2319-S2.E AMS HARG NEED 965
E2SHB 2319 - S AMD 190
By Senators Hargrove, Kastama, Pflug
ADOPTED 03/01/2012
Strike everything after the enacting clause and insert the following:
"PART
I
DEFINITIONS
Sec. 1. RCW 48.43.005 and 2011 c 315 s 2 and 2011 c 314 s 3 are each reenacted and 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) "Adverse benefit determination" means a denial, reduction, or termination of, or a failure to provide or make payment, in whole or in part, for a benefit, including a denial, reduction, termination, or failure to provide or make payment that is based on a determination of an enrollee's or applicant's eligibility to participate in a plan, and including, with respect to group health plans, a denial, reduction, or termination of, or a failure to provide or make payment, in whole or in part, for a benefit resulting from the application of any utilization review, as well as a failure to cover an item or service for which benefits are otherwise provided because it is determined to be experimental or investigational or not medically necessary or appropriate.
(3) "Applicant" means a person who applies for enrollment in an individual health plan as the subscriber or an enrollee, or the dependent or spouse of a subscriber or enrollee.
(4) "Basic health plan" means the plan described under chapter 70.47 RCW, as revised from time to time.
(5) "Basic health plan model plan" means a health plan as required in RCW 70.47.060(2)(e).
(6) "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.
(7) "Board" means the governing board of
the Washington health benefit exchange established in chapter 43.71 RCW.
(8)(a) For grandfathered health benefit plans issued before January 1,
2014, and renewed thereafter, "catastrophic health plan"
means:
(((a))) (i) 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 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))) (ii) 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 six
thousand 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)).
(b) 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. For a plan year beginning in 2014, the out-of-pocket limits must be adjusted as specified in section 1302(c)(1) of P.L. 111-148 of 2010, as amended. The adjusted amount shall apply on the following January 1st.
(c) For health benefit plans issued on or after January
1, 2014, "catastrophic health plan" means:
(i) A health benefit plan that meets the definition of catastrophic plan
set forth in section 1302(e) of P.L. 111-148 of 2010, as amended; or
(ii) A health benefit plan offered outside the exchange marketplace that
requires a calendar year deductible or out-of-pocket expenses under the plan,
other than for premiums, for covered benefits, that meets or exceeds the
commissioner's annual adjustment under (b) of this subsection.
(((8))) (9) "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.
(((9))) (10) "Concurrent review"
means utilization review conducted during a patient's hospital stay or course
of treatment.
(((10))) (11) "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.
(((11))) (12) "Dependent" means,
at a minimum, the enrollee's legal spouse and dependent children who qualify
for coverage under the enrollee's health benefit plan.
(((12))) (13) "Emergency medical
condition" means a medical condition manifesting itself by acute symptoms
of sufficient severity, including severe pain, such that a prudent layperson,
who possesses an average knowledge of health and medicine, could reasonably
expect the absence of immediate medical attention to result in a condition (a)
placing the health of the individual, or with respect to a pregnant woman, the
health of the woman or her unborn child, in serious jeopardy, (b) serious
impairment to bodily functions, or (c) serious dysfunction of any bodily organ
or part.
(((13))) (14) "Emergency
services" means a medical screening examination, as required under section
1867 of the social security act (42 U.S.C. 1395dd), that is within the
capability of the emergency department of a hospital, including ancillary
services routinely available to the emergency department to evaluate that
emergency medical condition, and further medical examination and treatment, to
the extent they are within the capabilities of the staff and facilities
available at the hospital, as are required under section 1867 of the social
security act (42 U.S.C. 1395dd) to stabilize the patient. Stabilize, with
respect to an emergency medical condition, has the meaning given in section
1867(e)(3) of the social security act (42 U.S.C. 1395dd(e)(3)).
(((14))) (15) "Employee" has the
same meaning given to the term, as of January 1, 2008, under section 3(6) of
the federal employee retirement income security act of 1974.
(((15))) (16) "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.
(((16))) (17) "Exchange" means the
Washington health benefit exchange established under chapter 43.71 RCW.
(18) "Final external review decision" means a
determination by an independent review organization at the conclusion of an
external review.
(((17))) (19) "Final internal adverse
benefit determination" means an adverse benefit determination that has
been upheld by a health plan or carrier at the completion of the internal appeals
process, or an adverse benefit determination with respect to which the internal
appeals process has been exhausted under the exhaustion rules described in RCW
48.43.530 and 48.43.535.
(((18))) (20) "Grandfathered health
plan" means a group health plan or an individual health plan that under
section 1251 of the patient protection and affordable care act, P.L. 111‑148
(2010) and as amended by the health care and education reconciliation act, P.L.
111‑152 (2010) is not subject to subtitles A or C of the act as amended.
(((19))) (21) "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.
(((20))) (22) "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.
(((21))) (23) "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.
(((22))) (24) "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.
(((23))) (25) "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, and includes "issuers"
as that term is used in the patient protection and affordable care act (P.L.
111-148).
(((24))) (26) "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 or 48.83 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 or illness‑triggered fixed payment insurance, hospital confinement fixed payment insurance, or other fixed payment insurance offered as an independent, noncoordinated benefit;
(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.
(((25))) (27) "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.
(((26))) (28) "Open enrollment"
means a period of time as defined in rule to be held at the same time each
year, during which applicants may enroll in a carrier's individual health
benefit plan without being subject to health screening or otherwise required to
provide evidence of insurability as a condition for enrollment.
(((27))) (29) "Preexisting
condition" means any medical condition, illness, or injury that existed
any time prior to the effective date of coverage.
(((28))) (30) "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.
(((29))) (31) "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.
(((30))) (32) "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 employed an average of at
least one but no more than fifty employees, during the previous calendar year
and employed at least one employee on the first day of the plan year, 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
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 who is covered as a group of one must also: (a) Have been employed
by the same small employer or small group for at least twelve months prior to
application for small group coverage, and (b) verify that he or she derived 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 a self-employed
individual or sole proprietor in an agricultural trade or business, must have
derived 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.
(((31))) (33) "Special
enrollment" means a defined period of time of not less than thirty-one
days, triggered by a specific qualifying event experienced by the applicant,
during which applicants may enroll in the carrier's individual health benefit
plan without being subject to health screening or otherwise required to provide
evidence of insurability as a condition for enrollment.
(((32))) (34) "Standard health
questionnaire" means the standard health questionnaire designated under
chapter 48.41 RCW.
(((33))) (35) "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.
(((34))) (36) "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.
PART
II
THE WASHINGTON HEALTH BENEFIT EXCHANGE
Sec. 2. RCW 43.71.010 and 2011 c 317 s 2 are each amended to read as follows:
The definitions in this section apply throughout this chapter unless the context clearly requires otherwise. Terms and phrases used in this chapter that are not defined in this section must be defined as consistent with implementation of a state health benefit exchange pursuant to the affordable care act.
(1) "Affordable care act" means the federal patient protection and affordable care act, P.L. 111-148, as amended by the federal health care and education reconciliation act of 2010, P.L. 111-152, or federal regulations or guidance issued under the affordable care act.
(2) "Authority" means the Washington state health care authority, established under chapter 41.05 RCW.
(3) "Board" means the governing board established in RCW 43.71.020.
(4) "Commissioner" means the insurance commissioner, established in Title 48 RCW.
(5) "Exchange" means the Washington health benefit exchange established in RCW 43.71.020.
(6) "Self-sustaining" means capable of operating without direct state tax subsidy. Self-sustaining sources include, but are not limited to, federal grants, federal premium tax subsidies and credits, charges to health carriers, and premiums paid by enrollees.
Sec. 3. RCW 43.71.020 and 2011 c 317 s 3 are each amended to read as follows:
(1) The Washington health benefit exchange is established and constitutes a self-sustaining public-private partnership separate and distinct from the state, exercising functions delineated in chapter 317, Laws of 2011. By January 1, 2014, the exchange shall operate consistent with the affordable care act subject to statutory authorization. The exchange shall have a governing board consisting of persons with expertise in the Washington health care system and private and public health care coverage. The initial membership of the board shall be appointed as follows:
(a) By October 1, 2011, each of the two largest caucuses in both the house of representatives and the senate shall submit to the governor a list of five nominees who are not legislators or employees of the state or its political subdivisions, with no caucus submitting the same nominee.
(i) The nominations from the largest caucus in the house of representatives must include at least one employee benefit specialist;
(ii) The nominations from the second largest caucus in the house of representatives must include at least one health economist or actuary;
(iii) The nominations from the largest caucus in the senate must include at least one representative of health consumer advocates;
(iv) The nominations from the second largest caucus in the senate must include at least one representative of small business;
(v) The remaining nominees must have demonstrated and acknowledged expertise in at least one of the following areas: Individual health care coverage, small employer health care coverage, health benefits plan administration, health care finance and economics, actuarial science, or administering a public or private health care delivery system.
(b) By December 15, 2011, the governor shall appoint two members from each list submitted by the caucuses under (a) of this subsection. The appointments made under this subsection (1)(b) must include at least one employee benefits specialist, one health economist or actuary, one representative of small business, and one representative of health consumer advocates. The remaining four members must have a demonstrated and acknowledged expertise in at least one of the following areas: Individual health care coverage, small employer health care coverage, health benefits plan administration, health care finance and economics, actuarial science, or administering a public or private health care delivery system.
(c) By December 15, 2011, the governor shall appoint a ninth member to serve as chair. The chair may not be an employee of the state or its political subdivisions. The chair shall serve as a nonvoting member except in the case of a tie.
(d) The following members shall serve as nonvoting, ex officio members of the board:
(i) The insurance commissioner or his or her designee; and
(ii) The administrator of the health care authority, or his or her designee.
(2) Initial members of the board shall serve staggered terms not to exceed four years. Members appointed thereafter shall serve two-year terms.
(3) A member of the board whose term has expired or who otherwise leaves the board shall be replaced by gubernatorial appointment. When the person leaving was nominated by one of the caucuses of the house of representatives or the senate, his or her replacement shall be appointed from a list of five nominees submitted by that caucus within thirty days after the person leaves. If the member to be replaced is the chair, the governor shall appoint a new chair within thirty days after the vacancy occurs. A person appointed to replace a member who leaves the board prior to the expiration of his or her term shall serve only the duration of the unexpired term. Members of the board may be reappointed to multiple terms.
(4) No board member may be appointed if his or her participation in the decisions of the board could benefit his or her own financial interests or the financial interests of an entity he or she represents. A board member who develops such a conflict of interest shall resign or be removed from the board.
(5) Members of the board must 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. Meetings of the board are at the call of the chair.
(6) The exchange and the board are subject only to the provisions of chapter 42.30 RCW, the open public meetings act, and chapter 42.56 RCW, the public records act, and not to any other law or regulation generally applicable to state agencies. Consistent with the open public meetings act, the board may hold executive sessions to consider proprietary or confidential nonpublished information.
(7)(a) The board shall establish an advisory committee to allow for the views of the health care industry and other stakeholders to be heard in the operation of the health benefit exchange.
(b) The board may establish technical advisory committees or seek the advice of technical experts when necessary to execute the powers and duties included in chapter 317, Laws of 2011.
(8) Members of the board are not civilly or criminally liable and may 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 chapter 317, Laws of 2011. Nothing in this section prohibits legal actions against the board to enforce the board's statutory or contractual duties or obligations.
(9) In recognition of the government-to-government relationship between the state of Washington and the federally recognized tribes in the state of Washington, the board shall consult with the American Indian health commission.
Sec. 4. RCW 43.71.030 and 2011 c 317 s 4 are each amended to read as follows:
(1) The exchange may, consistent with the purposes of
this chapter: (a) Sue and be sued in its own name; (b) make and execute
agreements, contracts, and other instruments, with any public or private person
or entity; (c) employ, contract with, or engage personnel; (d) pay administrative
costs; ((and)) (e) accept grants, donations, loans of funds, and
contributions in money, services, materials or otherwise, from the United
States or any of its agencies, from the state of Washington and its agencies or
from any other source, and use or expend those moneys, services, materials, or
other contributions; (f) aggregate or delegate the aggregation of funds that
comprise the premium for a health plan; and (g) complete other duties necessary
to begin open enrollment in qualified health plans through the exchange
beginning October 1, 2013.
(2) ((The powers and duties of the exchange and the
board are limited to those necessary to apply for and administer grants,
establish information technology infrastructure, and undertake additional
administrative functions necessary to begin operation of the exchange by
January 1, 2014. Any actions relating to substantive issues included in RCW
43.71.040 must be consistent with statutory direction on those issues.)) The
board shall develop a methodology to ensure the exchange is self-sustaining
after December 31, 2014. The board shall seek input from health carriers to
develop funding mechanisms that fairly and equitably apportion among carriers
the reasonable administrative costs and expenses incurred to implement the
provisions of this chapter. The board shall submit its recommendations to the
legislature by December 1, 2012. If the legislature does not enact legislation
during the 2013 regular session to modify or reject the board's
recommendations, the board may proceed with implementation of the
recommendations.
(3) The board shall establish policies that permit city and county
governments, Indian tribes, tribal organizations, urban Indian organizations,
private foundations, and other entities to pay premiums on behalf of qualified
individuals.
(4) The employees of the exchange may participate in the public
employees' retirement system under chapter 41.40 RCW and the public employees'
benefits board under chapter 41.05 RCW.
(5) Qualified employers may access coverage for their employees through
the exchange for small groups under section 1311 of P.L. 111-148 of 2010, as
amended. The exchange shall enable any qualified employer to specify a level
of coverage so that any of its employees may enroll in any qualified health
plan offered through the small group exchange at the specified level of
coverage.
(6) The exchange shall report its activities and status to the governor
and the legislature as requested, and no less often than annually.
Sec. 5. RCW 43.71.060 and 2011 c 317 s 7 are each amended to read as follows:
(1) The health benefit exchange account is created in
the custody of the state treasurer. All receipts from federal grants received
under the affordable care act ((shall)) may be deposited into the
account. Expenditures from the account may be used only for purposes
consistent with the grants. Until March 15, 2012, only the administrator of
the health care authority, or his or her designee, may authorize expenditures
from the account. Beginning March 15, 2012, only the board of the Washington
health benefit exchange or designee may authorize expenditures from the
account. The account is subject to allotment procedures under chapter 43.88
RCW, but an appropriation is not required for expenditures.
(2) This section expires January 1, 2014.
PART
III
MARKET RULES
NEW SECTION. Sec. 6. A new section is added to chapter 48.43 RCW to read as follows:
(1) For plan or policy years beginning January 1, 2014, a carrier must offer individual or small group health benefit plans that meet the definition of silver and gold level plans in section 1302 of P.L. 111-148 of 2010, as amended, in any market outside the exchange in which it offers a plan that meets the definition of bronze level in section 1302 of P.L. 111-148 of 2010, as amended.
(2) A health benefit plan meeting the definition of a catastrophic plan in RCW 48.43.005(8)(c)(i)may only be sold through the exchange.
(3) By December 1, 2016, the exchange board, in consultation with the commissioner, must complete a review of the impact of this section on the health and viability of the markets inside and outside the exchange and submit the recommendations to the legislature on whether to maintain the market rules or let them expire.
(4) The commissioner shall evaluate plans offered at each actuarial value defined in section 1302 of P.L. 111-148 of 2010, as amended, and determine whether variation in prescription drug benefit cost-sharing, both inside and outside the exchange in both the individual and small group markets results in adverse selection. If so, the commissioner may adopt rules to assure substantial equivalence of prescription drug cost-sharing.
NEW SECTION. Sec. 7. A new section is added to chapter 48.43 RCW to read as follows:
All health plans, other than catastrophic health plans, offered outside of the exchange must conform with the actuarial value tiers specified in section 1302 of P.L. 111-148 of 2010, as amended, as bronze, silver, gold, or platinum.
PART
IV
QUALIFIED HEALTH PLANS
NEW SECTION. Sec. 8. A new section is added to chapter 43.71 RCW to read as follows:
(1) The board shall certify a plan as a qualified health plan to be offered through the exchange if the plan is determined by the:
(a) Insurance commissioner to meet the requirements of Title 48 RCW and rules adopted by the commissioner pursuant to chapter 34.05 RCW to implement the requirements of Title 48 RCW;
(b) Board to meet the requirements of the affordable care act for certification as a qualified health plan; and
(c) Board to include tribal clinics and urban Indian clinics as essential community providers in the plan's provider network consistent with federal law. If consistent with federal law, integrated delivery systems shall be exempt from the requirement to include essential community providers in the provider network.
(2) Consistent with section 1311 of P.L. 111-148 of 2010, as amended, the board shall allow stand-alone dental plans to offer coverage in the exchange beginning January 1, 2014. Dental benefits offered in the exchange must be offered and priced separately to assure transparency for consumers.
(3) The board may permit direct primary care medical home plans, consistent with section 1301 of P.L. 111-148 of 2010, as amended, to be offered in the exchange beginning January 1, 2014.
(4) Upon request by the board, a state agency shall provide information to the board for its use in determining if the requirements under subsection (1)(b) or (c) of this section have been met. Unless the agency and the board agree to a later date, the agency shall provide the information within sixty days of the request. The exchange shall reimburse the agency for the cost of compiling and providing the requested information within one hundred eighty days of its receipt.
(5) A decision by the board denying a request to certify or recertify a plan as a qualified health plan may be appealed according to procedures adopted by the board.
NEW SECTION. Sec. 9. A new section is added to chapter 43.71 RCW to read as follows:
The board shall establish a rating system consistent with section 1311 of P.L. 111-148 of 2010, as amended, for qualified health plans to assist consumers in evaluating plan choices in the exchange. Rating factors established by the board may include, but are not limited to:
(1) Affordability with respect to premiums, deductibles, and point- of-service cost-sharing;
(2) Enrollee satisfaction;
(3) Provider reimbursement methods that incentivize health homes or chronic care management or care coordination for enrollees with complex, high-cost, or multiple chronic conditions;
(4) Promotion of appropriate primary care and preventive services utilization;
(5) High standards for provider network adequacy, including consumer choice of providers and service locations and robust provider participation intended to improve access to underserved populations through participation of essential community providers, family planning providers and pediatric providers;
(6) High standards for covered services, including languages spoken or transportation assistance; and
(7) Coverage of benefits for spiritual care services that are deductible under section 213(d) of the internal revenue code.
Sec. 10. RCW 48.42.010 and 1985 c 264 s 15 are each amended to read as follows:
(1) Notwithstanding any other provision of law, and except as provided in this chapter, any person or other entity which provides coverage in this state for life insurance, annuities, loss of time, medical, surgical, chiropractic, physical therapy, speech pathology, audiology, professional mental health, dental, hospital, or optometric expenses, whether the coverage is by direct payment, reimbursement, the providing of services, or otherwise, shall be subject to the authority of the state insurance commissioner, unless the person or other entity shows that while providing the services it is subject to the jurisdiction and regulation of another agency of this state, any subdivisions thereof, or the federal government.
(2) "Another agency of this state, any subdivision thereof, or the federal government" does not include the Washington health benefit exchange under chapter 43.71 RCW or P.L. 111-148 of 2010, as amended.
Sec. 11. RCW 48.42.020 and 1983 c 36 s 2 are each amended to read as follows:
(1) A person or entity may show that it is subject to the jurisdiction and regulation of another agency of this state, any subdivision thereof, or the federal government, by providing to the insurance commissioner the appropriate certificate, license, or other document issued by the other governmental agency which permits or qualifies it to provide the coverage as defined in RCW 48.42.010.
(2) "Another agency of this state, any subdivision thereof, or the federal government" does not include the Washington health benefit exchange under chapter 43.71 RCW or P.L. 111-148 of 2010, as amended.
NEW SECTION. Sec. 12. A new section is added to chapter 48.43 RCW to read as follows:
Certification by the Washington health benefit exchange of a plan as a qualified health plan, or of a carrier as a qualified issuer, does not exempt the plan or carrier from any of the requirements of this title or rules adopted by the commissioner pursuant to chapter 34.05 RCW to implement this title.
PART
V
ESSENTIAL HEALTH BENEFITS
NEW SECTION. Sec. 13. A new section is added to chapter 48.43 RCW to read as follows:
(1) Consistent with federal law, the commissioner, in consultation with the board and the health care authority, shall, by rule, select the largest small group plan in the state by enrollment as the benchmark plan for the individual and small group market for purposes of establishing the essential health benefits in Washington state under P.L. 111-148 of 2010, as amended.
(2) If the essential health benefits benchmark plan for the individual and small group market does not include all of the ten benefit categories specified by section 1302 of P.L. 111-148, as amended, the commissioner, in consultation with the board and the health care authority, shall, by rule, supplement the benchmark plan benefits as needed to meet the minimum requirements of section 1302.
(3) A health plan required to offer the essential health benefits, other than a health plan offered through the federal basic health program or medicaid, under P.L. 111-148 of 2010, as amended, may not be offered in the state unless the commissioner finds that it is substantially equal to the benchmark plan. When making this determination, the commissioner must:
(a) Ensure that the plan covers the ten essential health benefits categories specified in section 1302 of P.L. 111-148 of 2010, as amended; and
(b) May consider whether the health plan has a benefit design that would create a risk of biased selection based on health status and whether the health plan contains meaningful scope and level of benefits in each of the ten essential health benefit categories specified by section 1302 of P.L. 111-148 of 2010, as amended.
(4) Beginning December 15, 2012, and every year thereafter, the commissioner shall submit to the legislature a list of state-mandated health benefits, the enforcement of which will result in federally imposed costs to the state related to the plans sold through the exchange because the benefits are not included in the essential health benefits designated under federal law. The list must include the anticipated costs to the state of each state-mandated health benefit on the list and any statutory changes needed if funds are not appropriated to defray the state costs for the listed mandate. The commissioner may enforce a mandate on the list for the entire market only if funds are appropriated in an omnibus appropriations act specifically to pay the state portion of the identified costs.
NEW SECTION. Sec. 14. Nothing in this act prohibits the offering of benefits for spiritual care services deductible under section 213(d) of the internal revenue code in health plans inside and outside of the exchange.
PART
VI
THE BASIC HEALTH OPTION
NEW SECTION. Sec. 15. A new section is added to chapter 70.47 RCW to read as follows:
(1) On or before December 1, 2012, the director of the health care authority shall submit a report to the legislature on whether to proceed with implementation of a federal basic health option, under section 1331 of P.L. 111-148 of 2010, as amended. The report shall address whether:
(a) Sufficient funding is available to support the design and development work necessary for the program to provide health coverage to enrollees beginning January 1, 2014;
(b) Anticipated federal funding under section 1331 will be sufficient, absent any additional state funding, to cover the provision of essential health benefits and costs for administering the basic health plan. Enrollee premium levels will be below the levels that would apply to persons with income between one hundred thirty-four and two hundred percent of the federal poverty level through the exchange; and
(c) Health plan payment rates will be sufficient to ensure enrollee access to a robust provider network and health homes, as described under RCW 70.47.100.
(2) If the legislature determines to proceed with implementation of a federal basic health option, the director shall provide the necessary certifications to the secretary of the federal department of health and human services under section 1331 of P.L. 111-148 of 2010, as amended, to proceed with adoption of the federal basic health program option.
(3) Prior to making this finding, the director shall:
(a) Actively consult with the board of the Washington health benefit exchange, the office of the insurance commissioner, consumer advocates, provider organizations, carriers, and other interested organizations;
(b) Consider any available objective analysis specific to Washington state, by an independent nationally recognized consultant that has been actively engaged in analysis and economic modeling of the federal basic health program option for multiple states.
(4) The director shall report any findings and supporting analysis made under this section to the governor and relevant policy and fiscal committees of the legislature.
(5) To the extent funding is available specifically for this purpose in the operating budget, the health care authority shall assume the federal basic health plan option will be implemented in Washington state, and initiate the necessary design and development work. If the legislature determines under subsection (1) of this section not to proceed with implementation, the authority may cease activities related to basic health program implementation.
(6) If implemented, the federal basic health program must be guided by the following principles:
(a) Meeting the minimum state certification standards in section 1331 of the federal patient protection and affordable care act;
(b) To the extent allowed by the federal department of health and human services, twelve-month continuous eligibility for the basic health program, and corresponding twelve-month continuous enrollment in standard health plans by enrollees; or, in lieu of twelve-month continuous eligibility, financing mechanisms that enable enrollees to remain with a plan for the entire plan year;
(c) Achieving an appropriate balance between:
(i) Premiums and cost-sharing minimized to increase the affordability of insurance coverage;
(ii) Standard health plan contracting requirements that minimize plan and provider administrative costs, while incentivizing improvements in quality and enrollee health outcomes; and
(iii) Health plan payment rates and provider payment rates that are sufficient to ensure enrollee access to a robust provider network and health homes, as described under RCW 70.47.100; and
(d) Transparency in program administration, including active and ongoing consultation with basic health program enrollees and interested organizations, and ensuring adequate enrollee notice and appeal rights.
PART
VII
RISK ADJUSTMENT AND REINSURANCE
NEW SECTION. Sec. 16. A new section is added to chapter 48.43 RCW to read as follows:
(1)(a) The commissioner, in consultation with the board, shall adopt rules establishing the reinsurance and risk adjustment programs required by P.L. 111-148 of 2010, as amended.
(b) The commissioner must include in deliberations related to reinsurance rule making an analysis of an invisible high risk pool option, in which the full premium and risk associated with certain high-risk or high-cost enrollees would be ceded to the transitional reinsurance program. The analysis must include a determination as to whether that option is authorized under the federal reinsurance program regulations, whether the option would provide sufficiently comprehensive coverage for current nonmedicare high risk pool enrollees, and how an invisible high risk pool option could be designed to ensure that carriers ceding risk provide effective care management to high-risk or high-cost enrollees.
(2) Consistent with federal law, the rules for the reinsurance program must, at a minimum, establish:
(a) A mechanism to collect reinsurance contribution funds;
(b) A reinsurance payment formula; and
(c) A mechanism to disburse reinsurance payments.
(3)(a) The commissioner may adjust the rules adopted under this section as needed to preserve a healthy market both inside and outside of the exchange.
(b) The rules adopted under this section must identify and may require submission of the data needed to support operation of the reinsurance and risk adjustment programs established under this section. The commissioner must identify by rule the sources of the data, and other requirements related to the collection, validation, correction, interpretation, transmission or exchange, and retention of the data.
(4) The commissioner shall contract with one or more nonprofit entities to administer the risk adjustment and reinsurance programs.
(5) Contribution amounts for the transitional reinsurance program under section 1341 of P.L. 111-148 of 2010, as amended, may be increased to include amounts sufficient to cover the costs of administration of the reinsurance program including reasonable costs incurred for preoperational and planning activities related to the reinsurance program.
PART
VIII
THE WASHINGTON STATE HEALTH INSURANCE POOL
NEW SECTION. Sec. 17. A new section is added to chapter 48.41 RCW to read as follows:
(1) The board shall review populations that may need ongoing access to coverage through the pool, with specific attention to those persons who may be excluded from or may receive inadequate coverage beginning January 1, 2014, such as persons with end-stage renal disease or HIV/AIDS, or persons not eligible for coverage in the exchange.
(2) If the review under subsection (1) of this section indicates a continued need for coverage through the pool after December 31, 2013, the board shall submit recommendations regarding any modifications to pool eligibility requirements for new and ongoing enrollment after December 31, 2013. The recommendations must address any needed modifications to the standard health questionnaire or other eligibility screening tool that could be used in a manner consistent with federal law to determine eligibility for enrollment in the pool.
(3) The board shall complete an analysis of current pool assessment requirements in relation to assessments that will fund the reinsurance program and recommend changes to pool assessments or any credits against assessments that may be considered for the reinsurance program. The analysis shall recommend whether the categories of members paying assessments should be adjusted to make the assessment fair and equitable among all payers.
(4) The board shall report its recommendations to the governor and the legislature by December 1, 2012.
NEW SECTION. Sec. 18. A new section is added to chapter 48.41 RCW to read as follows:
(1) The pool is authorized to contract with the commissioner to administer risk management functions if necessary, consistent with section 16 of this act, and consistent with P.L. 111-148 of 2010, as amended. Prior to entering into a contract, the pool may conduct preoperational and planning activities related to these programs, including defining and implementing an appropriate legal structure or structures to administer and coordinate the reinsurance or risk adjustment programs.
(2) The reasonable costs incurred by the pool for preoperational and planning activities related to the reinsurance program may be reimbursed from federal funds or from the additional contributions authorized under section 16 of this act to pay the administrative costs of the reinsurance program.
(3) If the pool contracts to administer and coordinate the reinsurance or risk adjustment program, the board must submit recommendations to the legislature with suggestions for additional consumer representatives or other representative members to the board.
(4) The pool shall report on these activities to the appropriate committees of the senate and house of representatives by December 15, 2012, and December 15, 2013.
PART
IX
EXCHANGE EMPLOYEES
NEW SECTION. Sec. 19. A new section is added to chapter 41.04 RCW to read as follows:
Except for chapters 41.05 and 41.40 RCW, this title does not apply to any position in or employee of the Washington health benefit exchange established in chapter 43.71 RCW.
NEW SECTION. Sec. 20. A new section is added to chapter 43.01 RCW to read as follows:
This chapter does not apply to any position in or employee of the Washington health benefit exchange established in chapter 43.71 RCW.
NEW SECTION. Sec. 21. A new section is added to chapter 43.03 RCW to read as follows:
This chapter does not apply to any position in or employee of the Washington health benefit exchange established in chapter 43.71 RCW.
Sec. 22. RCW 41.05.011 and 2011 1st sp.s. c 15 s 54 are each reenacted and amended to read as follows:
The definitions in this section apply throughout this chapter unless the context clearly requires otherwise.
(1) "Authority" means the Washington state health care authority.
(2) "Board" means the public employees' benefits board established under RCW 41.05.055.
(3) "Dependent care assistance program" means a benefit plan whereby state and public employees may pay for certain employment related dependent care with pretax dollars as provided in the salary reduction plan under this chapter pursuant to 26 U.S.C. Sec. 129 or other sections of the internal revenue code.
(4) "Director" means the director of the authority.
(5) "Emergency service personnel killed in the line of duty" means law enforcement officers and firefighters as defined in RCW 41.26.030, members of the Washington state patrol retirement fund as defined in RCW 43.43.120, and reserve officers and firefighters as defined in RCW 41.24.010 who die as a result of injuries sustained in the course of employment as determined consistent with Title 51 RCW by the department of labor and industries.
(6) "Employee" includes all employees of the
state, whether or not covered by civil service; elected and appointed officials
of the executive branch of government, including full-time members of boards,
commissions, or committees; justices of the supreme court and judges of the
court of appeals and the superior courts; and members of the state
legislature. Pursuant to contractual agreement with the authority,
"employee" may also include: (a) Employees of a county,
municipality, or other political subdivision of the state and members of the
legislative authority of any county, city, or town who are elected to office after
February 20, 1970, if the legislative authority of the county, municipality, or
other political subdivision of the state seeks and receives the approval of the
authority to provide any of its insurance programs by contract with the
authority, as provided in RCW 41.04.205 and 41.05.021(1)(g); (b) employees of
employee organizations representing state civil service employees, at the
option of each such employee organization, and, effective October 1, 1995,
employees of employee organizations currently pooled with employees of school
districts for the purpose of purchasing insurance benefits, at the option of
each such employee organization; (c) employees of a school district if the
authority agrees to provide any of the school districts' insurance programs by
contract with the authority as provided in RCW 28A.400.350; ((and)) (d)
employees of a tribal government, if the governing body of the tribal
government seeks and receives the approval of the authority to provide any of
its insurance programs by contract with the authority, as provided in RCW
41.05.021(1) (f) and (g); and (e) employees of the Washington health benefit
exchange if the governing board of the exchange established in RCW 43.71.020
seeks and receives approval of the authority to provide any of its insurance
programs by contract with the authority, as provided in RCW 41.05.021(1) (g)
and (n). "Employee" does not include: Adult family homeowners;
unpaid volunteers; patients of state hospitals; inmates; employees of the
Washington state convention and trade center as provided in RCW 41.05.110;
students of institutions of higher education as determined by their
institution; and any others not expressly defined as employees under this
chapter or by the authority under this chapter.
(7) "Employer" means the state of Washington.
(8) "Employing agency" means a division, department, or separate agency of state government, including an institution of higher education; a county, municipality, school district, educational service district, or other political subdivision; and a tribal government covered by this chapter.
(9) "Faculty" means an academic employee of an institution of higher education whose workload is not defined by work hours but whose appointment, workload, and duties directly serve the institution's academic mission, as determined under the authority of its enabling statutes, its governing body, and any applicable collective bargaining agreement.
(10) "Flexible benefit plan" means a benefit plan that allows employees to choose the level of health care coverage provided and the amount of employee contributions from among a range of choices offered by the authority.
(11) "Insuring entity" means an insurer as defined in chapter 48.01 RCW, a health care service contractor as defined in chapter 48.44 RCW, or a health maintenance organization as defined in chapter 48.46 RCW.
(12) "Medical flexible spending arrangement" means a benefit plan whereby state and public employees may reduce their salary before taxes to pay for medical expenses not reimbursed by insurance as provided in the salary reduction plan under this chapter pursuant to 26 U.S.C. Sec. 125 or other sections of the internal revenue code.
(13) "Participant" means an individual who fulfills the eligibility and enrollment requirements under the salary reduction plan.
(14) "Plan year" means the time period established by the authority.
(15) "Premium payment plan" means a benefit plan whereby state and public employees may pay their share of group health plan premiums with pretax dollars as provided in the salary reduction plan under this chapter pursuant to 26 U.S.C. Sec. 125 or other sections of the internal revenue code.
(16) "Retired or disabled school employee" means:
(a) Persons who separated from employment with a school district or educational service district and are receiving a retirement allowance under chapter 41.32 or 41.40 RCW as of September 30, 1993;
(b) Persons who separate from employment with a school district or educational service district on or after October 1, 1993, and immediately upon separation receive a retirement allowance under chapter 41.32, 41.35, or 41.40 RCW;
(c) Persons who separate from employment with a school district or educational service district due to a total and permanent disability, and are eligible to receive a deferred retirement allowance under chapter 41.32, 41.35, or 41.40 RCW.
(17) "Salary" means a state employee's monthly salary or wages.
(18) "Salary reduction plan" means a benefit plan whereby state and public employees may agree to a reduction of salary on a pretax basis to participate in the dependent care assistance program, medical flexible spending arrangement, or premium payment plan offered pursuant to 26 U.S.C. Sec. 125 or other sections of the internal revenue code.
(19) "Seasonal employee" means an employee hired to work during a recurring, annual season with a duration of three months or more, and anticipated to return each season to perform similar work.
(20) "Separated employees" means persons who separate from employment with an employer as defined in:
(a) RCW 41.32.010(17) on or after July 1, 1996; or
(b) RCW 41.35.010 on or after September 1, 2000; or
(c) RCW 41.40.010 on or after March 1, 2002;
and who are at least age fifty-five and have at least ten years of service under the teachers' retirement system plan 3 as defined in RCW 41.32.010(33), the Washington school employees' retirement system plan 3 as defined in RCW 41.35.010, or the public employees' retirement system plan 3 as defined in RCW 41.40.010.
(21) "State purchased health care" or "health care" means medical and health care, pharmaceuticals, and medical equipment purchased with state and federal funds by the department of social and health services, the department of health, the basic health plan, the state health care authority, the department of labor and industries, the department of corrections, the department of veterans affairs, and local school districts.
(22) "Tribal government" means an Indian tribal government as defined in section 3(32) of the employee retirement income security act of 1974, as amended, or an agency or instrumentality of the tribal government, that has government offices principally located in this state.
Sec. 23. RCW 41.05.021 and 2011 1st sp.s. c 15 s 56 are each amended to read as follows:
(1) The Washington state health care authority is created within the executive branch. The authority shall have a director appointed by the governor, with the consent of the senate. The director shall serve at the pleasure of the governor. The director may employ a deputy director, and such assistant directors and special assistants as may be needed to administer the authority, who shall be exempt from chapter 41.06 RCW, and any additional staff members as are necessary to administer this chapter. The director may delegate any power or duty vested in him or her by law, including authority to make final decisions and enter final orders in hearings conducted under chapter 34.05 RCW. The primary duties of the authority shall be to: Administer state employees' insurance benefits and retired or disabled school employees' insurance benefits; administer the basic health plan pursuant to chapter 70.47 RCW; administer the children's health program pursuant to chapter 74.09 RCW; study state-purchased health care programs in order to maximize cost containment in these programs while ensuring access to quality health care; implement state initiatives, joint purchasing strategies, and techniques for efficient administration that have potential application to all state-purchased health services; and administer grants that further the mission and goals of the authority. The authority's duties include, but are not limited to, the following:
(a) To administer health care benefit programs for employees and retired or disabled school employees as specifically authorized in RCW 41.05.065 and in accordance with the methods described in RCW 41.05.075, 41.05.140, and other provisions of this chapter;
(b) To analyze state-purchased health care programs and to explore options for cost containment and delivery alternatives for those programs that are consistent with the purposes of those programs, including, but not limited to:
(i) Creation of economic incentives for the persons for whom the state purchases health care to appropriately utilize and purchase health care services, including the development of flexible benefit plans to offset increases in individual financial responsibility;
(ii) Utilization of provider arrangements that encourage cost containment, including but not limited to prepaid delivery systems, utilization review, and prospective payment methods, and that ensure access to quality care, including assuring reasonable access to local providers, especially for employees residing in rural areas;
(iii) Coordination of state agency efforts to purchase drugs effectively as provided in RCW 70.14.050;
(iv) Development of recommendations and methods for purchasing medical equipment and supporting services on a volume discount basis;
(v) Development of data systems to obtain utilization data from state-purchased health care programs in order to identify cost centers, utilization patterns, provider and hospital practice patterns, and procedure costs, utilizing the information obtained pursuant to RCW 41.05.031; and
(vi) 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;
(c) To analyze areas of public and private health care interaction;
(d) To provide information and technical and administrative assistance to the board;
(e) To review and approve or deny applications from counties, municipalities, and other political subdivisions of the state to provide state-sponsored insurance or self-insurance programs to their employees in accordance with the provisions of RCW 41.04.205 and (g) of this subsection, setting the premium contribution for approved groups as outlined in RCW 41.05.050;
(f) To review and approve or deny the application when the governing body of a tribal government applies to transfer their employees to an insurance or self‑insurance program administered under this chapter. In the event of an employee transfer pursuant to this subsection (1)(f), members of the governing body are eligible to be included in such a transfer if the members are authorized by the tribal government to participate in the insurance program being transferred from and subject to payment by the members of all costs of insurance for the members. The authority shall: (i) Establish the conditions for participation; (ii) have the sole right to reject the application; and (iii) set the premium contribution for approved groups as outlined in RCW 41.05.050. Approval of the application by the authority transfers the employees and dependents involved to the insurance, self‑insurance, or health care program approved by the authority;
(g) To ensure the continued status of the employee insurance or self-insurance programs administered under this chapter as a governmental plan under section 3(32) of the employee retirement income security act of 1974, as amended, the authority shall limit the participation of employees of a county, municipal, school district, educational service district, or other political subdivision, the Washington health benefit exchange, or a tribal government, including providing for the participation of those employees whose services are substantially all in the performance of essential governmental functions, but not in the performance of commercial activities;
(h) To establish billing procedures and collect funds from school districts in a way that minimizes the administrative burden on districts;
(i) To publish and distribute to nonparticipating school districts and educational service districts by October 1st of each year a description of health care benefit plans available through the authority and the estimated cost if school districts and educational service district employees were enrolled;
(j) To apply for, receive, and accept grants, gifts, and other payments, including property and service, from any governmental or other public or private entity or person, and make arrangements as to the use of these receipts to implement initiatives and strategies developed under this section;
(k) To issue, distribute, and administer grants that further the mission and goals of the authority;
(l) To adopt rules consistent with this chapter as described in RCW 41.05.160 including, but not limited to:
(i) Setting forth the criteria established by the board under RCW 41.05.065 for determining whether an employee is eligible for benefits;
(ii) Establishing an appeal process in accordance with chapter 34.05 RCW by which an employee may appeal an eligibility determination;
(iii) Establishing a process to assure that the eligibility determinations of an employing agency comply with the criteria under this chapter, including the imposition of penalties as may be authorized by the board;
(m)(i) To administer the medical services programs established under chapter 74.09 RCW as the designated single state agency for purposes of Title XIX of the federal social security act;
(ii) To administer the state children's health insurance program under chapter 74.09 RCW for purposes of Title XXI of the federal social security act;
(iii) To enter into agreements with the department of social and health services for administration of medical care services programs under Titles XIX and XXI of the social security act. The agreements shall establish the division of responsibilities between the authority and the department with respect to mental health, chemical dependency, and long-term care services, including services for persons with developmental disabilities. The agreements shall be revised as necessary, to comply with the final implementation plan adopted under section 116, chapter 15, Laws of 2011 1st sp. sess.;
(iv) To adopt rules to carry out the purposes of chapter 74.09 RCW;
(v) To appoint such advisory committees or councils as
may be required by any federal statute or regulation as a condition to the
receipt of federal funds by the authority. The director may appoint statewide
committees or councils in the following subject areas: (A) Health facilities;
(B) children and youth services; (C) blind services; (D) medical and health
care; (E) drug abuse and alcoholism; (F) rehabilitative services; and (G) such
other subject matters as are or come within the authority's responsibilities.
The statewide councils shall have representation from both major political
parties and shall have substantial consumer representation. Such committees or
councils shall be constituted as required by federal law or as the director in
his or her discretion may determine. The members of the committees or councils
shall hold office for three years except in the case of a vacancy, in which
event appointment shall be only for the remainder of the unexpired term for
which the vacancy occurs. No member shall serve more than two consecutive
terms. Members of such state advisory committees or councils may be paid their
travel expenses in accordance with RCW 43.03.050 and 43.03.060 as now existing
or hereafter amended;
(n) To review and approve or deny the application from the governing
board of the Washington health benefit exchange to provide state-sponsored
insurance or self-insurance programs to employees of the exchange. The
authority shall (i) establish the conditions for participation; (ii) have the
sole right to reject an application; and (iii) set the premium contribution for
approved groups as outlined in RCW 41.05.050.
(2) On and after January 1, 1996, the public employees' benefits board may implement strategies to promote managed competition among employee health benefit plans. Strategies may include but are not limited to:
(a) Standardizing the benefit package;
(b) Soliciting competitive bids for the benefit package;
(c) Limiting the state's contribution to a percent of the lowest priced qualified plan within a geographical area;
(d) Monitoring the impact of the approach under this subsection with regards to: Efficiencies in health service delivery, cost shifts to subscribers, access to and choice of managed care plans statewide, and quality of health services. The health care authority shall also advise on the value of administering a benchmark employer-managed plan to promote competition among managed care plans.
PART
X
MISCELLANEOUS
NEW SECTION. Sec. 24. The health care authority shall pursue an application for the state to participate in the individual market wellness program demonstration as described in section 2705 of P.L. 111-148 of 2010, as amended. The health care authority shall pursue activities that will prepare the state to apply for the demonstration project once announced by the United States department of health and human services.
NEW SECTION. Sec. 25. A new section is added to chapter 43.71 RCW to read as follows:
A person or entity functioning as a navigator consistent with the requirements of section 1311(i) of P.L. 111-148 of 2010, as amended, shall not be considered soliciting or negotiating insurance as stated under chapter 48.17 RCW.
NEW SECTION. Sec. 26. A new section is added to chapter 43.71 RCW to read as follows:
If at any time the exchange is no longer self-sustaining as defined in RCW 43.71.010, the operations of the exchange shall be suspended.
NEW SECTION. Sec. 27. 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. 28. Sections 4, 16, 18, and 19 through 23 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 immediately."
E2SHB 2319 - S COMM AMD
By Committee on Health & Long-Term Care
On page 1, line 2 of the title, after "act;" strike the remainder of the title and insert "amending RCW 43.71.010, 43.71.020, 43.71.030, 43.71.060, 48.42.010, 48.42.020, and 41.05.021; reenacting and amending RCW 48.43.005 and 41.05.011; adding new sections to chapter 48.43 RCW; adding new sections to chapter 43.71 RCW; adding a new section to chapter 70.47 RCW; adding new sections to chapter 48.41 RCW; adding a new section to chapter 41.04 RCW; adding a new section to chapter 43.01 RCW; adding a new section to chapter 43.03 RCW; creating new sections; providing an expiration date; and declaring an emergency."
|
|
EFFECT: EFFECT Definitions: Modified definition
of "self-sustaining" to remove the word "participating." |
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