to the department by electronic means
information regarding each prescription dispensed for a drug included
under subsection (1) of this section. Drug prescriptions for more than
immediate one day use should be reported. The information submitted
for each prescription shall include, but not be limited to:
(a) Patient identifier;
(b) Drug dispensed;
(c) Date of dispensing;
(d) Quantity dispensed;
(e) Prescriber; and
(f) Dispenser.
(3) Each dispenser shall submit the information in accordance with
transmission methods established by the department.
(4) The data submission requirements of this section do not apply
to:
(a) Medications provided to patients receiving inpatient services
provided at hospitals licensed under chapter 70.41 RCW; or patients of
such hospitals receiving services at the clinics, day surgery areas, or
other settings within the hospital's license where the medications are
administered in single doses; or
(b) Pharmacies operated by the department of corrections for the
purpose of providing medications to offenders in department of
corrections institutions who are receiving pharmaceutical services from
a department of corrections pharmacy, except that the department of
corrections must submit data related to each offender's current
prescriptions for controlled substances upon the offender's release
from a department of corrections institution.
(5) The department shall seek federal grants to support the
activities described in this act. The department may not require a
practitioner or a pharmacist to pay a fee or tax specifically dedicated
to the operation of the system.
NEW SECTION. Sec. 44 To the extent that funding is provided for
such purpose through federal or private grants, or is appropriated by
the legislature, the health care authority shall study the feasibility
of enhancing the prescription monitoring program established in section
43 of this act in order to improve the quality of state purchased
health services by reducing legend drug abuse, reducing duplicative and
overprescribing of legend drugs, and improving legend drug prescribing
practices. The study shall address the steps necessary to expand the
program to allow those who prescribe or dispense prescription drugs to
perform a web-based inquiry and obtain real time information regarding
the legend drug utilization history of persons for whom they are
providing medical or pharmaceutical care when such persons are
receiving health services through state purchased health care programs.
NEW SECTION. Sec. 45 (1) Prescription information submitted to
the department shall be confidential, in compliance with chapter 70.02
RCW and federal health care information privacy requirements and not
subject to disclosure, except as provided in subsections (3) and (4) of
this section.
(2) The department shall maintain procedures to ensure that the
privacy and confidentiality of patients and patient information
collected, recorded, transmitted, and maintained is not disclosed to
persons except as in subsections (3) and (4) of this section.
(3) The department may provide data in the prescription monitoring
program to the following persons:
(a) Persons authorized to prescribe or dispense controlled
substances, for the purpose of providing medical or pharmaceutical care
for their patients;
(b) An individual who requests the individual's own prescription
monitoring information;
(c) Health professional licensing, certification, or regulatory
agency or entity;
(d) Appropriate local, state, and federal law enforcement or
prosecutorial officials who are engaged in a bona fide specific
investigation involving a designated person;
(e) Authorized practitioners of the department of social and health
services regarding medicaid program recipients;
(f) The director or director's designee within the department of
labor and industries regarding workers' compensation claimants;
(g) The director or the director's designee within the department
of corrections regarding offenders committed to the department of
corrections;
(h) Other entities under grand jury subpoena or court order; and
(i) Personnel of the department for purposes of administration and
enforcement of this chapter or chapter 69.50 RCW.
(4) The department may provide data to public or private entities
for statistical, research, or educational purposes after removing
information that could be used to identify individual patients,
dispensers, prescribers, and persons who received prescriptions from
dispensers.
(5) A dispenser or practitioner acting in good faith is immune from
any civil, criminal, or administrative liability that might otherwise
be incurred or imposed for requesting, receiving, or using information
from the program.
NEW SECTION. Sec. 46 The department may contract with another
agency of this state or with a private vendor, as necessary, to ensure
the effective operation of the prescription monitoring program. Any
contractor is bound to comply with the provisions regarding
confidentiality of prescription information in section 45 of this act
and is subject to the penalties specified in section 48 of this act for
unlawful acts.
NEW SECTION. Sec. 47 The department shall adopt rules to
implement this chapter.
NEW SECTION. Sec. 48 (1) A dispenser who knowingly fails to
submit prescription monitoring information to the department as
required by this chapter or knowingly submits incorrect prescription
information is subject to disciplinary action under chapter 18.130 RCW.
(2) A person authorized to have prescription monitoring information
under this chapter who knowingly discloses such information in
violation of this chapter is subject to civil penalty.
(3) A person authorized to have prescription monitoring information
under this chapter who uses such information in a manner or for a
purpose in violation of this chapter is subject to civil penalty.
(4) In accordance with chapter 70.02 RCW and federal health care
information privacy requirements, any physician or pharmacist
authorized to access a patient's prescription monitoring may discuss or
release that information to other health care providers involved with
the patient in order to provide safe and appropriate care coordination.
Sec. 49 RCW 42.56.360 and 2006 c 209 s 9 and 2006 c 8 s 112 are
each reenacted and amended to read as follows:
(1) The following health care information is exempt from disclosure
under this chapter:
(a) Information obtained by the board of pharmacy as provided in
RCW 69.45.090;
(b) Information obtained by the board of pharmacy or the department
of health and its representatives as provided in RCW 69.41.044,
69.41.280, and 18.64.420;
(c) Information and documents created specifically for, and
collected and maintained by a quality improvement committee under RCW
43.70.510 or 70.41.200, or by a peer review committee under RCW
4.24.250, or by a quality assurance committee pursuant to RCW 74.42.640
or 18.20.390, and notifications or reports of adverse events or
incidents made under RCW 70.56.020 or 70.56.040, regardless of which
agency is in possession of the information and documents;
(d)(i) Proprietary financial and commercial information that the
submitting entity, with review by the department of health,
specifically identifies at the time it is submitted and that is
provided to or obtained by the department of health in connection with
an application for, or the supervision of, an antitrust exemption
sought by the submitting entity under RCW 43.72.310;
(ii) If a request for such information is received, the submitting
entity must be notified of the request. Within ten business days of
receipt of the notice, the submitting entity shall provide a written
statement of the continuing need for confidentiality, which shall be
provided to the requester. Upon receipt of such notice, the department
of health shall continue to treat information designated under this
subsection (1)(d) as exempt from disclosure;
(iii) If the requester initiates an action to compel disclosure
under this chapter, the submitting entity must be joined as a party to
demonstrate the continuing need for confidentiality;
(e) Records of the entity obtained in an action under RCW 18.71.300
through 18.71.340;
(f) Except for published statistical compilations and reports
relating to the infant mortality review studies that do not identify
individual cases and sources of information, any records or documents
obtained, prepared, or maintained by the local health department for
the purposes of an infant mortality review conducted by the department
of health under RCW 70.05.170; ((and))
(g) Complaints filed under chapter 18.130 RCW after July 27, 1997,
to the extent provided in RCW 18.130.095(1); and
(h) Information obtained by the department of health under chapter
70.-- RCW (sections 42 through 48 of this act).
(2) Chapter 70.02 RCW applies to public inspection and copying of
health care information of patients.
NEW SECTION. Sec. 50 The definitions in this section apply
throughout this chapter unless the context clearly requires otherwise.
(1) "Health care provider" means an individual who holds a license
issued by a disciplining authority identified in RCW 18.130.040 and who
practices his or her profession in a health care facility or provides
a health service.
(2) "Health 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,
ambulatory diagnostic, treatment, or surgical facilities, 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,
including a public hospital district, or instrumentality of the state
and such other facilities as required by federal law and implementing
regulations.
(3) "Health service" or "service" means that service, including
primary care service, offered or provided by health care facilities and
health care providers relating to the prevention, cure, or treatment of
illness, injury, or disease.
(4) "Health service area" means a geographic region appropriate for
effective health planning that includes a broad range of health
services.
(5) "Office" means the office of financial management.
(6) "Strategy" means the statewide health resources strategy.
NEW SECTION. Sec. 51 (1) The office shall serve as a
coordinating body for public and private efforts to improve quality in
health care, promote cost-effectiveness in health care, and plan health
facility and health service availability. In addition, the office
shall facilitate access to health care data collected by public and
private organizations as needed to conduct its planning
responsibilities.
(2) The office shall:
(a) Conduct strategic health planning activities related to the
preparation of the strategy, as specified in this chapter;
(b) Develop a computerized system for accessing, analyzing, and
disseminating data relevant to strategic health planning
responsibilities. The office may contract with an organization to
create the computerized system capable of meeting the needs of the
office;
(c) Maintain access to deidentified data collected and stored by
any public and private organizations as necessary to support its
planning responsibilities, including state-purchased health care
program data, hospital discharge data, and private efforts to collect
utilization and claims-related data. The office is authorized to enter
into any data sharing agreements and contractual arrangements necessary
to obtain data or to distribute data. Among the sources of
deidentified data that the office may access are any databases
established pursuant to the recommendations of the health information
infrastructure advisory board established by chapter 261, Laws of 2005.
The office may store limited data sets as necessary to support its
activities. Unless specifically authorized, the office shall not
collect data directly from the records of health care providers and
health care facilities, but shall make use of databases that have
already collected such information; and
(d) Conduct research and analysis or arrange for research and
analysis projects to be conducted by public or private organizations to
further the purposes of the strategy.
(3) The office shall establish a technical advisory committee to
assist in the development of the strategy. Members of the committee
shall include health economists, health planners, representatives of
government and nongovernment health care purchasers, representatives of
state agencies that use or regulate entities with an interest in health
planning, representatives of acute care facilities, representatives of
long-term care facilities, representatives of community-based long-term
care providers, representatives of health care providers, a
representative of one or more federally recognized Indian tribes, and
representatives of health care consumers. The committee shall include
members with experience in the provision of health services to rural
communities.
NEW SECTION. Sec. 52 (1) The office, in consultation with the
technical advisory committee established under section 51 of this act,
shall develop a statewide health resources strategy. The strategy
shall establish statewide health planning policies and goals related to
the availability of health care facilities and services, quality of
care, and cost of care. The strategy shall identify needs according to
geographic regions suitable for comprehensive health planning as
designated by the office.
(2) The development of the strategy shall consider the following
general goals and principles:
(a) That excess capacity of health services and facilities place
considerable economic burden on the public who pay for the construction
and operation of these facilities as patients, health insurance
purchasers, carriers, and taxpayers; and
(b) That the development and ongoing maintenance of current and
accurate health care information and statistics related to cost and
quality of health care, as well as projections of need for health
facilities and services, are essential to effective strategic health
planning.
(3) The strategy, with public input by health service areas, shall
include:
(a) A health system assessment and objectives component that:
(i) Describes state and regional population demographics, health
status indicators, and trends in health status and health care needs;
and
(ii) Identifies key policy objectives for the state health system
related to access to care, health outcomes, quality, and cost-effectiveness;
(b) A health care facilities and services plan that shall assess
the demand for health care facilities and services to inform state
health planning efforts and direct certificate of need determinations,
for those facilities and services subject to certificate of need as
provided in chapter 70.38 RCW. The plan shall include:
(i) An inventory of each geographic region's existing health care
facilities and services;
(ii) Projections of need for each category of health care facility
and service, including those subject to certificate of need;
(iii) Policies to guide the addition of new or expanded health care
facilities and services to promote the use of quality, evidence-based,
cost-effective health care delivery options, including any
recommendations for criteria, standards, and methods relevant to the
certificate of need review process; and
(iv) An assessment of the availability of health care providers,
public health resources, transportation infrastructure, and other
considerations necessary to support the needed health care facilities
and services in each region;
(c) A health care data resource plan that identifies data elements
necessary to properly conduct planning activities and to review
certificate of need applications, including data related to inpatient
and outpatient utilization and outcomes information, and financial and
utilization information related to charity care, quality, and cost.
The plan shall inventory existing data resources, both public and
private, that store and disclose information relevant to the health
planning process, including information necessary to conduct
certificate of need activities pursuant to chapter 70.38 RCW. The plan
shall identify any deficiencies in the inventory of existing data
resources and the data necessary to conduct comprehensive health
planning activities. The plan may recommend that the office be
authorized to access existing data sources and conduct appropriate
analyses of such data or that other agencies expand their data
collection activities as statutory authority permits. The plan may
identify any computing infrastructure deficiencies that impede the
proper storage, transmission, and analysis of health planning data.
The plan shall provide recommendations for increasing the availability
of data related to health planning to provide greater community
involvement in the health planning process and consistency in data used
for certificate of need applications and determinations;
(d) An assessment of emerging trends in health care delivery and
technology as they relate to access to health care facilities and
services, quality of care, and costs of care. The assessment shall
recommend any changes to the scope of health care facilities and
services covered by the certificate of need program that may be
warranted by these emerging trends. In addition, the assessment may
recommend any changes to criteria used by the department to review
certificate of need applications, as necessary;
(e) A rural health resource plan to assess the availability of
health resources in rural areas of the state, assess the unmet needs of
these communities, and evaluate how federal and state reimbursement
policies can be modified, if necessary, to more efficiently and
effectively meet the health care needs of rural communities. The plan
shall consider the unique health care needs of rural communities, the
adequacy of the rural health workforce, and transportation needs for
accessing appropriate care.
(4) The office shall submit the initial strategy to the governor
and the appropriate committees of the senate and house of
representatives by January 1, 2010. Every two years the office shall
submit an updated strategy. The health care facilities and services
plan as it pertains to a distinct geographic planning region may be
updated by individual categories on a rotating, biannual schedule.
(5) The office shall hold at least one public hearing and allow
opportunity to submit written comments prior to the issuance of the
initial strategy or an updated strategy. A public hearing shall be
held prior to issuing a draft of an updated health care facilities and
services plan, and another public hearing shall be held before final
adoption of an updated health care facilities and services plan. Any
hearing related to updating a health care facilities and services plan
for a specific planning region shall be held in that region with
sufficient notice to the public and an opportunity to comment.
NEW SECTION. Sec. 53 The office shall submit the strategy to the
department of health to direct its activities related to the
certificate of need review program under chapter 70.38 RCW. As the
health care facilities and services plan is updated for any specific
geographic planning region, the office shall submit that plan to the
department of health to direct its activities related to the
certificate of need review program under chapter 70.38 RCW. The office
shall not issue determinations of the merits of specific project
proposals submitted by applicants for certificates of need.
NEW SECTION. Sec. 54 (1) The office may respond to requests for
data and other information from its computerized system for special
studies and analysis consistent with requirements for confidentiality
of patient, provider, and facility-specific records. The office may
require requestors to pay any or all of the reasonable costs associated
with such requests that might be approved.
(2) Data elements related to the identification of individual
patient's, provider's, and facility's care outcomes are confidential,
are exempt from RCW 42.56.030 through 42.56.570 and 42.17.350 through
42.17.450, and are not subject to discovery by subpoena or admissible
as evidence.
Sec. 55 RCW 70.38.015 and 1989 1st ex.s. c 9 s 601 are each
amended to read as follows:
It is declared to be the public policy of this state:
(1) That strategic health planning ((to)) efforts must be supported
by appropriately tailored regulatory activities that can effectuate the
goals and principles of the statewide health resources strategy
developed pursuant to chapter 43.-- RCW (sections 50 through 54 of this
act). The implementation of the strategy can promote, maintain, and
assure the health of all citizens in the state, ((to)) provide
accessible health services, health manpower, health facilities, and
other resources while controlling ((excessive)) increases in costs, and
((to)) recognize prevention as a high priority in health programs((, is
essential to the health, safety, and welfare of the people of the
state. Health planning should be responsive to changing health and
social needs and conditions)). Involvement in health planning from
both consumers and providers throughout the state should be encouraged;
(2) ((That the development of health services and resources,
including the construction, modernization, and conversion of health
facilities, should be accomplished in a planned, orderly fashion,
consistent with identified priorities and without unnecessary
duplication or fragmentation)) That the certificate of need program is
a component of a health planning regulatory process that is consistent
with the statewide health resources strategy and public policy goals
that are clearly articulated and regularly updated;
(3) That the development and maintenance of adequate health care
information, statistics and projections of need for health facilities
and services is essential to effective health planning and resources
development;
(4) That the development of nonregulatory approaches to health care
cost containment should be considered, including the strengthening of
price competition; and
(5) That health planning should be concerned with public health and
health care financing, access, and quality, recognizing their close
interrelationship and emphasizing cost control of health services,
including cost-effectiveness and cost-benefit analysis.
NEW SECTION. Sec. 56 (1) For the purposes of this section and
RCW 70.38.015 and 70.38.135, "statewide health resource strategy" or
"strategy" means the statewide health resource strategy developed by
the office of financial management pursuant to chapter 43.-- RCW
(sections 50 through 54 of this act).
(2) Effective January 1, 2010, for those facilities and services
covered by the certificate of need programs, certificate of need
determinations must be consistent with the statewide health resources
strategy developed pursuant to section 52 of this act, including any
health planning policies and goals identified in the statewide health
resources strategy in effect at the time of application. The
department may waive specific terms of the strategy if the applicant
demonstrates that consistency with those terms will create an undue
burden on the population that a particular project would serve, or in
emergency circumstances which pose a threat to public health.
Sec. 57 RCW 70.38.135 and 1989 1st ex.s. c 9 s 607 are each
amended to read as follows:
The secretary shall have authority to:
(1) Provide when needed temporary or intermittent services of
experts or consultants or organizations thereof, by contract, when such
services are to be performed on a part time or fee-for-service basis;
(2) Make or cause to be made such on-site surveys of health care or
medical facilities as may be necessary for the administration of the
certificate of need program;
(3) Upon review of recommendations, if any, from the board of
health or the office of financial management as contained in the
Washington health resources strategy:
(a) Promulgate rules under which health care facilities providers
doing business within the state shall submit to the department such
data related to health and health care as the department finds
necessary to the performance of its functions under this chapter;
(b) Promulgate rules pertaining to the maintenance and operation of
medical facilities which receive federal assistance under the
provisions of Title XVI;
(c) Promulgate rules in implementation of the provisions of this
chapter, including the establishment of procedures for public hearings
for predecisions and post-decisions on applications for certificate of
need;
(d) Promulgate rules providing circumstances and procedures of
expedited certificate of need review if there has not been a
significant change in existing health facilities of the same type or in
the need for such health facilities and services;
(4) Grant allocated state funds to qualified entities, as defined
by the department, to fund not more than seventy-five percent of the
costs of regional planning activities, excluding costs related to
review of applications for certificates of need, provided for in this
chapter or approved by the department; and
(5) Contract with and provide reasonable reimbursement for
qualified entities to assist in determinations of certificates of need.
Sec. 58 RCW 70.47A.030 and 2006 c 255 s 3 are each amended to
read as follows:
(1) To the extent funding is appropriated in the operating budget
for this purpose, the ((small employer)) health insurance partnership
((program)) is established. The administrator shall be responsible for
the implementation and operation of the ((small employer)) health
insurance partnership ((program)), directly or by contract. The
administrator shall offer premium subsidies to eligible ((employees))
partnership participants under RCW 70.47A.040.
(2) Consistent with policies adopted by the board under section 59
of this act, the administrator shall, directly or by contract:
(a) Establish and administer procedures for enrolling small
employers in the partnership, including publicizing the existence of
the partnership and disseminating information on enrollment, and
establishing rules related to minimum participation of employees in
small groups purchasing health insurance through the partnership.
Opportunities to publicize the program for outreach and education of
small employers on the value of insurance shall explore the use of
online employer guides. As a condition of participating in the
partnership, a small employer must agree to establish a cafeteria plan
under section 125 of the federal internal revenue code that will enable
employees to use pretax dollars to pay their share of their health
benefit plan premium. The partnership shall provide technical
assistance to small employers for this purpose;
(b) Establish and administer procedures for health benefit plan
enrollment by employees of small employers during open enrollment
periods and outside of open enrollment periods upon the occurrence of
any qualifying event specified in the federal health insurance
portability and accountability act of 1996 or applicable state law.
Neither the employer nor the partnership shall limit an employee's
choice of coverage from among all the health benefit plans offered;
(c) Establish and manage a system for the partnership to be
designated as the sponsor or administrator of a participating small
employer health benefit plan and to undertake the obligations required
of a plan administrator under federal law;
(d) Establish and manage a system of collecting and transmitting to
the applicable carriers all premium payments or contributions made by
or on behalf of partnership participants, including employer
contributions, automatic payroll deductions for partnership
participants, premium subsidy payments, and contributions from
philanthropies;
(e) Establish and manage a system for determining eligibility for
and making premium subsidy payments under this act;
(f) Establish a mechanism to apply a surcharge to all health
benefit plans, which shall be used only to pay for administrative and
operational expenses of the partnership. The surcharge must be applied
uniformly to all health benefit plans offered through the partnership
and must be included in the premium for each health benefit plan.
Surcharges may not be used to pay any premium assistance payments under
this chapter;
(g) Design a schedule of premium subsidies that is based upon gross
family income, giving appropriate consideration to family size and the
ages of all family members based on a benchmark health benefit plan
designated by the board. The amount of an eligible partnership
participant's premium subsidy shall be determined by applying a sliding
scale subsidy schedule with the percentage of premium similar to that
developed for subsidized basic health plan enrollees under RCW
70.47.060. The subsidy shall be applied to the employee's premium
obligation for his or her health benefit plan, so that employees
benefit financially from any employer contribution to the cost of their
coverage through the partnership.
(3) The administrator may enter into interdepartmental agreements
with the office of the insurance commissioner, the department of social
and health services, and any other state agencies necessary to
implement this chapter.
*NEW SECTION. Sec. 59 A new section is added to chapter 70.47A
RCW to read as follows:
(1) The health insurance partnership board is hereby established.
The governor shall appoint a nine-member board composed as follows:
(a) Two representatives of small employers;
(b) Two representatives of employees of small employers, one of
whom shall represent low-wage employees;
(c) Four employee health plan benefits specialists; and
(d) The administrator.
(2) The governor shall appoint the initial members of the board to
staggered terms not to exceed four years. Initial appointments shall
be made on or before June 1, 2007. Members appointed thereafter shall
serve two-year terms. Members of the board shall be compensated in
accordance with RCW 43.03.250 and shall be reimbursed for their travel
expenses while on official business in accordance with RCW 43.03.050
and 43.03.060. The board shall prescribe rules for the conduct of its
business. The administrator shall be chair of the board. Meetings of
the board shall be at the call of the chair.
(3) The board may establish technical advisory committees or seek
the advice of technical experts when necessary to execute the powers
and duties included in this section.
(4) The board and employees of the board shall not be civilly or
criminally liable and shall not have any penalty or cause of action of
any nature arise against them for any action taken or not taken,
including any discretionary decision or failure to make a discretionary
decision, when the action or inaction is done in good faith and in the
performance of the powers and duties under this chapter. Nothing in
this section prohibits legal actions against the board to enforce the
board's statutory or contractual duties or obligations.
*Sec. 59 was vetoed. See message at end of chapter.
NEW SECTION. Sec. 60 A new section is added to chapter 43.70 RCW
to read as follows:
(1) Protecting the public's health across the state is a
fundamental responsibility of the state. With any new state funding of
the public health system as appropriated for the purposes of sections
60 through 65 of this act, the state expects that measurable benefits
will be realized to the health of the residents of Washington. A
transparent process that shows the impact of increased public health
spending on performance measures related to the health outcomes in
subsection (2) of this section is of great value to the state and its
residents. In addition, a well-funded public health system is expected
to become a more integral part of the state's emergency preparedness
system.
(2) Subject to the availability of amounts appropriated for the
purposes of sections 60 through 65 of this act, distributions to local
health jurisdictions shall deliver the following outcomes:
(a) Create a disease response system capable of responding at all
times;
(b) Stop the increase in, and reduce, sexually transmitted disease
rates;
(c) Reduce vaccine preventable diseases;
(d) Build capacity to quickly contain disease outbreaks;
(e) Decrease childhood and adult obesity and types I and II
diabetes rates, and resulting kidney failure and dialysis;
(f) Increase childhood immunization rates;
(g) Improve birth outcomes and decrease child abuse;
(h) Reduce animal-to-human disease rates; and
(i) Monitor and protect drinking water across jurisdictional
boundaries.
(3) Benchmarks for these outcomes shall be drawn from the national
healthy people 2010 goals, other reliable data sets, and any subsequent
national goals.
NEW SECTION. Sec. 61 A new section is added to chapter 43.70 RCW
to read as follows:
The definitions in this section apply throughout sections 60
through 65 of this act unless the context clearly requires otherwise.
(1) "Core public health functions of statewide significance" or
"public health functions" means health services that:
(a) Address: Communicable disease prevention and response;
preparation for, and response to, public health emergencies caused by
pandemic disease, earthquake, flood, or terrorism; prevention and
management of chronic diseases and disabilities; promotion of healthy
families and the development of children; assessment of local health
conditions, risks, and trends, and evaluation of the effectiveness of
intervention efforts; and environmental health concerns;
(b) Promote uniformity in the public health activities conducted by
all local health jurisdictions in the public health system, increase
the overall strength of the public health system, or apply to broad
public health efforts; and
(c) If left neglected or inadequately addressed, are reasonably
likely to have a significant adverse impact on counties beyond the
borders of the local health jurisdiction.
(2) "Local health jurisdiction" or "jurisdiction" means a county
board of health organized under chapter 70.05 RCW, a health district
organized under chapter 70.46 RCW, or a combined city and county health
department organized under chapter 70.08 RCW.
NEW SECTION. Sec. 62 A new section is added to chapter 43.70 RCW
to read as follows:
(1) The department shall accomplish the tasks included in
subsection (2) of this section by utilizing the expertise of varied
interests, as provided in this subsection.
(a) In addition to the perspectives of local health jurisdictions,
the state board of health, the Washington health foundation, and
department staff that are currently engaged in development of the
public health services improvement plan under RCW 43.70.520, the
secretary shall actively engage:
(i) Individuals or entities with expertise in the development of
performance measures, accountability and systems management, such as
the University of Washington school of public health and community
medicine, and experts in the development of evidence-based medical
guidelines or public health practice guidelines; and
(ii) Individuals or entities who will be impacted by performance
measures developed under this section and have relevant expertise, such
as community clinics, public health nurses, large employers, tribal
health providers, family planning providers, and physicians.
(b) In developing the performance measures, consideration shall be
given to levels of performance necessary to promote uniformity in core
public health functions of statewide significance among all local
health jurisdictions, best scientific evidence, national standards of
performance, and innovations in public health practice. The
performance measures shall be developed to meet the goals and outcomes
in section 60 of this act. The office of the state auditor shall
provide advice and consultation to the committee to assist in the
development of effective performance measures and health status
indicators.
(c) On or before November 1, 2007, the experts assembled under this
section shall provide recommendations to the secretary related to the
activities and services that qualify as core public health functions of
statewide significance and performance measures. The secretary shall
provide written justification for any departure from the
recommendations.
(2) By January 1, 2008, the department shall:
(a) Adopt a prioritized list of activities and services performed
by local health jurisdictions that qualify as core public health
functions of statewide significance as defined in section 61 of this
act; and
(b) Adopt appropriate performance measures with the intent of
improving health status indicators applicable to the core public health
functions of statewide significance that local health jurisdictions
must provide.
(3) The secretary may revise the list of activities and the
performance measures in future years as appropriate. Prior to
modifying either the list or the performance measures, the secretary
must provide a written explanation of the rationale for such changes.
(4) The department and the local health jurisdictions shall abide
by the prioritized list of activities and services and the performance
measures developed pursuant to this section.
(5) The department, in consultation with representatives of county
governments, shall provide local jurisdictions with financial
incentives to encourage and increase local investments in core public
health functions. The local jurisdictions shall not supplant existing
local funding with such state-incented resources.
NEW SECTION. Sec. 63 A new section is added to chapter 43.70 RCW
to read as follows:
Beginning November 15, 2009, the department shall report to the
legislature and the governor annually on the distribution of funds to
local health jurisdictions under sections 60 through 65 of this act and
the use of those funds. The initial report must discuss the
performance measures adopted by the secretary and any impact the
funding in this act has had on local health jurisdiction performance
and health status indicators. Future reports shall evaluate trends in
performance over time and the effects of expenditures on performance
over time.
Sec. 64 RCW 43.70.520 and 1993 c 492 s 467 are each
amended to
read as follows:
(1) The legislature finds that the public health functions of
community assessment, policy development, and assurance of service
delivery are essential elements in achieving the objectives of health
reform in Washington state. The legislature further finds that the
population-based services provided by state and local health
departments are cost-effective and are a critical strategy for the
long-term containment of health care costs. The legislature further
finds that the public health system in the state lacks the capacity to
fulfill these functions consistent with the needs of a reformed health
care system. The legislature further finds that public health nurses
and nursing services are an essential part of our public health system,
delivering evidence-based care and providing core services including
prevention of illness, injury, or disability; the promotion of health;
and maintenance of the health of populations.
(2) The department of health shall develop, in consultation with
local health departments and districts, the state board of health, the
health services commission, area Indian health service, and other state
agencies, health services providers, and citizens concerned about
public health, a public health services improvement plan. The plan
shall provide a detailed accounting of deficits in the core functions
of assessment, policy development, assurance of the current public
health system, how additional public health funding would be used, and
describe the benefits expected from expanded expenditures.
(3) The plan shall include:
(a) Definition of minimum standards for public health protection
through assessment, policy development, and assurances:
(i) Enumeration of communities not meeting those standards;
(ii) A budget and staffing plan for bringing all communities up to
minimum standards;
(iii) An analysis of the costs and benefits expected from adopting
minimum public health standards for assessment, policy development, and
assurances;
(b) Recommended strategies and a schedule for improving public
health programs throughout the state, including:
(i) Strategies for transferring personal health care services from
the public health system, into the uniform benefits package where
feasible; and
(ii) ((Timing of increased funding for public health services
linked to specific objectives for improving public health)) Linking
funding for public health services to performance measures that relate
to achieving improved health outcomes; and
(c) A recommended level of dedicated funding for public health
services to be expressed in terms of a percentage of total health
service expenditures in the state or a set per person amount; such
recommendation shall also include methods to ensure that such funding
does not supplant existing federal, state, and local funds received by
local health departments, and methods of distributing funds among local
health departments.
(4) The department shall coordinate this planning process with the
study activities required in section 258, chapter 492, Laws of 1993.
(5) By March 1, 1994, the department shall provide initial
recommendations of the public health services improvement plan to the
legislature regarding minimum public health standards, and public
health programs needed to address urgent needs, such as those cited in
subsection (7) of this section.
(6) By December 1, 1994, the department shall present the public
health services improvement plan to the legislature, with specific
recommendations for each element of the plan to be implemented over the
period from 1995 through 1997.
(7) Thereafter, the department shall update the public health
services improvement plan for presentation to the legislature prior to
the beginning of a new biennium.
(8) Among the specific population-based public health activities to
be considered in the public health services improvement plan are:
Health data assessment and chronic and infectious disease surveillance;
rapid response to outbreaks of communicable disease; efforts to prevent
and control specific communicable diseases, such as tuberculosis and
acquired immune deficiency syndrome; health education to promote
healthy behaviors and to reduce the prevalence of chronic disease, such
as those linked to the use of tobacco; access to primary care in
coordination with existing community and migrant health clinics and
other not for profit health care organizations; programs to ensure
children are born as healthy as possible and they receive immunizations
and adequate nutrition; efforts to prevent intentional and
unintentional injury; programs to ensure the safety of drinking water
and food supplies; poison control; trauma services; and other
activities that have the potential to improve the health of the
population or special populations and reduce the need for or cost of
health services.
NEW SECTION. Sec. 65 A new section is added to chapter 43.70 RCW
to read as follows:
(1) Each local health jurisdiction shall submit to the secretary
such data as the secretary determines is necessary to allow the
secretary to assess whether the local health jurisdiction has used the
funds in a manner consistent with achieving the performance measures in
section 62 of this act.
(2) If the secretary determines that the data submitted
demonstrates that the local health jurisdiction is not spending the
funds in a manner consistent with achieving the performance measures,
the secretary shall:
(a) Provide a report to the governor identifying the local health
jurisdiction and the specific items that the secretary identified as
inconsistent with achieving the performance measures; and
(b) Require that the local health jurisdiction submit a plan of
correction to the secretary within sixty days of receiving notice from
the secretary, which explains the measures that the jurisdiction will
take to resume spending funds in a manner consistent with achieving the
performance measures. The secretary shall provide technical assistance
to the local health jurisdiction to support the jurisdiction in
successfully completing the activities included in the plan of
correction.
(3) Upon a determination by the secretary that a local health
jurisdiction that had previously been identified as not spending the
funds in a manner consistent with achieving the performance measures
has resumed consistency, the secretary shall notify the governor that
the jurisdiction has returned to consistent status.
(4) Any local health jurisdiction that has not resumed spending
funds in a manner consistent with achieving the performance measures
within one year of the secretary reporting the jurisdiction to the
governor shall be precluded from receiving any funds appropriated for
the purposes of sections 60 through 65 of this act. Funds may resume
once the local health jurisdiction has demonstrated to the satisfaction
of the secretary that it has returned to consistent status.
Sec. 66 RCW 70.48.130 and 1993 c 409 s 1 are each amended to read
as follows:
It is the intent of the legislature that all jail inmates receive
appropriate and cost-effective emergency and necessary medical care.
Governing units, the department of social and health services, and
medical care providers shall cooperate to achieve the best rates
consistent with adequate care.
Payment for emergency or necessary health care shall be by the
governing unit, except that the department of social and health
services shall directly reimburse the provider pursuant to chapter
74.09 RCW, in accordance with the rates and benefits established by the
department, if the confined person is eligible under the department's
medical care programs as authorized under chapter 74.09 RCW. After
payment by the department, the financial responsibility for any
remaining balance, including unpaid client liabilities that are a
condition of eligibility or participation under chapter 74.09 RCW,
shall be borne by the medical care provider and the governing unit as
may be mutually agreed upon between the medical care provider and the
governing unit. In the absence of mutual agreement between the medical
care provider and the governing unit, the financial responsibility for
any remaining balance shall be borne equally between the medical care
provider and the governing unit. Total payments from all sources to
providers for care rendered to confined persons eligible under chapter
74.09 RCW shall not exceed the amounts that would be paid by the
department for similar services provided under Title XIX medicaid,
unless additional resources are obtained from the confined person.
As part of the screening process upon booking or preparation of an
inmate into jail, general information concerning the inmate's ability
to pay for medical care shall be identified, including insurance or
other medical benefits or resources to which an inmate is entitled.
This information shall be made available to the department, the
governing unit, and any provider of health care services.
The governing unit or provider may obtain reimbursement from the
confined person for the cost of health care services not provided under
chapter 74.09 RCW, including reimbursement from any insurance program
or from other medical benefit programs available to the confined
person. Nothing in this chapter precludes civil or criminal remedies
to recover the costs of medical care provided jail inmates or paid for
on behalf of inmates by the governing unit. As part of a judgment and
sentence, the courts are authorized to order defendants to repay all or
part of the medical costs incurred by the governing unit or provider
during confinement.
To the extent that a confined person is unable to be financially
responsible for medical care and is ineligible for the department's
medical care programs under chapter 74.09 RCW, or for coverage from
private sources, and in the absence of an interlocal agreement or other
contracts to the contrary, the governing unit may obtain reimbursement
for the cost of such medical services from the unit of government
((whose law enforcement officers)) that initiated the charges on which
the person is being held in the jail: PROVIDED, That reimbursement for
the cost of such services shall be by the state for state prisoners
being held in a jail who are accused of either escaping from a state
facility or of committing an offense in a state facility.
There shall be no right of reimbursement to the governing unit from
units of government ((whose law enforcement officers)) that initiated
the charges for which a person is being held in the jail for care
provided after the charges are disposed of by sentencing or otherwise,
unless by intergovernmental agreement pursuant to chapter 39.34 RCW.
Under no circumstance shall necessary medical services be denied or
delayed because of disputes over the cost of medical care or a
determination of financial responsibility for payment of the costs of
medical care provided to confined persons.
Nothing in this section shall limit any existing right of any
party, governing unit, or unit of government against the person
receiving the care for the cost of the care provided.
NEW SECTION. Sec. 67 The following acts or parts of acts are
each repealed:
(1) RCW 70.38.919 (Effective date -- State health plan -- 1989 1st
ex.s. c 9) and 1989 1st ex.s. c 9 s 610; and
(2) 2006 c 255 s 10 (uncodified).
NEW SECTION. Sec. 68 If
any provision of this act or its
application to any person or circumstance is held invalid, the
remainder of the act or the application of the provision to other
persons or circumstances is not affected.
NEW SECTION. Sec. 69 Sections 42 through 48 of this act
constitute a new chapter in Title
NEW SECTION. Sec. 70 Sections 50 through 54 of this act
constitute a new chapter in Title
NEW SECTION. Sec. 71 Subheadings used in this act are not any
part of the law.
NEW SECTION. Sec. 72 Sections 18 through 22 of this act take
effect January 1, 2009.
NEW SECTION. Sec. 73 If specific funding for the purposes of the
following sections of this act, referencing the section of this act by
bill or chapter number and section number, is not provided by June 30,
2007, in the omnibus appropriations act, the section is null and void:
(1) Section 9 of this act (Washington state quality forum);
(2) Section 10 of this act (health records banking pilot project);
(3) Section 14 of this act;
(4) Section 40 of this act (state employee health program);
(5) Section 41 of this act (state employee health demonstration
project); and
(6) Sections 50 through 57 of this act.
*NEW SECTION. Sec. 74 Sections 58 and 59 of this act are
necessary for the immediate preservation of the public peace, health,
or safety, or support of the state government and its existing public
institutions, and take effect July 1, 2007.
*Sec. 74 was vetoed. See message at end of chapter.
NEW SECTION. Sec. 75 Section 30 of 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.
NEW SECTION. Sec. 76 Section
66 of this act expires June 30,
2009.