| State of Washington | 62nd Legislature | 2011 Regular Session |
READ FIRST TIME 03/24/11.
AN ACT Relating to changing the designation of the medicaid single state agency from the department of social and health services to the health care authority and transferring the related powers, functions, and duties to the health care authority; amending RCW 74.09.037, 74.09.050, 74.09.055, 74.09.075, 74.09.080, 74.09.120, 74.09.160, 74.09.180, 74.09.185, 74.09.190, 74.09.200, 74.09.210, 74.09.240, 74.09.260, 74.09.280, 74.09.290, 74.09.300, 74.09.470, 74.09.480, 74.09.490, 74.09.500, 74.09.510, 74.09.515, 74.09.520, 74.09.521, 74.09.5222, 74.09.5225, 74.09.530, 74.09.540, 74.09.555, 74.09.565, 74.09.575, 74.09.585, 74.09.595, 74.09.655, 74.09.658, 74.09.659, 74.09.700, 74.09.710, 74.09.715, 74.09.720, 74.09.725, 74.09.730, 74.09.770, 74.09.790, 74.09.800, 74.09.810, 74.09.820, 41.05.011, 41.05.015, 41.05.021, 41.05.036, 41.05.037, 41.05.140, 41.05.185, 43.20A.365, 74.04.005, 74.04.015, 74.04.025, 74.04.050, 74.04.055, 74.04.060, 74.04.062, 74.04.290, 7.68.080, 43.41.160, 43.41.260, 43.70.670, 47.06B.020, 47.06B.060, 47.06B.070, 48.01.235, 48.43.008, 48.43.517, 69.41.030, 69.41.190, 70.01.010, 70.47.010, 70.47.110, 70.48.130, 70.168.040, 70.225.040, 74.09A.005, 74.09A.010, 74.09A.020, 74.09A.030, and 74.09.015; reenacting and amending RCW 74.09.010, 74.09.035, 74.09.522, and 70.47.020; adding new sections to chapter 74.09 RCW; adding a new section to chapter 43.20A RCW; adding a new chapter to Title 41 RCW; creating new sections; recodifying RCW 43.20A.365; repealing RCW 74.09.085, 74.09.110, 74.09.5221, 74.09.5227, 74.09.755, 43.20A.860, and 74.04.270; providing an effective date; providing an expiration date; and declaring an emergency.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF WASHINGTON:
NEW SECTION. Sec. 1 The legislature finds that:
(1) Washington state government must be organized to be efficient,
cost-effective, and responsive to its residents;
(2) The cost of state-purchased health care continues to grow at an
unsustainable rate, now representing nearly one-third of the state's
budget and hindering our ability to invest in other essential services
such as education and public safety;
(3) Responsibility for state health care purchasing is currently
spread over multiple agencies, but successful interagency collaboration
on quality and cost initiatives has helped demonstrate the benefits to
the state of centralized health care purchasing;
(4) Consolidating the majority of state health care purchasing into
a single state agency will best position the state to work with others,
including private sector purchasers, health insurance carriers, health
care providers, and consumers to increase the quality and affordability
of health care for all state residents;
(5) The development and implementation of uniform state policies
for all state-purchased health care is among the purposes for which the
health care authority was originally created; and
(6) The state will be best able to take advantage of the
opportunities and meet its obligations under the federal affordable
care act, including establishment of a health benefit exchange and
medicaid expansion, if primary responsibility for doing so rests with
a single state agency.
The legislature therefore intends, where appropriate, to
consolidate state health care purchasing within the health care
authority, positioning the state to use its full purchasing power to
get the greatest value for its money, and allowing other agencies to
focus even more intently on their core missions.
Sec. 2 RCW 74.09.010 and 2010 1st sp.s. c 8 s 28 are each
reenacted and amended to read as follows:
((As used in this chapter:)) 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) "Children's health program" means the health care services
program provided to children under eighteen years of age and in
households with incomes at or below the federal poverty level as
annually defined by the federal department of health and human services
as adjusted for family size, and who are not otherwise eligible for
medical assistance or the limited casualty program for the medically
needy.
(((2) "Committee" means the children's health services committee
created in section 3 of this act.))
(3) "County" means the board of county commissioners, county
council, county executive, or tribal jurisdiction, or its designee.
((A combination of two or more county authorities or tribal
jurisdictions may enter into joint agreements to fulfill the
requirements of RCW 74.09.415 through 74.09.435.))
(4) "Department" means the department of social and health
services.
(5) "Department of health" means the Washington state department of
health created pursuant to RCW 43.70.020.
(6) "Director" means the director of the Washington state health
care authority.
(7) "Full benefit dual eligible beneficiary" means an individual
who, for any month: Has coverage for the month under a medicare
prescription drug plan or medicare advantage plan with part D coverage;
and is determined eligible by the state for full medicaid benefits for
the month under any eligibility category in the state's medicaid plan
or a section 1115 demonstration waiver that provides pharmacy benefits.
(((7))) (8) "Internal management" means the administration of
medical assistance, medical care services, the children's health
program, and the limited casualty program.
(((8))) (9) "Limited casualty program" means the medical care
program provided to medically needy persons as defined under Title XIX
of the federal social security act, and to medically indigent persons
who are without income or resources sufficient to secure necessary
medical services.
(((9))) (10) "Medical assistance" means the federal aid medical
care program provided to categorically needy persons as defined under
Title XIX of the federal social security act.
(((10))) (11) "Medical care services" means the limited scope of
care financed by state funds and provided to disability lifeline
benefits recipients, and recipients of alcohol and drug addiction
services provided under chapter 74.50 RCW.
(((11))) (12) "Nursing home" means nursing home as defined in RCW
18.51.010.
(((12))) (13) "Poverty" means the federal poverty level determined
annually by the United States department of health and human services,
or successor agency.
(((13))) (14) "Secretary" means the secretary of social and health
services.
Sec. 3 RCW 74.09.035 and 2010 1st sp.s. c 8 s 29 and 2010 c 94 s
22 are each reenacted and amended to read as follows:
(1) To the extent of available funds, medical care services may be
provided to recipients of disability lifeline benefits, persons denied
disability lifeline benefits under RCW 74.04.005(5)(b) or 74.04.655 who
otherwise meet the requirements of RCW 74.04.005(5)(a), and recipients
of alcohol and drug addiction services provided under chapter 74.50
RCW, in accordance with medical eligibility requirements established by
the ((department)) authority. To the extent authorized in the
operating budget, upon implementation of a federal medicaid 1115 waiver
providing federal matching funds for medical care services, these
services also may be provided to persons who have been terminated from
disability lifeline benefits under RCW 74.04.005(5)(h).
(2) Determination of the amount, scope, and duration of medical
care services shall be limited to coverage as defined by the
((department)) authority, except that adult dental, and routine foot
care shall not be included unless there is a specific appropriation for
these services.
(3) The ((department)) authority shall enter into performance-based
contracts with one or more managed health care systems for the
provision of medical care services to recipients of disability lifeline
benefits. The contract must provide for integrated delivery of medical
and mental health services.
(4) The ((department)) authority shall establish standards of
assistance and resource and income exemptions, which may include
deductibles and co-insurance provisions. In addition, the
((department)) authority may include a prohibition against the
voluntary assignment of property or cash for the purpose of qualifying
for assistance.
(5) Residents of skilled nursing homes, intermediate care
facilities, and intermediate care facilities for ((the mentally
retarded)) persons with intellectual disabilities, as that term is
described by federal law, who are eligible for medical care services
shall be provided medical services to the same extent as provided to
those persons eligible under the medical assistance program.
(6) Payments made by the ((department)) authority under this
program shall be the limit of expenditures for medical care services
solely from state funds.
(7) Eligibility for medical care services shall commence with the
date of certification for disability lifeline benefits or the date of
eligibility for alcohol and drug addiction services provided under
chapter 74.50 RCW.
Sec. 4 RCW 74.09.037 and 2004 c 115 s 3 are each amended to read
as follows:
Any card issued ((after December 31, 2005,)) by the ((department))
authority or a managed health care system to a person receiving
services under this chapter, that must be presented to providers for
purposes of claims processing, may not display an identification number
that includes more than a four-digit portion of the person's complete
social security number.
Sec. 5 RCW 74.09.050 and 2000 c 5 s 15 are each amended to read
as follows:
(1) The ((secretary)) director shall appoint such professional
personnel and other assistants and employees, including professional
medical screeners, as may be reasonably necessary to carry out the
provisions of this chapter. The medical screeners shall be supervised
by one or more physicians who shall be appointed by the ((secretary))
director or his or her designee. The ((secretary)) director shall
appoint a medical director who is licensed under chapter 18.57 or 18.71
RCW.
(2) Whenever the director's authority is not specifically limited
by law, he or she has complete charge and supervisory powers over the
authority. The director is authorized to create such administrative
structures as deemed appropriate, except as otherwise specified by law.
The director has the power to employ such assistants and personnel as
may be necessary for the general administration of the authority.
Except as elsewhere specified, such employment must be in accordance
with the rules of the state civil service law, chapter 41.06 RCW.
Sec. 6 RCW 74.09.055 and 2006 c 24 s 1 are each amended to read
as follows:
The ((department)) authority is authorized to establish copayment,
deductible, or coinsurance, or other cost-sharing requirements for
recipients of any medical programs defined in RCW 74.09.010, except
that premiums shall not be imposed on children in households at or
below two hundred percent of the federal poverty level.
Sec. 7 RCW 74.09.075 and 1979 c 141 s 337 are each amended to
read as follows:
The department or authority, as appropriate, shall provide (((a)))
(1) for evaluation of employability when a person is applying for
public assistance representing a medical condition as a basis for need,
and (((b))) (2) for medical reports to be used in the evaluation of
total and permanent disability. It shall further provide for medical
consultation and assistance in determining the need for special diets,
housekeeper and attendant services, and other requirements as found
necessary because of the medical condition under the rules promulgated
by the secretary or director.
Sec. 8 RCW 74.09.080 and 1979 c 141 s 338 are each amended to
read as follows:
In carrying out the administrative responsibility of this chapter,
the department or authority, as appropriate:
(1) May contract with an individual or a group, may utilize
existing local state public assistance offices, or establish separate
welfare medical care offices on a county or multicounty unit basis as
found necessary; and
(2) Shall determine both financial and functional eligibility for
persons applying for long-term care services under chapter 74.39 or
74.39A RCW as a unified process in a single long-term care
organizational unit.
Sec. 9 RCW 74.09.120 and 2010 c 94 s 23 are each amended to read
as follows:
((The department shall purchase necessary physician and dentist
services by contract or "fee for service.")) (1) The department shall
purchase nursing home care by contract and payment for the care shall
be in accordance with the provisions of chapter 74.46 RCW and rules
adopted by the department ((under the authority of RCW 74.46.800)). No
payment shall be made to a nursing home which does not permit
inspection by the authority and the department ((of social and health
services)) of every part of its premises and an examination of all
records, including financial records, methods of administration,
general and special dietary programs, the disbursement of drugs and
methods of supply, and any other records the authority or the
department deems relevant to the regulation of nursing home operations,
enforcement of standards for resident care, and payment for nursing
home services.
(2) The department may purchase nursing home care by contract in
veterans' homes operated by the state department of veterans affairs
and payment for the care shall be in accordance with the provisions of
chapter 74.46 RCW and rules adopted by the department under the
authority of RCW 74.46.800.
(3) The department may purchase care in institutions for persons
with intellectual disabilities, also known as intermediate care
facilities for persons with intellectual disabilities. The department
shall establish rules for reasonable accounting and reimbursement
systems for such care. Institutions for persons with intellectual
disabilities include licensed nursing homes, public institutions,
licensed boarding homes with fifteen beds or less, and hospital
facilities certified as intermediate care facilities for persons with
intellectual disabilities under the federal medicaid program to provide
health, habilitative, or rehabilitative services and twenty-four hour
supervision for persons with intellectual disabilities or related
conditions and includes in the program "active treatment" as federally
defined.
(4) The department may purchase care in institutions for mental
diseases by contract. The department shall establish rules for
reasonable accounting and reimbursement systems for such care.
Institutions for mental diseases are certified under the federal
medicaid program and primarily engaged in providing diagnosis,
treatment, or care to persons with mental diseases, including medical
attention, nursing care, and related services.
(5) Both the department and the authority may each purchase all
other services provided under this chapter by contract or at rates
established by the department or the authority respectively.
Sec. 10 RCW 74.09.160 and 1991 c 103 s 1 are each amended to read
as follows:
Each vendor or group who has a contract and is rendering service to
eligible persons as defined in this chapter shall submit such charges
as agreed upon between the department or authority, as appropriate, and
the individual or group no later than twelve months from the date of
service. If the final charges are not presented within the twelve-month period, they shall not be a charge against the state. Said
twelve-month period may also be extended by regulation, but only if
required by applicable federal law or regulation, and to no more than
the extension of time so required. ((For services rendered prior to
July 28, 1991, final charges shall not be a charge against the state
unless they are presented within one hundred twenty days from the date
of service.))
Sec. 11 RCW 74.09.180 and 1997 c 236 s 1 are each amended to read
as follows:
(1) The provisions of this chapter shall not apply to recipients
whose personal injuries are occasioned by negligence or wrong of
another: PROVIDED, HOWEVER, That the ((secretary)) director may
furnish assistance, under the provisions of this chapter, for the
results of injuries to or illness of a recipient, and the
((department)) authority shall thereby be subrogated to the recipient's
rights against the recovery had from any tort feasor or the tort
feasor's insurer, or both, and shall have a lien thereupon to the
extent of the value of the assistance furnished by the ((department))
authority. To secure reimbursement for assistance provided under this
section, the ((department)) authority may pursue its remedies under
((RCW 43.20B.060)) section 95 of this act.
(2) The rights and remedies provided to the ((department))
authority in this section to secure reimbursement for assistance,
including the ((department's)) authority's lien and subrogation rights,
may be delegated to a managed health care system by contract entered
into pursuant to RCW 74.09.522. A managed health care system may
enforce all rights and remedies delegated to it by the ((department))
authority to secure and recover assistance provided under a managed
health care system consistent with its agreement with the
((department)) authority.
Sec. 12 RCW 74.09.185 and 1995 c 34 s 6 are each amended to read
as follows:
To the extent that payment for covered expenses has been made under
medical assistance for health care items or services furnished to an
individual, in any case where a third party has a legal liability to
make payments, the state is considered to have acquired the rights of
the individual to payment by any other party for those health care
items or services. Recovery pursuant to the subrogation rights,
assignment, or enforcement of the lien granted to the ((department))
authority by this section shall not be reduced, prorated, or applied to
only a portion of a judgment, award, or settlement, except as provided
in ((RCW 43.20B.050 and 43.20B.060)) sections 94 and 95 of this act.
The doctrine of equitable subrogation shall not apply to defeat,
reduce, or prorate recovery by the ((department)) authority as to its
assignment, lien, or subrogation rights.
Sec. 13 RCW 74.09.190 and 1979 c 141 s 342 are each amended to
read as follows:
Nothing in this chapter shall be construed as empowering the
secretary or director to compel any recipient of public assistance and
a medical indigent person to undergo any physical examination, surgical
operation, or accept any form of medical treatment contrary to the
wishes of said person who relies on or is treated by prayer or
spiritual means in accordance with the creed and tenets of any well
recognized church or religious denomination.
Sec. 14 RCW 74.09.200 and 1979 ex.s. c 152 s 1 are each amended
to read as follows:
The legislature finds and declares it to be in the public interest
and for the protection of the health and welfare of the residents of
the state of Washington that a proper regulatory and inspection program
be instituted in connection with the providing of medical, dental, and
other health services to recipients of public assistance and medically
indigent persons. In order to effectively accomplish such purpose and
to assure that the recipient of such services receives such services as
are paid for by the state of Washington, the acceptance by the
recipient of such services, and by practitioners of reimbursement for
performing such services, shall authorize the secretary ((of the
department of social and health services)) or ((his designee))
director, to inspect and audit all records in connection with the
providing of such services.
Sec. 15 RCW 74.09.210 and 1989 c 175 s 146 are each amended to
read as follows:
(1) No person, firm, corporation, partnership, association, agency,
institution, or other legal entity, but not including an individual
public assistance recipient of health care, shall, on behalf of himself
or others, obtain or attempt to obtain benefits or payments under this
chapter in a greater amount than that to which entitled by means of:
(a) A willful false statement;
(b) By willful misrepresentation, or by concealment of any material
facts; or
(c) By other fraudulent scheme or device, including, but not
limited to:
(i) Billing for services, drugs, supplies, or equipment that were
unfurnished, of lower quality, or a substitution or misrepresentation
of items billed; or
(ii) Repeated billing for purportedly covered items, which were not
in fact so covered.
(2) Any person or entity knowingly violating any of the provisions
of subsection (1) of this section shall be liable for repayment of any
excess benefits or payments received, plus interest at the rate and in
the manner provided in RCW 43.20B.695. Such person or other entity
shall further, in addition to any other penalties provided by law, be
subject to civil penalties. The secretary or director, as appropriate,
may assess civil penalties in an amount not to exceed three times the
amount of such excess benefits or payments: PROVIDED, That these civil
penalties shall not apply to any acts or omissions occurring prior to
September 1, 1979. RCW 43.20A.215 governs notice of a civil fine and
provides the right to an adjudicative proceeding.
(3) A criminal action need not be brought against a person for that
person to be civilly liable under this section.
(4) In all proceedings under this section, service, adjudicative
proceedings, and judicial review of such determinations shall be in
accordance with chapter 34.05 RCW, the administrative procedure act.
(5) Civil penalties shall be deposited in the general fund upon
their receipt.
Sec. 16 RCW 74.09.240 and 1995 c 319 s 1 are each amended to read
as follows:
(1) Any person, including any corporation, that solicits or
receives any remuneration (including any kickback, bribe, or rebate)
directly or indirectly, overtly or covertly, in cash or in kind
(a) in return for referring an individual to a person for the
furnishing or arranging for the furnishing of any item or service for
which payment may be made in whole or in part under this chapter, or
(b) in return for purchasing, leasing, ordering, or arranging for
or recommending purchasing, leasing, or ordering any goods, facility,
service, or item for which payment may be made in whole or in part
under this chapter,
shall be guilty of a class C felony; however, the fine, if imposed,
shall not be in an amount more than twenty-five thousand dollars,
except as authorized by RCW 9A.20.030.
(2) Any person, including any corporation, that offers or pays any
remuneration (including any kickback, bribe, or rebate) directly or
indirectly, overtly or covertly, in cash or in kind to any person to
induce such person
(a) to refer an individual to a person for the furnishing or
arranging for the furnishing of any item or service for which payment
may be made, in whole or in part, under this chapter, or
(b) to purchase, lease, order, or arrange for or recommend
purchasing, leasing, or ordering any goods, facility, service, or item
for which payment may be made in whole or in part under this chapter,
shall be guilty of a class C felony; however, the fine, if imposed,
shall not be in an amount more than twenty-five thousand dollars,
except as authorized by RCW 9A.20.030.
(3)(a) Except as provided in 42 U.S.C. 1395 nn, physicians are
prohibited from self-referring any client eligible under this chapter
for the following designated health services to a facility in which the
physician or an immediate family member has a financial relationship:
(i) Clinical laboratory services;
(ii) Physical therapy services;
(iii) Occupational therapy services;
(iv) Radiology including magnetic resonance imaging, computerized
axial tomography, and ultrasound services;
(v) Durable medical equipment and supplies;
(vi) Parenteral and enteral nutrients equipment and supplies;
(vii) Prosthetics, orthotics, and prosthetic devices;
(viii) Home health services;
(ix) Outpatient prescription drugs;
(x) Inpatient and outpatient hospital services;
(xi) Radiation therapy services and supplies.
(b) For purposes of this subsection, "financial relationship" means
the relationship between a physician and an entity that includes
either:
(i) An ownership or investment interest; or
(ii) A compensation arrangement.
For purposes of this subsection, "compensation arrangement" means
an arrangement involving remuneration between a physician, or an
immediate family member of a physician, and an entity.
(c) The department or authority, as appropriate, is authorized to
adopt by rule amendments to 42 U.S.C. 1395 nn enacted after July 23,
1995.
(d) This section shall not apply in any case covered by a general
exception specified in 42 U.S.C. Sec. 1395 nn.
(4) Subsections (1) and (2) of this section shall not apply to:
(a) A discount or other reduction in price obtained by a provider
of services or other entity under this chapter if the reduction in
price is properly disclosed and appropriately reflected in the costs
claimed or charges made by the provider or entity under this
chapter((,)); and
(b) Any amount paid by an employer to an employee (who has a bona
fide employment relationship with such employer) for employment in the
provision of covered items or services.
(5) Subsections (1) and (2) of this section, if applicable to the
conduct involved, shall supersede the criminal provisions of chapter
19.68 RCW, but shall not preclude administrative proceedings authorized
by chapter 19.68 RCW.
Sec. 17 RCW 74.09.260 and 1991 sp.s. c 8 s 7 are each amended to
read as follows:
Any person, including any corporation, that knowingly:
(1) Charges, for any service provided to a patient under any
medical care plan authorized under this chapter, money or other
consideration at a rate in excess of the rates established by the
department ((of social and health services)) or authority, as
appropriate; or
(2) Charges, solicits, accepts, or receives, in addition to any
amount otherwise required to be paid under such plan, any gift, money,
donation, or other consideration (other than a charitable, religious,
or philanthropic contribution from an organization or from a person
unrelated to the patient):
(a) As a precondition of admitting a patient to a hospital or
nursing facility; or
(b) As a requirement for the patient's continued stay in such
facility,
when the cost of the services provided therein to the patient is paid
for, in whole or in part, under such plan, shall be guilty of a class
C felony: PROVIDED, That the fine, if imposed, shall not be in an
amount more than twenty-five thousand dollars, except as authorized by
RCW 9A.20.030.
Sec. 18 RCW 74.09.280 and 1979 ex.s. c 152 s 9 are each amended
to read as follows:
The secretary ((of social and health services)) or director may by
rule require that any application, statement, or form filled out by
suppliers of medical care under this chapter shall contain or be
verified by a written statement that it is made under the penalties of
perjury and such declaration shall be in lieu of any oath otherwise
required, and each such paper shall in such event so state. The making
or subscribing of any such papers or forms containing any false or
misleading information may be prosecuted and punished under chapter
9A.72 RCW.
Sec. 19 RCW 74.09.290 and 1994 sp.s. c 9 s 749 are each amended
to read as follows:
The secretary ((of the department of social and health services))
or ((his authorized representative)) director shall have the authority
to:
(1) Conduct audits and investigations of providers of medical and
other services furnished pursuant to this chapter, except that the
Washington state medical quality assurance commission shall generally
serve in an advisory capacity to the secretary or director in the
conduct of audits or investigations of physicians. Any overpayment
discovered as a result of an audit of a provider under this authority
shall be offset by any underpayments discovered in that same audit
sample. In order to determine the provider's actual, usual, customary,
or prevailing charges, the secretary or director may examine such
random representative records as necessary to show accounts billed and
accounts received except that in the conduct of such examinations,
patient names, other than public assistance applicants or recipients,
shall not be noted, copied, or otherwise made available to the
department or authority. In order to verify costs incurred by the
department or authority for treatment of public assistance applicants
or recipients, the secretary or director may examine patient records or
portions thereof in connection with services to such applicants or
recipients rendered by a health care provider, notwithstanding the
provisions of RCW 5.60.060, 18.53.200, 18.83.110, or any other statute
which may make or purport to make such records privileged or
confidential: PROVIDED, That no original patient records shall be
removed from the premises of the health care provider, and that the
disclosure of any records or information by the department ((of social
and health services)) or the authority is prohibited and shall be
punishable as a class C felony according to chapter 9A.20 RCW, unless
such disclosure is directly connected to the official purpose for which
the records or information were obtained: PROVIDED FURTHER, That the
disclosure of patient information as required under this section shall
not subject any physician or other health services provider to any
liability for breach of any confidential relationship between the
provider and the patient, but no evidence resulting from such
disclosure may be used in any civil, administrative, or criminal
proceeding against the patient unless a waiver of the applicable
evidentiary privilege is obtained: PROVIDED FURTHER, That the
secretary or director shall destroy all copies of patient medical
records in their possession upon completion of the audit, investigation
or proceedings;
(2) Approve or deny applications to participate as a provider of
services furnished pursuant to this chapter;
(3) Terminate or suspend eligibility to participate as a provider
of services furnished pursuant to this chapter; and
(4) Adopt, promulgate, amend, and repeal administrative rules, in
accordance with the administrative procedure act, chapter 34.05 RCW, to
carry out the policies and purposes of RCW 74.09.200 through 74.09.290.
Sec. 20 RCW 74.09.300 and 1979 ex.s. c 152 s 11 are each amended
to read as follows:
Whenever the secretary ((of the department of social and health
services)) or director imposes a civil penalty under RCW 74.09.210, or
terminates or suspends a provider's eligibility under RCW 74.09.290, he
or she shall, if the provider is licensed pursuant to Titles 18, 70, or
71 RCW, give written notice of such imposition, termination, or
suspension to the appropriate licensing agency or disciplinary board.
Sec. 21 RCW 74.09.470 and 2009 c 463 s 2 are each amended to read
as follows:
(1) Consistent with the goals established in RCW 74.09.402, through
the apple health for kids program authorized in this section, the
((department)) authority shall provide affordable health care coverage
to children under the age of nineteen who reside in Washington state
and whose family income at the time of enrollment is not greater than
two hundred fifty percent of the federal poverty level as adjusted for
family size and determined annually by the federal department of health
and human services, and effective January 1, 2009, and only to the
extent that funds are specifically appropriated therefor, to children
whose family income is not greater than three hundred percent of the
federal poverty level. In administering the program, the
((department)) authority shall take such actions as may be necessary to
ensure the receipt of federal financial participation under the medical
assistance program, as codified at Title XIX of the federal social
security act, the state children's health insurance program, as
codified at Title XXI of the federal social security act, and any other
federal funding sources that are now available or may become available
in the future. The ((department)) authority and the caseload forecast
council shall estimate the anticipated caseload and costs of the
program established in this section.
(2) The ((department)) authority shall accept applications for
enrollment for children's health care coverage; establish appropriate
minimum-enrollment periods, as may be necessary; and determine
eligibility based on current family income. The ((department))
authority shall make eligibility determinations within the time frames
for establishing eligibility for children on medical assistance, as
defined by RCW 74.09.510. The application and annual renewal processes
shall be designed to minimize administrative barriers for applicants
and enrolled clients, and to minimize gaps in eligibility for families
who are eligible for coverage. If a change in family income results in
a change in the source of funding for coverage, the ((department))
authority shall transfer the family members to the appropriate source
of funding and notify the family with respect to any change in premium
obligation, without a break in eligibility. The ((department))
authority shall use the same eligibility redetermination and appeals
procedures as those provided for children on medical assistance
programs. The ((department)) authority shall modify its eligibility
renewal procedures to lower the percentage of children failing to
annually renew. The ((department)) authority shall manage its
outreach, application, and renewal procedures with the goals of: (a)
Achieving year by year improvements in enrollment, enrollment rates,
renewals, and renewal rates; (b) maximizing the use of existing program
databases to obtain information related to earned and unearned income
for purposes of eligibility determination and renewals, including, but
not limited to, the basic food program, the child care subsidy program,
federal social security administration programs, and the employment
security department wage database; (c) streamlining renewal processes
to rely primarily upon data matches, online submissions, and telephone
interviews; and (d) implementing any other eligibility determination
and renewal processes to allow the state to receive an enhanced federal
matching rate and additional federal outreach funding available through
the federal children's health insurance program reauthorization act of
2009 by January 2010. The department shall advise the governor and the
legislature regarding the status of these efforts by September 30,
2009. The information provided should include the status of the
department's efforts, the anticipated impact of those efforts on
enrollment, and the costs associated with that enrollment.
(3) To ensure continuity of care and ease of understanding for
families and health care providers, and to maximize the efficiency of
the program, the amount, scope, and duration of health care services
provided to children under this section shall be the same as that
provided to children under medical assistance, as defined in RCW
74.09.520.
(4) The primary mechanism for purchasing health care coverage under
this section shall be through contracts with managed health care
systems as defined in RCW 74.09.522, subject to conditions,
limitations, and appropriations provided in the biennial appropriations
act. However, the ((department)) authority shall make every effort
within available resources to purchase health care coverage for
uninsured children whose families have access to dependent coverage
through an employer-sponsored health plan or another source when it is
cost-effective for the state to do so, and the purchase is consistent
with requirements of Title XIX and Title XXI of the federal social
security act. To the extent allowable under federal law, the
((department)) authority shall require families to enroll in available
employer-sponsored coverage, as a condition of participating in the
program established under this section, when it is cost-effective for
the state to do so. Families who enroll in available employer-
sponsored coverage under this section shall be accounted for separately
in the annual report required by RCW 74.09.053.
(5)(a) To reflect appropriate parental responsibility, the
((department)) authority shall develop and implement a schedule of
premiums for children's health care coverage due to the ((department))
authority from families with income greater than two hundred percent of
the federal poverty level. For families with income greater than two
hundred fifty percent of the federal poverty level, the premiums shall
be established in consultation with the senate majority and minority
leaders and the speaker and minority leader of the house of
representatives. Premiums shall be set at a reasonable level that does
not pose a barrier to enrollment. The amount of the premium shall be
based upon family income and shall not exceed the premium limitations
in Title XXI of the federal social security act. Premiums shall not be
imposed on children in households at or below two hundred percent of
the federal poverty level as articulated in RCW 74.09.055.
(b) Beginning no later than January 1, 2010, the ((department))
authority shall offer families whose income is greater than three
hundred percent of the federal poverty level the opportunity to
purchase health care coverage for their children through the programs
administered under this section without an explicit premium subsidy
from the state. The design of the health benefit package offered to
these children should provide a benefit package substantially similar
to that offered in the apple health for kids program, and may differ
with respect to cost-sharing, and other appropriate elements from that
provided to children under subsection (3) of this section including,
but not limited to, application of preexisting conditions, waiting
periods, and other design changes needed to offer affordable coverage.
The amount paid by the family shall be in an amount equal to the rate
paid by the state to the managed health care system for coverage of the
child, including any associated and administrative costs to the state
of providing coverage for the child. Any pooling of the program
enrollees that results in state fiscal impact must be identified and
brought to the legislature for consideration.
(6) The ((department)) authority shall undertake and continue a
proactive, targeted outreach and education effort with the goal of
enrolling children in health coverage and improving the health literacy
of youth and parents. The ((department)) authority shall collaborate
with the department of social and health services, department of
health, local public health jurisdictions, the office of the
superintendent of public instruction, the department of early learning,
health educators, health care providers, health carriers, community-based organizations, and parents in the design and development of this
effort. The outreach and education effort shall include the following
components:
(a) Broad dissemination of information about the availability of
coverage, including media campaigns;
(b) Assistance with completing applications, and community-based
outreach efforts to help people apply for coverage. Community-based
outreach efforts should be targeted to the populations least likely to
be covered;
(c) Use of existing systems, such as enrollment information from
the free and reduced-price lunch program, the department of early
learning child care subsidy program, the department of health's women,
infants, and children program, and the early childhood education and
assistance program, to identify children who may be eligible but not
enrolled in coverage;
(d) Contracting with community-based organizations and government
entities to support community-based outreach efforts to help families
apply for coverage. These efforts should be targeted to the
populations least likely to be covered. The ((department)) authority
shall provide informational materials for use by government entities
and community-based organizations in their outreach activities, and
should identify any available federal matching funds to support these
efforts;
(e) Development and dissemination of materials to engage and inform
parents and families statewide on issues such as: The benefits of
health insurance coverage; the appropriate use of health services,
including primary care provided by health care practitioners licensed
under chapters 18.71, 18.57, 18.36A, and 18.79 RCW, and emergency
services; the value of a medical home, well-child services and
immunization, and other preventive health services with linkages to
department of health child profile efforts; identifying and managing
chronic conditions such as asthma and diabetes; and the value of good
nutrition and physical activity;
(f) An evaluation of the outreach and education efforts, based upon
clear, cost-effective outcome measures that are included in contracts
with entities that undertake components of the outreach and education
effort;
(g) An implementation plan to develop online application capability
that is integrated with the ((department's)) automated client
eligibility system, and to develop data linkages with the office of the
superintendent of public instruction for free and reduced-price lunch
enrollment information and the department of early learning for child
care subsidy program enrollment information.
(7) The ((department)) authority shall take action to increase the
number of primary care physicians providing dental disease preventive
services including oral health screenings, risk assessment, family
education, the application of fluoride varnish, and referral to a
dentist as needed.
(8) The department shall monitor the rates of substitution between
private-sector health care coverage and the coverage provided under
this section ((and shall report to appropriate committees of the
legislature by December 2010)).
Sec. 22 RCW 74.09.480 and 2009 c 463 s 4 are each amended to read
as follows:
(1) The ((department)) authority, in collaboration with the
department of health, department of social and health services, health
carriers, local public health jurisdictions, children's health care
providers including pediatricians, family practitioners, and pediatric
subspecialists, community and migrant health centers, parents, and
other purchasers, shall establish a concise set of explicit performance
measures that can indicate whether children enrolled in the program are
receiving health care through an established and effective medical
home, and whether the overall health of enrolled children is improving.
Such indicators may include, but are not limited to:
(a) Childhood immunization rates;
(b) Well child care utilization rates, including the use of
behavioral and oral health screening, and validated, structured
developmental screens using tools, that are consistent with nationally
accepted pediatric guidelines and recommended administration schedule,
once funding is specifically appropriated for this purpose;
(c) Care management for children with chronic illnesses;
(d) Emergency room utilization;
(e) Visual acuity and eye health;
(f) Preventive oral health service utilization; and
(g) Children's mental health status. In defining these measures
the ((department)) authority shall be guided by the measures provided
in RCW 71.36.025.
Performance measures and targets for each performance measure must
be established and monitored each biennium, with a goal of achieving
measurable, improved health outcomes for the children of Washington
state each biennium.
(2) Beginning in calendar year 2009, targeted provider rate
increases shall be linked to quality improvement measures established
under this section. The ((department)) authority, in conjunction with
those groups identified in subsection (1) of this section, shall
develop parameters for determining criteria for increased payment,
alternative payment methodologies, or other incentives for those
practices and health plans that incorporate evidence-based practice and
improve and achieve sustained improvement with respect to the measures.
(3) The department shall provide a report to the governor and the
legislature related to provider performance on these measures,
beginning in September 2010 for 2007 through 2009 and the authority
shall provide the report biennially thereafter. ((The department shall
advise the legislature as to its progress towards developing this
biennial reporting system by September 30, 2009.))
Sec. 23 RCW 74.09.490 and 2007 c 359 s 5 are each amended to read
as follows:
(1)(((a))) The ((department)) authority, in consultation with the
evidence-based practice institute established in RCW 71.24.061, shall
develop and implement policies to improve prescribing practices for
treatment of emotional or behavioral disturbances in children, improve
the quality of children's mental health therapy through increased use
of evidence-based and research-based practices and reduced variation in
practice, improve communication and care coordination between primary
care and mental health providers, and prioritize care in the family
home or care which integrates the family where out-of-home placement is
required.
(((b))) (2) The ((department)) authority shall identify those
children with emotional or behavioral disturbances who may be at high
risk due to off-label use of prescription medication, use of multiple
medications, high medication dosage, or lack of coordination among
multiple prescribing providers, and establish one or more mechanisms to
evaluate the appropriateness of the medication these children are
using, including but not limited to obtaining second opinions from
experts in child psychiatry.
(((c))) (3) The ((department)) authority shall review the
psychotropic medications of all children under five and establish one
or more mechanisms to evaluate the appropriateness of the medication
these children are using, including but not limited to obtaining second
opinions from experts in child psychiatry.
(((d))) (4) The ((department)) authority shall track prescriptive
practices with respect to psychotropic medications with the goal of
reducing the use of medication.
(((e))) (5) The ((department)) authority shall encourage the use of
cognitive behavioral therapies and other treatments which are
empirically supported or evidence-based, in addition to or in the place
of prescription medication where appropriate.
(((2) The department shall convene a representative group of
regional support networks, community mental health centers, and managed
health care systems contracting with the department under RCW 74.09.522
to:))
(a) Establish mechanisms and develop contract language that ensures
increased coordination of and access to medicaid mental health benefits
available to children and their families, including ensuring access to
services that are identified as a result of a developmental screen
administered through early periodic screening, diagnosis, and
treatment;
(b) Define managed health care system and regional support network
contractual performance standards that track access to and utilization
of services; and
(c) Set standards for reducing the number of children that are
prescribed antipsychotic drugs and receive no outpatient mental health
services with their medication.
(3) The department shall submit a report on progress and any
findings under this section to the legislature by January 1, 2009.
Sec. 24 RCW 74.09.500 and 1979 c 141 s 343 are each amended to
read as follows:
There is hereby established a new program of federal-aid assistance
to be known as medical assistance to be administered by the ((state
department of social and health services)) authority. The ((department
of social and health services)) authority is authorized to comply with
the federal requirements for the medical assistance program provided in
the social security act and particularly Title XIX of Public Law (89-97), as amended, in order to secure federal matching funds for such
program.
Sec. 25 RCW 74.09.510 and 2010 c 94 s 24 are each amended to read
as follows:
Medical assistance may be provided in accordance with eligibility
requirements established by the ((department)) authority, as defined in
the social security Title XIX state plan for mandatory categorically
needy persons and:
(1) Individuals who would be eligible for cash assistance except
for their institutional status;
(2) Individuals who are under twenty-one years of age, who would be
eligible for medicaid, but do not qualify as dependent children and who
are in (a) foster care, (b) subsidized adoption, (c) a nursing facility
or an intermediate care facility for persons with intellectual
disabilities, or (d) inpatient psychiatric facilities;
(3) Individuals who:
(a) Are under twenty-one years of age;
(b) On or after July 22, 2007, were in foster care under the legal
responsibility of the department or a federally recognized tribe
located within the state; and
(c) On their eighteenth birthday, were in foster care under the
legal responsibility of the department or a federally recognized tribe
located within the state;
(4) Persons who are aged, blind, or disabled who: (a) Receive only
a state supplement, or (b) would not be eligible for cash assistance if
they were not institutionalized;
(5) Categorically eligible individuals who meet the income and
resource requirements of the cash assistance programs;
(6) Individuals who are enrolled in managed health care systems,
who have otherwise lost eligibility for medical assistance, but who
have not completed a current six-month enrollment in a managed health
care system, and who are eligible for federal financial participation
under Title XIX of the social security act;
(7) Children and pregnant women allowed by federal statute for whom
funding is appropriated;
(8) Working individuals with disabilities authorized under section
1902(a)(10)(A)(ii) of the social security act for whom funding is
appropriated;
(9) Other individuals eligible for medical services under RCW
74.09.035 and 74.09.700 for whom federal financial participation is
available under Title XIX of the social security act;
(10) Persons allowed by section 1931 of the social security act for
whom funding is appropriated; and
(11) Women who: (a) Are under sixty-five years of age; (b) have
been screened for breast and cervical cancer under the national breast
and cervical cancer early detection program administered by the
department of health or tribal entity and have been identified as
needing treatment for breast or cervical cancer; and (c) are not
otherwise covered by health insurance. Medical assistance provided
under this subsection is limited to the period during which the woman
requires treatment for breast or cervical cancer, and is subject to any
conditions or limitations specified in the omnibus appropriations act.
Sec. 26 RCW 74.09.515 and 2007 c 359 s 8 are each amended to read
as follows:
(1) The ((department)) authority shall adopt rules and policies
providing that when youth who were enrolled in a medical assistance
program immediately prior to confinement are released from confinement,
their medical assistance coverage will be fully reinstated on the day
of their release, subject to any expedited review of their continued
eligibility for medical assistance coverage that is required under
federal or state law.
(2) The ((department)) authority, in collaboration with the
department, county juvenile court administrators, and regional support
networks, shall establish procedures for coordination between
department field offices, juvenile rehabilitation administration
institutions, and county juvenile courts that result in prompt
reinstatement of eligibility and speedy eligibility determinations for
youth who are likely to be eligible for medical assistance services
upon release from confinement. Procedures developed under this
subsection must address:
(a) Mechanisms for receiving medical assistance services'
applications on behalf of confined youth in anticipation of their
release from confinement;
(b) Expeditious review of applications filed by or on behalf of
confined youth and, to the extent practicable, completion of the review
before the youth is released; and
(c) Mechanisms for providing medical assistance services' identity
cards to youth eligible for medical assistance services immediately
upon their release from confinement.
(3) For purposes of this section, "confined" or "confinement" means
detained in a facility operated by or under contract with the
department of social and health services, juvenile rehabilitation
administration, or detained in a juvenile detention facility operated
under chapter 13.04 RCW.
(4) The ((department)) authority shall adopt standardized statewide
screening and application practices and forms designed to facilitate
the application of a confined youth who is likely to be eligible for a
medical assistance program.
Sec. 27 RCW 74.09.520 and 2007 c 3 s 1 are each amended to read
as follows:
(1) The term "medical assistance" may include the following care
and services subject to rules adopted by the authority or department:
(a) Inpatient hospital services; (b) outpatient hospital services; (c)
other laboratory and X- ray services; (d) nursing facility services;
(e) physicians' services, which shall include prescribed medication and
instruction on birth control devices; (f) medical care, or any other
type of remedial care as may be established by the secretary or
director; (g) home health care services; (h) private duty nursing
services; (i) dental services; (j) physical and occupational therapy
and related services; (k) prescribed drugs, dentures, and prosthetic
devices; and eyeglasses prescribed by a physician skilled in diseases
of the eye or by an optometrist, whichever the individual may select;
(l) personal care services, as provided in this section; (m) hospice
services; (n) other diagnostic, screening, preventive, and
rehabilitative services; and (o) like services when furnished to a
child by a school district in a manner consistent with the requirements
of this chapter. For the purposes of this section, neither the
authority nor the department may ((not)) cut off any prescription
medications, oxygen supplies, respiratory services, or other life-sustaining medical services or supplies.
"Medical assistance," notwithstanding any other provision of law,
shall not include routine foot care, or dental services delivered by
any health care provider, that are not mandated by Title XIX of the
social security act unless there is a specific appropriation for these
services.
(2) ((The department shall amend the state plan for medical
assistance under Title XIX of the federal social security act to
include personal care services, as defined in 42 C.F.R. 440.170(f), in
the categorically needy program.)) The department shall adopt, amend, or rescind such
administrative rules as are necessary to ensure that Title XIX personal
care services are provided to eligible persons in conformance with
federal regulations.
(3)
(a) These administrative rules shall include financial eligibility
indexed according to the requirements of the social security act
providing for medicaid eligibility.
(b) The rules shall require clients be assessed as having a medical
condition requiring assistance with personal care tasks. Plans of care
for clients requiring health-related consultation for assessment and
service planning may be reviewed by a nurse.
(c) The department shall determine by rule which clients have a
health-related assessment or service planning need requiring registered
nurse consultation or review. This definition may include clients that
meet indicators or protocols for review, consultation, or visit.
(((4))) (3) The department shall design and implement a means to
assess the level of functional disability of persons eligible for
personal care services under this section. The personal care services
benefit shall be provided to the extent funding is available according
to the assessed level of functional disability. Any reductions in
services made necessary for funding reasons should be accomplished in
a manner that assures that priority for maintaining services is given
to persons with the greatest need as determined by the assessment of
functional disability.
(((5))) (4) Effective July 1, 1989, the ((department)) authority
shall offer hospice services in accordance with available funds.
(((6))) (5) For Title XIX personal care services administered by
aging and disability services administration of the department, the
department shall contract with area agencies on aging:
(a) To provide case management services to individuals receiving
Title XIX personal care services in their own home; and
(b) To reassess and reauthorize Title XIX personal care services or
other home and community services as defined in RCW 74.39A.009 in home
or in other settings for individuals consistent with the intent of this
section:
(i) Who have been initially authorized by the department to receive
Title XIX personal care services or other home and community services
as defined in RCW 74.39A.009; and
(ii) Who, at the time of reassessment and reauthorization, are
receiving such services in their own home.
(((7))) (6) In the event that an area agency on aging is unwilling
to enter into or satisfactorily fulfill a contract or an individual
consumer's need for case management services will be met through an
alternative delivery system, the department is authorized to:
(a) Obtain the services through competitive bid; and
(b) Provide the services directly until a qualified contractor can
be found.
(((8))) (7) Subject to the availability of amounts appropriated for
this specific purpose, ((effective July 1, 2007,)) the ((department))
authority may offer medicare part D prescription drug copayment
coverage to full benefit dual eligible beneficiaries.
Sec. 28 RCW 74.09.521 and 2009 c 388 s 1 are each amended to read
as follows:
(1) To the extent that funds are specifically appropriated for this
purpose the ((department)) authority shall revise its medicaid healthy
options managed care and fee-for-service program standards under
medicaid, Title XIX of the federal social security act to improve
access to mental health services for children who do not meet the
regional support network access to care standards. ((Effective July 1,
2008, the)) The program standards shall be revised to allow outpatient
therapy services to be provided by licensed mental health
professionals, as defined in RCW 71.34.020, or by a mental health
professional regulated under Title 18 RCW who is under the direct
supervision of a licensed mental health professional, and up to twenty
outpatient therapy hours per calendar year, including family therapy
visits integral to a child's treatment. This section shall be
administered in a manner consistent with federal early and periodic
screening, diagnosis, and treatment requirements related to the receipt
of medically necessary services when a child's need for such services
is identified through developmental screening.
(2) The ((department)) authority and the children's mental health
evidence-based practice institute established in RCW 71.24.061 shall
collaborate to encourage and develop incentives for the use of
prescribing practices and evidence-based and research-based treatment
practices developed under RCW 74.09.490 by mental health professionals
serving children under this section.
Sec. 29 RCW 74.09.522 and 1997 c 59 s 15 and 1997 c 34 s 1 are
each reenacted and amended to read as follows:
(1) For the purposes of this section, "managed health care system"
means any health care organization, including health care providers,
insurers, health care service contractors, health maintenance
organizations, health insuring organizations, or any combination
thereof, that provides directly or by contract health care services
covered under RCW 74.09.520 and rendered by licensed providers, on a
prepaid capitated basis and that meets the requirements of section
1903(m)(1)(A) of Title XIX of the federal social security act or
federal demonstration waivers granted under section 1115(a) of Title XI
of the federal social security act.
(2) The ((department of social and health services)) authority
shall enter into agreements with managed health care systems to provide
health care services to recipients of temporary assistance for needy
families under the following conditions:
(a) Agreements shall be made for at least thirty thousand
recipients statewide;
(b) Agreements in at least one county shall include enrollment of
all recipients of temporary assistance for needy families;
(c) To the extent that this provision is consistent with section
1903(m) of Title XIX of the federal social security act or federal
demonstration waivers granted under section 1115(a) of Title XI of the
federal social security act, recipients shall have a choice of systems
in which to enroll and shall have the right to terminate their
enrollment in a system: PROVIDED, That the ((department)) authority
may limit recipient termination of enrollment without cause to the
first month of a period of enrollment, which period shall not exceed
twelve months: AND PROVIDED FURTHER, That the ((department)) authority
shall not restrict a recipient's right to terminate enrollment in a
system for good cause as established by the ((department)) authority by
rule;
(d) To the extent that this provision is consistent with section
1903(m) of Title XIX of the federal social security act, participating
managed health care systems shall not enroll a disproportionate number
of medical assistance recipients within the total numbers of persons
served by the managed health care systems, except as authorized by the
((department)) authority under federal demonstration waivers granted
under section 1115(a) of Title XI of the federal social security act;
(e) In negotiating with managed health care systems the
((department)) authority shall adopt a uniform procedure to negotiate
and enter into contractual arrangements, including standards regarding
the quality of services to be provided; and financial integrity of the
responding system;
(f) The ((department)) authority shall seek waivers from federal
requirements as necessary to implement this chapter;
(g) The ((department)) authority shall, wherever possible, enter
into prepaid capitation contracts that include inpatient care.
However, if this is not possible or feasible, the ((department))
authority may enter into prepaid capitation contracts that do not
include inpatient care;
(h) The ((department)) authority shall define those circumstances
under which a managed health care system is responsible for out-of-plan
services and assure that recipients shall not be charged for such
services; and
(i) Nothing in this section prevents the ((department)) authority
from entering into similar agreements for other groups of people
eligible to receive services under this chapter.
(3) The ((department)) authority shall ensure that publicly
supported community health centers and providers in rural areas, who
show serious intent and apparent capability to participate as managed
health care systems are seriously considered as contractors. The
((department)) authority shall coordinate its managed care activities
with activities under chapter 70.47 RCW.
(4) The ((department)) authority shall work jointly with the state
of Oregon and other states in this geographical region in order to
develop recommendations to be presented to the appropriate federal
agencies and the United States congress for improving health care of
the poor, while controlling related costs.
(5) The legislature finds that competition in the managed health
care marketplace is enhanced, in the long term, by the existence of a
large number of managed health care system options for medicaid
clients. In a managed care delivery system, whose goal is to focus on
prevention, primary care, and improved enrollee health status,
continuity in care relationships is of substantial importance, and
disruption to clients and health care providers should be minimized.
To help ensure these goals are met, the following principles shall
guide the ((department)) authority in its healthy options managed
health care purchasing efforts:
(a) All managed health care systems should have an opportunity to
contract with the ((department)) authority to the extent that minimum
contracting requirements defined by the ((department)) authority are
met, at payment rates that enable the ((department)) authority to
operate as far below appropriated spending levels as possible,
consistent with the principles established in this section.
(b) Managed health care systems should compete for the award of
contracts and assignment of medicaid beneficiaries who do not
voluntarily select a contracting system, based upon:
(i) Demonstrated commitment to or experience in serving low-income
populations;
(ii) Quality of services provided to enrollees;
(iii) Accessibility, including appropriate utilization, of services
offered to enrollees;
(iv) Demonstrated capability to perform contracted services,
including ability to supply an adequate provider network;
(v) Payment rates; and
(vi) The ability to meet other specifically defined contract
requirements established by the ((department)) authority, including
consideration of past and current performance and participation in
other state or federal health programs as a contractor.
(c) Consideration should be given to using multiple year
contracting periods.
(d) Quality, accessibility, and demonstrated commitment to serving
low-income populations shall be given significant weight in the
contracting, evaluation, and assignment process.
(e) All contractors that are regulated health carriers must meet
state minimum net worth requirements as defined in applicable state
laws. The ((department)) authority shall adopt rules establishing the
minimum net worth requirements for contractors that are not regulated
health carriers. This subsection does not limit the authority of the
((department)) Washington state health care authority to take action
under a contract upon finding that a contractor's financial status
seriously jeopardizes the contractor's ability to meet its contract
obligations.
(f) Procedures for resolution of disputes between the
((department)) authority and contract bidders or the ((department))
authority and contracting carriers related to the award of, or failure
to award, a managed care contract must be clearly set out in the
procurement document. ((In designing such procedures, the department
shall give strong consideration to the negotiation and dispute
resolution processes used by the Washington state health care authority
in its managed health care contracting activities.))
(6) The ((department)) authority may apply the principles set forth
in subsection (5) of this section to its managed health care purchasing
efforts on behalf of clients receiving supplemental security income
benefits to the extent appropriate.
Sec. 30 RCW 74.09.5222 and 2009 c 545 s 4 are each amended to
read as follows:
(1) The ((department)) authority shall submit a section 1115
demonstration waiver request to the federal department of health and
human services to expand and revise the medical assistance program as
codified in Title XIX of the federal social security act. The waiver
request should be designed to ensure the broadest federal financial
participation under Title XIX and XXI of the federal social security
act. To the extent permitted under federal law, the waiver request
should include the following components:
(a) Establishment of a single eligibility standard for low-income
persons, including expansion of categorical eligibility to include
childless adults. The ((department)) authority shall request that the
single eligibility standard be phased in such that incremental steps
are taken to cover additional low-income parents and individuals over
time, with the goal of offering coverage to persons with household
income at or below two hundred percent of the federal poverty level;
(b) Establishment of a single seamless application and eligibility
determination system for all state low-income medical programs included
in the waiver. Applications may be electronic and may include an
electronic signature for verification and authentication. Eligibility
determinations should maximize federal financing where possible;
(c) The delivery of all low-income coverage programs as a single
program, with a common core benefit package that may be similar to the
basic health benefit package or an alternative benefit package approved
by the secretary of the federal department of health and human
services, including the option of supplemental coverage for select
categorical groups, such as children, and individuals who are aged,
blind, and disabled;
(d) A program design to include creative and innovative approaches
such as: Coverage for preventive services with incentives to use
appropriate preventive care; enhanced medical home reimbursement and
bundled payment methodologies; cost-sharing options; use of care
management and care coordination programs to improve coordination of
medical and behavioral health services; application of an innovative
predictive risk model to better target care management services; and
mandatory enrollment in managed care, as may be necessary;
(e) The ability to impose enrollment limits or benefit design
changes for eligibility groups that were not eligible under the Title
XIX state plan in effect on the date of submission of the waiver
application;
(f) A premium assistance program whereby employers can participate
in coverage options for employees and dependents of employees otherwise
eligible under the waiver. The waiver should make every effort to
maximize enrollment in employer-sponsored health insurance when it is
cost-effective for the state to do so, and the purchase is consistent
with the requirements of Titles XIX and XXI of the federal social
security act. To the extent allowable under federal law, the
((department)) authority shall require enrollment in available
employer-sponsored coverage as a condition of eligibility for coverage
under the waiver; and
(g) The ability to share savings that might accrue to the federal
medicare program, Title XVIII of the federal social security act, from
improved care management for persons who are eligible for both medicare
and medicaid. Through the waiver application process, the
((department)) authority shall determine whether the state could serve,
directly or by contract, as a medicare special needs plan for persons
eligible for both medicare and medicaid.
(2) The ((department)) authority shall hold ongoing stakeholder
discussions as it is developing the waiver request, and provide
opportunities for public review and comment as the request is being
developed.
(3) The ((department and the health care)) authority shall identify
statutory changes that may be necessary to ensure successful and timely
implementation of the waiver request as submitted to the federal
department of health and human services as the apple health program for
adults.
(4) The legislature must authorize implementation of any waiver
approved by the federal department of health and human services under
this section.
Sec. 31 RCW 74.09.5225 and 2005 c 383 s 1 are each amended to
read as follows:
(1) Payments for recipients eligible for medical assistance
programs under this chapter for services provided by hospitals,
regardless of the beneficiary's managed care enrollment status, shall
be made based on allowable costs incurred during the year, when
services are provided by a rural hospital certified by the centers for
medicare and medicaid services as a critical access hospital. Any
additional payments made by the ((medical assistance administration))
authority for the healthy options program shall be no more than the
additional amounts per service paid under this section for other
medical assistance programs.
(2) Beginning on July 24, 2005, a moratorium shall be placed on
additional hospital participation in critical access hospital payments
under this section. However, rural hospitals that applied for
certification to the centers for medicare and medicaid services prior
to January 1, 2005, but have not yet completed the process or have not
yet been approved for certification, remain eligible for medical
assistance payments under this section.
Sec. 32 RCW 74.09.530 and 2007 c 315 s 2 are each amended to read
as follows:
(1)(a) The authority is designated as the single state agency for
purposes of Title XIX of the federal social security act.
(b) The amount and nature of medical assistance and the
determination of eligibility of recipients for medical assistance shall
be the responsibility of the ((department of social and health
services)) authority.
(c) The ((department)) authority shall establish reasonable
standards of assistance and resource and income exemptions which shall
be consistent with the provisions of the social security act and ((with
the)) federal regulations ((of the secretary of health, education and
welfare)) for determining eligibility of individuals for medical
assistance and the extent of such assistance to the extent that funds
are available from the state and federal government. The
((department)) authority shall not consider resources in determining
continuing eligibility for recipients eligible under section 1931 of
the social security act.
(d) The authority is authorized to collaborate with other state or
local agencies and nonprofit organizations in carrying out its duties
under this chapter and, to the extent appropriate, may enter into
agreements with such other entities.
(2) Individuals eligible for medical assistance under RCW
74.09.510(3) shall be transitioned into coverage under that subsection
immediately upon their termination from coverage under RCW
74.09.510(2)(a). The ((department)) authority shall use income
eligibility standards and eligibility determinations applicable to
children placed in foster care. The ((department, in consultation with
the health care)) authority((,)) shall provide information regarding
basic health plan enrollment and shall offer assistance with the
application and enrollment process to individuals covered under RCW
74.09.510(3) who are approaching their twenty-first birthday.
Sec. 33 RCW 74.09.540 and 2001 2nd sp.s. c 15 s 2 are each
amended to read as follows:
(1) It is the intent of the legislature to remove barriers to
employment for individuals with disabilities by providing medical
assistance to ((the)) working ((disabled)) individuals with
disabilities through a buy-in program in accordance with section
1902(a)(10)(A)(ii) of the social security act and eligibility and cost-sharing requirements established by the ((department)) authority.
(2) The ((department)) authority shall establish income, resource,
and cost-sharing requirements for the buy-in program in accordance with
federal law and any conditions or limitations specified in the omnibus
appropriations act. The ((department)) authority shall establish and
modify eligibility and cost-sharing requirements in order to administer
the program within available funds. The ((department)) authority shall
make every effort to coordinate benefits with employer-sponsored
coverage available to the working ((disabled)) individuals with
disabilities receiving benefits under this chapter.
Sec. 34 RCW 74.09.555 and 2010 1st sp.s. c 8 s 30 are each
amended to read as follows:
(1) The ((department)) authority shall adopt rules and policies
providing that when persons with a mental disorder, who were enrolled
in medical assistance immediately prior to confinement, are released
from confinement, their medical assistance coverage will be fully
reinstated on the day of their release, subject to any expedited review
of their continued eligibility for medical assistance coverage that is
required under federal or state law.
(2) The ((department)) authority, in collaboration with the
Washington association of sheriffs and police chiefs, the department of
corrections, and the regional support networks, shall establish
procedures for coordination between the authority and department field
offices, institutions for mental disease, and correctional
institutions, as defined in RCW 9.94.049, that result in prompt
reinstatement of eligibility and speedy eligibility determinations for
persons who are likely to be eligible for medical assistance services
upon release from confinement. Procedures developed under this
subsection must address:
(a) Mechanisms for receiving medical assistance services
applications on behalf of confined persons in anticipation of their
release from confinement;
(b) Expeditious review of applications filed by or on behalf of
confined persons and, to the extent practicable, completion of the
review before the person is released;
(c) Mechanisms for providing medical assistance services identity
cards to persons eligible for medical assistance services immediately
upon their release from confinement; and
(d) Coordination with the federal social security administration,
through interagency agreements or otherwise, to expedite processing of
applications for federal supplemental security income or social
security disability benefits, including federal acceptance of
applications on behalf of confined persons.
(3) Where medical or psychiatric examinations during a person's
confinement indicate that the person is disabled, the correctional
institution or institution for mental diseases shall provide the
((department)) authority with that information for purposes of making
medical assistance eligibility and enrollment determinations prior to
the person's release from confinement. The ((department)) authority
shall, to the maximum extent permitted by federal law, use the
examination in making its determination whether the person is disabled
and eligible for medical assistance.
(4) For purposes of this section, "confined" or "confinement" means
incarcerated in a correctional institution, as defined in RCW 9.94.049,
or admitted to an institute for mental disease, as defined in 42 C.F.R.
part 435, Sec. 1009 on July 24, 2005.
(5) For purposes of this section, "likely to be eligible" means
that a person:
(a) Was enrolled in medicaid or supplemental security income or the
disability lifeline program immediately before he or she was confined
and his or her enrollment was terminated during his or her confinement;
or
(b) Was enrolled in medicaid or supplemental security income or the
disability lifeline program at any time during the five years before
his or her confinement, and medical or psychiatric examinations during
the person's confinement indicate that the person continues to be
disabled and the disability is likely to last at least twelve months
following release.
(6) The economic services administration within the department
shall adopt standardized statewide screening and application practices
and forms designed to facilitate the application of a confined person
who is likely to be eligible for medicaid.
Sec. 35 RCW 74.09.565 and 1989 c 87 s 4 are each amended to read
as follows:
(1) An agreement between spouses transferring or assigning rights
to future income from one spouse to the other shall be invalid for
purposes of determining eligibility for medical assistance or the
limited casualty program for the medically needy, but this subsection
does not affect agreements between spouses transferring or assigning
resources, and income produced by transferred or assigned resources
shall continue to be recognized as the separate income of the
transferee.
(2) In determining eligibility for medical assistance or the
limited casualty program for the medically needy for a married person
in need of institutional care, or care under home and community-based
waivers as defined in Title XIX of the social security act, if the
community income received in the name of the nonapplicant spouse
exceeds the community income received in the name of the applicant
spouse, the applicant's interest in that excess shall be considered
unavailable to the applicant.
(3) The department or authority, as appropriate, shall adopt rules
consistent with the provisions of section 1924 of the social security
act entitled "Treatment of Income and Resources for Certain
Institutionalized Spouses," in determining the allocation of income
between an institutionalized and community spouse.
(4) The department or authority, as appropriate, shall establish
the monthly maintenance needs allowance for the community spouse up to
the maximum amount allowed by state appropriation or within available
funds and permitted in section 1924 of the social security act. The
total monthly needs allowance shall not exceed one thousand five
hundred dollars, subject to adjustment provided in section 1924 of the
social security act.
Sec. 36 RCW 74.09.575 and 2003 1st sp.s. c 28 s 1 are each
amended to read as follows:
(1) The department or authority, as appropriate, shall promulgate
rules consistent with the treatment of resources provisions of section
1924 of the social security act ((entitled "Treatment of Income and
Resources for Certain Institutionalized Spouses,")) in determining the
allocation of resources between the institutionalized and community
spouse.
(2) In the interest of supporting the community spouse the
department or authority, as appropriate, shall allow the maximum
resource allowance amount permissible under the social security act for
the community spouse for persons institutionalized before August 1,
2003.
(3) For persons institutionalized on or after August 1, 2003, the
department or authority, as appropriate, in the interest of supporting
the community spouse, shall allow up to a maximum of forty thousand
dollars in resources for the community spouse. For the fiscal biennium
beginning July 1, 2005, and each fiscal biennium thereafter, the
maximum resource allowance amount for the community spouse shall be
adjusted for economic trends and conditions by increasing the amount
allowable by the consumer price index as published by the federal
bureau of labor statistics. However, in no case shall the amount
allowable exceed the maximum resource allowance permissible under the
social security act.
Sec. 37 RCW 74.09.585 and 1995 1st sp.s. c 18 s 81 are each
amended to read as follows:
(1) The department or authority, as appropriate, shall establish
standards consistent with section 1917 of the social security act in
determining the period of ineligibility for medical assistance due to
the transfer of resources.
(2) There shall be no penalty imposed for the transfer of assets
that are excluded in a determination of the individual's eligibility
for medicaid to the extent such assets are protected by the long-term
care insurance policy or contract pursuant to chapter 48.85 RCW.
(3) The department or authority, as appropriate, may waive a period
of ineligibility if the department or authority determines that denial
of eligibility would work an undue hardship.
Sec. 38 RCW 74.09.595 and 1989 c 87 s 8 are each amended to read
as follows:
The department or authority, as appropriate, shall in compliance
with section 1924 of the social security act adopt procedures which
provide due process for institutionalized or community spouses who
request a fair hearing as to the valuation of resources, the amount of
the community spouse resource allowance, or the monthly maintenance
needs allowance.
Sec. 39 RCW 74.09.655 and 2008 c 245 s 1 are each amended to read
as follows:
The ((department)) authority shall provide coverage under this
chapter for smoking cessation counseling services, as well as
prescription and nonprescription agents when used to promote smoking
cessation, so long as such agents otherwise meet the definition of
"covered outpatient drug" in 42 U.S.C. Sec. 1396r-8(k). However, the
((department)) authority may initiate an individualized inquiry and
determine and implement by rule appropriate coverage limitations as may
be required to encourage the use of effective, evidence-based services
and prescription and nonprescription agents. The ((department))
authority shall track per-capita expenditures for a cohort of clients
that receive smoking cessation benefits, and submit a cost-benefit
analysis to the legislature on or before January 1, 2012.
Sec. 40 RCW 74.09.658 and 2009 c 326 s 1 are each amended to read
as follows:
(1) The home health program shall require registered nurse
oversight and intervention, as appropriate. In-person contact between
a home health care registered nurse and a patient is not required under
the state's medical assistance program for home health services that
are: (a) Delivered with the assistance of telemedicine and (b)
otherwise eligible for reimbursement as a medically necessary skilled
home health nursing visit under the program.
(2) The department or authority, as appropriate, in consultation
with home health care service providers shall develop reimbursement
rules and, in rule, define the requirements that must be met for a
reimbursable skilled nursing visit when services are rendered without
a face-to-face visit and are assisted by telemedicine.
(3)(a) The department or authority, as appropriate, shall establish
the reimbursement rate for skilled home health nursing services
delivered with the assistance of telemedicine that meet the
requirements of a reimbursable visit as defined by the department or
authority, as appropriate.
(b) Reimbursement is not provided for purchase or lease of
telemedicine equipment.
(4) Any home health agency licensed under chapter 70.127 RCW and
eligible for reimbursement under the medical programs authorized under
this chapter may be reimbursed for services under this section if the
service meets the requirements for a reimbursable skilled nursing visit
((as defined by the department)).
(5) Nothing in this section shall be construed to alter the scope
of practice of any home health care services provider or authorizes the
delivery of home health care services in a setting or manner not
otherwise authorized by law.
(6) The use of telemedicine is not intended to replace registered
nurse health care ((visit[s])) visits when necessary.
(7) For the purposes of this section, "telemedicine" means the use
of telemonitoring to enhance the delivery of certain home health
medical services through:
(a) The provision of certain education related to health care
services using audio, video, or data communication instead of a face-to-face visit; or
(b) The collection of clinical data and the transmission of such
data between a patient at a distant location and the home health
provider through electronic processing technologies. Objective
clinical data that may be transmitted includes, but is not limited to,
weight, blood pressure, pulse, respirations, blood glucose, and pulse
oximetry.
Sec. 41 RCW 74.09.659 and 2009 c 545 s 5 are each amended to read
as follows:
(1) The ((department)) authority shall continue to submit
applications for the family planning waiver program.
(2) The ((department)) authority shall submit a request to the
federal department of health and human services to amend the current
family planning waiver program as follows:
(a) Provide coverage for sexually transmitted disease testing and
treatment;
(b) Return to the eligibility standards used in 2005 including, but
not limited to, citizenship determination based on declaration or
matching with federal social security databases, insurance eligibility
standards comparable to 2005, and confidential service availability for
minors and survivors of domestic and sexual violence; and
(c) Within available funds, increase income eligibility to two
hundred fifty percent of the federal poverty level, to correspond with
income eligibility for publicly funded maternity care services.
Sec. 42 RCW 74.09.700 and 2010 c 94 s 25 are each amended to read
as follows:
(1) To the extent of available funds and subject to any conditions
placed on appropriations made for this purpose, medical care may be
provided under the limited casualty program to persons not
((otherwise)) eligible for medical assistance or medical care services
who are medically needy as defined in the social security Title XIX
state plan and medical indigents in accordance with eligibility
requirements established by the ((department)) authority. The
eligibility requirements may include minimum levels of incurred medical
expenses. This includes residents of nursing facilities, residents of
intermediate care facilities for persons with intellectual
disabilities, and individuals who are otherwise eligible for section
1915(c) of the federal social security act home and community-based
waiver services, administered by the department ((of social and health
services aging and adult services administration,)) who are aged,
blind, or disabled as defined in Title XVI of the federal social
security act and whose income exceeds three hundred percent of the
federal supplement security income benefit level.
(2) Determination of the amount, scope, and duration of medical
coverage under the limited casualty program shall be the responsibility
of the ((department)) authority, subject to the following:
(a) Only the following services may be covered:
(i) For persons who are medically needy as defined in the social
security Title XIX state plan: Inpatient and outpatient hospital
services, and home and community-based waiver services;
(ii) For persons who are medically needy as defined in the social
security Title XIX state plan, and for persons who are medical
indigents under the eligibility requirements established by the
((department)) authority: Rural health clinic services; physicians'
and clinic services; prescribed drugs, dentures, prosthetic devices,
and eyeglasses; nursing facility services; and intermediate care
facility services for persons with intellectual disabilities; home
health services; hospice services; other laboratory and X-ray services;
rehabilitative services, including occupational therapy; medically
necessary transportation; and other services for which funds are
specifically provided in the omnibus appropriations act;
(b) Medical care services provided to the medically indigent and
received no more than seven days prior to the date of application shall
be retroactively certified and approved for payment on behalf of a
person who was otherwise eligible at the time the medical services were
furnished: PROVIDED, That eligible persons who fail to apply within
the seven-day time period for medical reasons or other good cause may
be retroactively certified and approved for payment.
(3) The ((department)) authority shall establish standards of
assistance and resource and income exemptions. All nonexempt income
and resources of limited casualty program recipients shall be applied
against the cost of their medical care services.
Sec. 43 RCW 74.09.710 and 2007 c 259 s 4 are each amended to read
as follows:
(1) The ((department of social and health services)) authority, in
collaboration with the department of health and the department of
social and health services, 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)) authority shall consider expansion of existing medical
home and chronic care management programs and build on the Washington
state collaborative initiative. The ((department)) authority 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)) authority and the
department, 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))
authority'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.
Sec. 44 RCW 74.09.715 and 2008 c 146 s 13 are each amended to
read as follows:
Within funds appropriated for this purpose, the ((department))
authority shall establish two dental access projects to serve seniors
and other adults who are categorically needy blind or disabled. The
projects shall provide:
(1) Enhanced reimbursement rates for certified dentists for
specific procedures, to begin no sooner than July 1, 2009;
(2) Reimbursement for trained medical providers for preventive oral
health services, to begin no sooner than July 1, 2009;
(3) Training, development, and implementation through a partnership
with the University of Washington school of dentistry;
(4) Local program coordination including outreach and case
management; and
(5) An evaluation that measures the change in utilization rates and
cost savings.
Sec. 45 RCW 74.09.720 and 1983 c 194 s 26 are each amended to
read as follows:
(1) A prevention of blindness program is hereby established in the
((department of social and health services)) authority to provide
prompt, specialized medical eye care, including assistance with costs
when necessary, for conditions in which sight is endangered or sight
can be restored or significantly improved. The ((department of social
and health services)) authority shall adopt rules concerning program
eligibility, levels of assistance, and the scope of services.
(2) The ((department of social and health services)) authority
shall employ on a part-time basis an ophthalmological and/or an
optometrical consultant to provide liaison with participating eye
physicians and to review medical recommendations made by an applicant's
eye physician to determine whether the proposed services meet program
standards.
(3) The ((department of social and health services)) authority and
the department of services for the blind shall formulate a cooperative
agreement concerning referral of clients between the two agencies and
the coordination of policies and services.
Sec. 46 RCW 74.09.725 and 2006 c 367 s 8 are each amended to read
as follows:
((The department)) The authority shall provide coverage for
prostate cancer screening under this chapter, provided that the
screening is delivered upon the recommendation of the patient's
physician, advanced registered nurse practitioner, or physician
assistant.
Sec. 47 RCW 74.09.730 and 2009 c 538 s 1 are each amended to read
as follows:
In establishing Title XIX payments for inpatient hospital services:
(1) To the extent funds are appropriated specifically for this
purpose, and subject to any conditions placed on appropriations made
for this purpose, the ((department of social and health services))
authority shall provide a disproportionate share hospital adjustment
considering the following components:
(a) A low-income care component based on a hospital's medicaid
utilization rate, its low-income utilization rate, its provision of
obstetric services, and other factors authorized by federal law;
(b) A medical indigency care component based on a hospital's
services to persons who are medically indigent; and
(c) A state-only component, to be paid from available state funds
to hospitals that do not qualify for federal payments under (b) of this
subsection, based on a hospital's services to persons who are medically
indigent;
(2) The payment methodology for disproportionate share hospitals
shall be specified by the ((department)) authority in regulation.
(3) Nothing in this section shall be construed as a right or an
entitlement by any hospital to any payment from the authority.
Sec. 48 RCW 74.09.770 and 1989 1st ex.s. c 10 s 2 are each
amended to read as follows:
(1) The legislature finds that Washington state and the nation as
a whole have a high rate of infant illness and death compared with
other industrialized nations. This is especially true for minority and
low-income populations. Premature and low weight births have been
directly linked to infant illness and death. The availability of
adequate maternity care throughout the course of pregnancy has been
identified as a major factor in reducing infant illness and death.
Further, the investment in preventive health care programs, such as
maternity care, contributes to the growth of a healthy and productive
society and is a sound approach to health care cost containment. The
legislature further finds that access to maternity care for low-income
women in the state of Washington has declined significantly in recent
years and has reached a crisis level.
(2) It is the purpose of this ((chapter [subchapter])) subchapter
to provide, consistent with appropriated funds, maternity care
necessary to ensure healthy birth outcomes for low-income families. To
this end, a maternity care access system is established based on the
following principles:
(a) The family is the fundamental unit in our society and should be
supported through public policy.
(b) Access to maternity care for eligible persons to ensure healthy
birth outcomes should be made readily available in an expeditious
manner through a single service entry point.
(c) Unnecessary barriers to maternity care for eligible persons
should be removed.
(d) Access to preventive and other health care services should be
available for low-income children.
(e) Each woman should be encouraged to and assisted in making her
own informed decisions about her maternity care.
(f) Unnecessary barriers to the provision of maternity care by
qualified health professionals should be removed.
(g) The system should be sensitive to cultural differences among
eligible persons.
(h) To the extent possible, decisions about the scope, content, and
delivery of services should be made at the local level involving a
broad representation of community interests.
(i) The maternity care access system should be evaluated at
appropriate intervals to determine effectiveness and need for
modification.
(j) Maternity care services should be delivered in a cost-effective
manner.
Sec. 49 RCW 74.09.790 and 1993 c 407 s 9 are each amended to read
as follows:
Unless the context clearly requires otherwise, the definitions in
this section apply throughout RCW 74.09.760 through 74.09.820 and
74.09.510:
(1) "At-risk eligible person" means an eligible person determined
by the ((department)) authority to need special assistance in applying
for and obtaining maternity care, including pregnant women who are
substance abusers, pregnant and parenting adolescents, pregnant
minority women, and other eligible persons who need special assistance
in gaining access to the maternity care system.
(2) "County authority" means the board of county commissioners,
county council, or county executive having the authority to participate
in the maternity care access program or its designee. Two or more
county authorities may enter into joint agreements to fulfill the
requirements of this chapter.
(3) "Department" means the department of social and health
services.
(4) "Eligible person" means a woman in need of maternity care or
a child, who is eligible for medical assistance pursuant to this
chapter or the prenatal care program administered by the ((department))
authority.
(5) "Maternity care services" means inpatient and outpatient
medical care, case management, and support services necessary during
prenatal, delivery, and postpartum periods.
(6) "Support services" means, at least, public health nursing
assessment and follow-up, health and childbirth education,
psychological assessment and counseling, outreach services, nutritional
assessment and counseling, needed vitamin and nonprescriptive drugs,
transportation, family planning services, and child care. Support
services may include alcohol and substance abuse treatment for pregnant
women who are addicted or at risk of being addicted to alcohol or drugs
to the extent funds are made available for that purpose.
(7) "Family planning services" means planning the number of one's
children by use of contraceptive techniques.
(8) "Authority" means the Washington state health care authority.
Sec. 50 RCW 74.09.800 and 1993 c 407 s 10 are each amended to
read as follows:
The ((department)) authority shall, consistent with the state
budget act, develop a maternity care access program designed to ensure
healthy birth outcomes as follows:
(1) Provide maternity care services to low-income pregnant women
and health care services to children in poverty to the maximum extent
allowable under the medical assistance program, Title XIX of the
federal social security act;
(2) Provide maternity care services to low-income women who are not
eligible to receive such services under the medical assistance program,
Title XIX of the federal social security act;
(3) ((By January 1, 1990,)) Have the following procedures in place
to improve access to maternity care services and eligibility
determinations for pregnant women applying for maternity care services
under the medical assistance program, Title XIX of the federal social
security act:
(a) Use of a shortened and simplified application form;
(b) Outstationing ((department)) authority staff to make
eligibility determinations;
(c) Establishing local plans at the county and regional level,
coordinated by the ((department)) authority; and
(d) Conducting an interview for the purpose of determining medical
assistance eligibility within five working days of the date of an
application by a pregnant woman and making an eligibility determination
within fifteen working days of the date of application by a pregnant
woman;
(4) Establish a maternity care case management system that shall
assist at-risk eligible persons with obtaining medical assistance
benefits and receiving maternity care services, including
transportation and child care services;
(5) Within available resources, establish appropriate reimbursement
levels for maternity care providers;
(6) Implement a broad-based public education program that stresses
the importance of obtaining maternity care early during pregnancy;
(7) Refer persons eligible for maternity care services under the
program established by this section to persons, agencies, or
organizations with maternity care service practices that primarily
emphasize healthy birth outcomes;
(8) Provide family planning services including information about
the synthetic progestin capsule implant form of contraception, for
twelve months immediately following a pregnancy to women who were
eligible for medical assistance under the maternity care access program
during that pregnancy or who were eligible only for emergency labor and
delivery services during that pregnancy; and
(9) Within available resources, provide family planning services to
women who meet the financial eligibility requirements for services
under subsections (1) and (2) of this section.
Sec. 51 RCW 74.09.810 and 1989 1st ex.s. c 10 s 6 are each
amended to read as follows:
(1) The ((department)) authority shall establish an alternative
maternity care service delivery system, if it determines that a county
or a group of counties is a maternity care distressed area. A
maternity care distressed area shall be defined by the ((department))
authority, in rule, as a county or a group of counties where eligible
women are unable to obtain adequate maternity care. The ((department))
authority shall include the following factors in its determination:
(a) Higher than average percentage of eligible persons in the
distressed area who receive late or no prenatal care;
(b) Higher than average percentage of eligible persons in the
distressed area who go out of the area to receive maternity care;
(c) Lower than average percentage of obstetrical care providers in
the distressed area who provide care to eligible persons;
(d) Higher than average percentage of infants born to eligible
persons per obstetrical care provider in the distressed area; and
(e) Higher than average percentage of infants that are of low birth
weight, five and one-half pounds or two thousand five hundred grams,
born to eligible persons in the distressed area.
(2) If the ((department)) authority determines that a maternity
care distressed area exists, it shall notify the relevant county
authority. The county authority shall, within one hundred twenty days,
submit a brief report to the ((department)) authority recommending
remedial action. The report shall be prepared in consultation with the
((department and its)) authority and with the department's local
community service offices, the local public health officer, community
health clinics, health care providers, hospitals, the business
community, labor representatives, and low-income advocates in the
distressed area. A county authority may contract with a local
nonprofit entity to develop the report. If the county authority is
unwilling or unable to develop the report, it shall notify the
((department)) authority within thirty days, and the ((department))
authority shall develop the report for the distressed area.
(3) The ((department)) authority shall review the report and use
it, to the extent possible, in developing strategies to improve
maternity care access in the distressed area. The ((department))
authority may contract with or directly employ qualified maternity care
health providers to provide maternity care services, if access to such
providers in the distressed area is not possible by other means. In
such cases, the ((department)) authority is authorized to pay that
portion of the health care providers' malpractice liability insurance
that represents the percentage of maternity care provided to eligible
persons by that provider through increased medical assistance payments.
Sec. 52 RCW 74.09.820 and 1989 1st ex.s. c 10 s 7 are each
amended to read as follows:
To the extent that federal matching funds are available, the
((department)) authority or the department of health ((if one is
created)) shall establish, in consultation with the health science
programs of the state's colleges and universities, and community health
clinics, a loan repayment program that will encourage maternity care
providers to practice in medically underserved areas in exchange for
repayment of part or all of their health education loans.
NEW SECTION. Sec. 53 A new section is added to chapter 74.09 RCW
to read as follows:
(1) The following persons have the right to an adjudicative
proceeding:
(a) Any applicant or recipient who is aggrieved by a decision of
the authority or an authorized agency of the authority; or
(b) A current or former recipient who is aggrieved by the
authority's claim that he or she owes a debt for overpayment of
assistance.
(2) For purposes of this section:
(a) "Action" means a termination, suspension, reduction, or denial
of eligibility or covered services for any medical services program
established in this chapter;
(b) "Applicant" means a person who has submitted an application for
benefits to the authority for any medical services program established
in this chapter;
(c) "Recipient" means a person who is receiving benefits from the
authority for any medical services program established in this chapter.
(3) An applicant or recipient has no right to an adjudicative
proceeding when the sole basis for the authority's decision is a
federal or state law requiring an assistance adjustment for some or all
applicants or recipients.
(4) An applicant or recipient must file an application for an
adjudicative proceeding with the authority within ninety calendar days
after receiving notice of the aggrieving decision.
(5)(a) The adjudicative proceeding is governed by the
administrative procedure act, chapter 34.05 RCW, and this subsection.
(b) The adjudicative proceeding shall be conducted at the local
community services office or other location in Washington convenient to
the applicant or recipient and, upon agreement by the applicant or
recipient, may be conducted telephonically.
(c) The applicant or recipient, or his or her representative, has
the right to inspect his or her file from the authority and, upon
request, to receive copies of authority documents relevant to the
proceedings free of charge.
(d) The applicant or recipient has the right to a copy of the audio
recording of the adjudicative proceeding free of charge.
(e) If a final adjudicative order is issued in favor of an
applicant, medical services benefits must be provided from the date of
denial of the application for assistance or forty-five days following
the date of application, whichever is sooner. If a final adjudicative
order is issued in favor of a recipient, medical services benefits must
be provided from the effective date of the authority's action.
(6) This subsection only applies to an adjudicative proceeding in
which the appellant is an applicant for or recipient of medical
services programs established under this chapter and the issue is his
or her eligibility or ineligibility due to the assignment or transfer
of a resource. The burden is on the authority or its authorized agency
to prove by a preponderance of the evidence that the person knowingly
and willingly assigned or transferred the resource at less than market
value for the purpose of qualifying or continuing to qualify for
medical services programs established under this chapter. If the
prevailing party in the adjudicative proceeding is the applicant or
recipient, he or she is entitled to reasonable attorneys' fees.
(7) When an applicant or recipient files a petition for judicial
review as provided in RCW 34.05.514 of a final adjudicative order
entered with respect to the medical services program, no filing fee may
be collected from the person and no bond may be required on any appeal.
In the event that the superior court, the court of appeals, or the
supreme court renders a decision in favor of the applicant or
recipient, the person is entitled to reasonable attorneys' fees and
costs. If a final judicial decision is made in favor of an applicant,
assistance must be paid from the date of the denial of the application
for assistance or forty-five days following the date of application,
whichever is sooner; or in the case of a recipient, from the effective
date of the authority's action.
(8) The provisions of RCW 74.08.080 do not apply to adjudicative
proceedings requested or conducted with respect to the medical services
program pursuant to this section.
(9) The authority shall adopt any rules it deems necessary to
implement this section.
Sec. 54 RCW 41.05.011 and 2009 c 537 s 3 are each amended to read
as follows:
The definitions in this section apply throughout this chapter
unless the context clearly requires otherwise.
(1) (("Administrator")) "Director" means the ((administrator))
director of the authority.
(2) "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.
(3) "Authority" means the Washington state health care authority.
(4) "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.
(5) "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.
(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). "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) "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.
(8) "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.
(9) "Board" means the public employees' benefits board established
under RCW 41.05.055.
(10) "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.
(11) "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.
(12) "Salary" means a state employee's monthly salary or wages.
(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) "Separated employees" means persons who separate from
employment with an employer as defined in:
(a) RCW 41.32.010(((11))) (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(((40))) (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.
(16) "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.
(17) "Employer" means the state of Washington.
(18) "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.
(19) "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.
(20) "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.
(21) "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.
(22) "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.
Sec. 55 RCW 41.05.015 and 2000 c 5 s 16 are each amended to read
as follows:
The ((administrator)) director shall designate a medical director
who is licensed under chapter 18.57 or 18.71 RCW. The director shall
also appoint such professional personnel and other assistants and
employees, including professional medical screeners, as may be
reasonably necessary to carry out the provisions of this chapter and
chapter 74.09 RCW. The medical screeners must be supervised by one or
more physicians whom the director or the director's designee shall
appoint.
Sec. 56 RCW 41.05.021 and 2009 c 537 s 4 are each amended to read
as follows:
(1) The Washington state health care authority is created within
the executive branch. The authority shall have ((an administrator)) a
director appointed by the governor, with the consent of the senate.
The ((administrator)) director shall serve at the pleasure of the
governor. The ((administrator)) director may employ ((up to seven
staff members)) 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
((administrator)) director may delegate any power or duty vested in him
or her by ((this chapter)) 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, 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 117 of this act;
(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.
(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.
Sec. 57 RCW 41.05.036 and 2009 c 300 s 2 are each amended to read
as follows:
The definitions in this section apply throughout RCW 41.05.039
through 41.05.046 unless the context clearly requires otherwise.
(1) (("Administrator")) "Director" means the ((administrator))
director of the state health care authority under this chapter.
(2) "Exchange" means the methods or medium by which health care
information may be electronically and securely exchanged among
authorized providers, payors, and patients within Washington state.
(3) "Health care provider" or "provider" has the same meaning as in
RCW 48.43.005.
(4) "Health data provider" means an organization that is a primary
source for health-related data for Washington residents, including but
not limited to:
(a) The children's health immunizations linkages and development
profile immunization registry provided by the department of health
pursuant to chapter 43.70 RCW;
(b) Commercial laboratories providing medical laboratory testing
results;
(c) Prescription drugs clearinghouses, such as the national patient
health information network; and
(d) Diagnostic imaging centers.
(5) "Lead organization" means a private sector organization or
organizations designated by the ((administrator)) director to lead
development of processes, guidelines, and standards under chapter 300,
Laws of 2009.
(6) "Payor" means public purchasers, as defined in this section,
carriers licensed under chapters 48.20, 48.21, 48.44, 48.46, and 48.62
RCW, and the Washington state health insurance pool established in
chapter 48.41 RCW.
(7) "Public purchaser" means the department of social and health
services, the department of labor and industries, and the health care
authority.
(8) "Secretary" means the secretary of the department of health.
Sec. 58 RCW 41.05.037 and 2007 c 259 s 15 are each amended 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,)) director shall provide all
persons enrolled in health plans under this chapter and chapters 70.47
and 74.09 RCW with access to a twenty-four hour, seven day a week nurse
hotline.
Sec. 59 RCW 41.05.140 and 2000 c 80 s 5 are each amended to read
as follows:
(1) Except for property and casualty insurance, the authority may
self-fund, self-insure, or enter into other methods of providing
insurance coverage for insurance programs under its jurisdiction,
including the basic health plan as provided in chapter 70.47 RCW. The
authority shall contract for payment of claims or other administrative
services for programs under its jurisdiction. If a program does not
require the prepayment of reserves, the authority shall establish such
reserves within a reasonable period of time for the payment of claims
as are normally required for that type of insurance under an insured
program. The authority shall endeavor to reimburse basic health plan
health care providers under this section at rates similar to the
average reimbursement rates offered by the statewide benchmark plan
determined through the request for proposal process.
(2) Reserves established by the authority for employee and retiree
benefit programs shall be held in a separate trust fund by the state
treasurer and shall be known as the public employees' and retirees'
insurance reserve fund. The state investment board shall act as the
investor for the funds and, except as provided in RCW 43.33A.160 and
43.84.160, one hundred percent of all earnings from these investments
shall accrue directly to the public employees' and retirees' insurance
reserve fund.
(3) Any savings realized as a result of a program created for
employees and retirees under this section shall not be used to increase
benefits unless such use is authorized by statute.
(4) Reserves established by the authority to provide insurance
coverage for the basic health plan under chapter 70.47 RCW shall be
held in a separate trust account in the custody of the state treasurer
and shall be known as the basic health plan self-insurance reserve
account. The state investment board shall act as the investor for the
funds as set forth in RCW 43.33A.230 and, except as provided in RCW
43.33A.160 and 43.84.160, one hundred percent of all earnings from
these investments shall accrue directly to the basic health plan self-insurance reserve account.
(5) Any program created under this section shall be subject to the
examination requirements of chapter 48.03 RCW as if the program were a
domestic insurer. In conducting an examination, the commissioner shall
determine the adequacy of the reserves established for the program.
(6) The authority shall keep full and adequate accounts and records
of the assets, obligations, transactions, and affairs of any program
created under this section.
(7) The authority shall file a quarterly statement of the financial
condition, transactions, and affairs of any program created under this
section in a form and manner prescribed by the insurance commissioner.
The statement shall contain information as required by the commissioner
for the type of insurance being offered under the program. A copy of
the annual statement shall be filed with the speaker of the house of
representatives and the president of the senate.
(8) The provisions of this section do not apply to the
administration of chapter 74.09 RCW.
Sec. 60 RCW 41.05.185 and 1997 c 276 s 1 are each amended to read
as follows:
The legislature finds that diabetes imposes a significant health
risk and tremendous financial burden on the citizens and government of
the state of Washington, and that access to the medically accepted
standards of care for diabetes, its treatment and supplies, and self-management training and education is crucial to prevent or delay the
short and long-term complications of diabetes and its attendant costs.
(1) The definitions in this subsection apply throughout this
section unless the context clearly requires otherwise.
(a) "Person with diabetes" means a person diagnosed by a health
care provider as having insulin using diabetes, noninsulin using
diabetes, or elevated blood glucose levels induced by pregnancy; and
(b) "Health care provider" means a health care provider as defined
in RCW 48.43.005.
(2) All state-purchased health care purchased or renewed after
January 1, 1998, except the basic health plan described in chapter
70.47 RCW and services provided under chapter 74.09 RCW, shall provide
benefits for at least the following services and supplies for persons
with diabetes:
(a) For state-purchased health care that includes coverage for
pharmacy services, appropriate and medically necessary equipment and
supplies, as prescribed by a health care provider, that includes but is
not limited to insulin, syringes, injection aids, blood glucose
monitors, test strips for blood glucose monitors, visual reading and
urine test strips, insulin pumps and accessories to the pumps, insulin
infusion devices, prescriptive oral agents for controlling blood sugar
levels, foot care appliances for prevention of complications associated
with diabetes, and glucagon emergency kits; and
(b) For all state-purchased health care, outpatient self-management
training and education, including medical nutrition therapy, as ordered
by the health care provider. Diabetes outpatient self-management
training and education may be provided only by health care providers
with expertise in diabetes. Nothing in this section prevents any state
agency purchasing health care according to this section from
restricting patients to seeing only health care providers who have
signed participating provider agreements with that state agency or an
insuring entity under contract with that state agency.
(3) Coverage required under this section may be subject to
customary cost-sharing provisions established for all other similar
services or supplies within a policy.
(4) Health care coverage may not be reduced or eliminated due to
this section.
(5) Services required under this section shall be covered when
deemed medically necessary by the medical director, or his or her
designee, subject to any referral and formulary requirements.
Sec. 61 RCW 43.20A.365 and 1997 c 430 s 2 are each amended to
read as follows:
A committee or council required by federal law, within the
((department of social and health services)) health care authority,
that makes policy recommendations regarding reimbursement for drugs
under the requirements of federal law or regulations is subject to
chapters 42.30 and 42.32 RCW.
Sec. 62 RCW 74.04.005 and 2010 1st sp.s. c 8 s 4 are each amended
to read as follows:
For the purposes of this title, unless the context indicates
otherwise, the following definitions shall apply:
(1) "Public assistance" or "assistance" -- Public aid to persons in
need thereof for any cause, including services, medical care,
assistance grants, disbursing orders, work relief, disability lifeline
benefits and federal aid assistance.
(2) "Department" -- The department of social and health services.
(3) "County or local office" -- The administrative office for one or
more counties or designated service areas.
(4) (("Director" or)) "Secretary" means the secretary of social and
health services.
(5) "Disability lifeline program" means a program that provides aid
and support in accordance with the conditions set out in this
subsection.
(a) Aid and assistance shall be provided to persons who are not
eligible to receive federal aid assistance, other than basic food
benefits transferred electronically and medical assistance and meet one
of the following conditions:
(i) Are pregnant and in need, based upon the current income and
resource requirements of the federal temporary assistance for needy
families program; or
(ii) Are incapacitated from gainful employment by reason of bodily
or mental infirmity that will likely continue for a minimum of ninety
days as determined by the department. The standard for incapacity in
this subsection, as evidenced by the ninety-day duration standard, is
not intended to be as stringent as federal supplemental security income
disability standards; and
(A) Are citizens or aliens lawfully admitted for permanent
residence or otherwise residing in the United States under color of
law;
(B) Have furnished the department their social security number. If
the social security number cannot be furnished because it has not been
issued or is not known, an application for a number shall be made prior
to authorization of benefits, and the social security number shall be
provided to the department upon receipt;
(C) Have not refused or failed without good cause to participate in
drug or alcohol treatment if an assessment by a certified chemical
dependency counselor indicates a need for such treatment. Good cause
must be found to exist when a person's physical or mental condition, as
determined by the department, prevents the person from participating in
drug or alcohol dependency treatment, when needed outpatient drug or
alcohol treatment is not available to the person in the county of his
or her residence or when needed inpatient treatment is not available in
a location that is reasonably accessible for the person; and
(D) Have not refused or failed without good cause to participate in
vocational rehabilitation services, if an assessment conducted under
RCW 74.04.655 indicates that the person might benefit from such
services. Good cause must be found to exist when a person's physical
or mental condition, as determined by the department, prevents the
person from participating in vocational rehabilitation services, or
when vocational rehabilitation services are not available to the person
in the county of his or her residence.
(b)(i) Persons who initially apply and are found eligible for
disability lifeline benefits based upon incapacity from gainful
employment under (a) of this subsection on or after September 2, 2010,
who are homeless and have been assessed as needing chemical dependency
or mental health treatment or both, must agree, as a condition of
eligibility for the disability lifeline program, to accept a housing
voucher in lieu of a cash grant if a voucher is available. The
department shall establish the dollar value of the housing voucher.
The dollar value of the housing voucher may differ from the value of
the cash grant. Persons receiving a housing voucher under this
subsection also shall receive a cash stipend of fifty dollars per
month.
(ii) If the department of commerce has determined under RCW
43.330.175 that sufficient housing is not available, persons described
in this subsection who apply for disability lifeline benefits during
the time period that housing is not available shall receive a cash
grant in lieu of a cash stipend and housing voucher.
(iii) Persons who refuse to accept a housing voucher under this
subsection but otherwise meet the eligibility requirements of (a) of
this subsection are eligible for medical care services benefits under
RCW 74.09.035, subject to the time limits in (h) of this subsection.
(c) The following persons are not eligible for the disability
lifeline program:
(i) Persons who are unemployable due primarily to alcohol or drug
addiction. These persons shall be referred to appropriate assessment,
treatment, shelter, or supplemental security income referral services
as authorized under chapter 74.50 RCW. Referrals shall be made at the
time of application or at the time of eligibility review. This
subsection shall not be construed to prohibit the department from
granting disability lifeline benefits to alcoholics and drug addicts
who are incapacitated due to other physical or mental conditions that
meet the eligibility criteria for the disability lifeline program;
(ii) Persons who refuse or fail to cooperate in obtaining federal
aid assistance, without good cause.
(d) Disability lifeline benefits shall be provided only to persons
who are not members of assistance units receiving federal aid
assistance, except as provided in (a) of this subsection, and who will
accept available services that can reasonably be expected to enable the
person to work or reduce the need for assistance unless there is good
cause to refuse. Failure to accept such services shall result in
termination until the person agrees to cooperate in accepting such
services and subject to the following maximum periods of ineligibility
after reapplication:
(i) First failure: One week;
(ii) Second failure within six months: One month;
(iii) Third and subsequent failure within one year: Two months.
(e) Persons who are likely eligible for federal supplemental
security income benefits shall be moved into the disability lifeline
expedited component of the disability lifeline program. Persons placed
in the expedited component of the program may, if otherwise eligible,
receive disability lifeline benefits pending application for federal
supplemental security income benefits. The monetary value of any
disability lifeline benefit that is subsequently duplicated by the
person's receipt of supplemental security income for the same period
shall be considered a debt due the state and shall by operation of law
be subject to recovery through all available legal remedies.
(f) For purposes of determining whether a person is incapacitated
from gainful employment under (a) of this subsection:
(i) The department shall adopt by rule medical criteria for
disability lifeline incapacity determinations to ensure that
eligibility decisions are consistent with statutory requirements and
are based on clear, objective medical information; and
(ii) The process implementing the medical criteria shall involve
consideration of opinions of the treating or consulting physicians or
health care professionals regarding incapacity, and any eligibility
decision which rejects uncontroverted medical opinion must set forth
clear and convincing reasons for doing so.
(g) Persons receiving disability lifeline benefits based upon a
finding of incapacity from gainful employment who remain otherwise
eligible shall have their benefits discontinued unless the recipient
demonstrates no material improvement in their medical or mental health
condition. The department may discontinue benefits when there was
specific error in the prior determination that found the person
eligible by reason of incapacitation.
(h)(i) Beginning September 1, 2010, no person who is currently
receiving or becomes eligible for disability lifeline program benefits
shall be eligible to receive benefits under the program for more than
twenty-four months in a sixty-month period. For purposes of this
subsection, months of receipt of general assistance-unemployable
benefits count toward the twenty-four month limit. Months during which
a person received benefits under the expedited component of the
disability lifeline or general assistance program or under the aged,
blind, or disabled component of the disability lifeline or general
assistance program shall not be included when determining whether a
person has been receiving benefits for more than twenty-four months.
On or before July 1, 2010, the department must review the cases of all
persons who have received disability lifeline benefits or general
assistance unemployable benefits for at least twenty months as of that
date. On or before September 1, 2010, the department must review the
cases of all remaining persons who have received disability lifeline
benefits for at least twelve months as of that date. The review should
determine whether the person meets the federal supplemental security
income disability standard and, if the person does not meet that
standard, whether the receipt of additional services could lead to
employability. If a need for additional services is identified, the
department shall provide case management services, such as assistance
with arranging transportation or locating stable housing, that will
facilitate the person's access to needed services. A person may not be
determined ineligible due to exceeding the time limit unless he or she
has received a case review under this subsection finding that the
person does not meet the federal supplemental security income
disability standard.
(ii) The time limits established under this subsection expire June
30, 2013.
(i) No person may be considered an eligible individual for
disability lifeline benefits with respect to any month if during that
month the person:
(i) Is fleeing to avoid prosecution of, or to avoid custody or
confinement for conviction of, a felony, or an attempt to commit a
felony, under the laws of the state of Washington or the place from
which the person flees; or
(ii) Is violating a condition of probation, community supervision,
or parole imposed under federal or state law for a felony or gross
misdemeanor conviction.
(6) "Disability lifeline expedited" means a component of the
disability lifeline program under which persons receiving disability
lifeline benefits have been determined, after examination by an
appropriate health care provider, to be likely to be eligible for
federal supplemental security income benefits based on medical and
behavioral health evidence that meets the disability standards used for
the federal supplemental security income program.
(7) "Federal aid assistance" -- The specific categories of assistance
for which provision is made in any federal law existing or hereafter
passed by which payments are made from the federal government to the
state in aid or in respect to payment by the state for public
assistance rendered to any category of needy persons for which
provision for federal funds or aid may from time to time be made, or a
federally administered needs-based program.
(8) "Applicant" -- Any person who has made a request, or on behalf of
whom a request has been made, to any county or local office for
assistance.
(9) "Recipient" -- Any person receiving assistance and in addition
those dependents whose needs are included in the recipient's
assistance.
(10) "Standards of assistance" -- The level of income required by an
applicant or recipient to maintain a level of living specified by the
department.
(11) "Resource" -- Any asset, tangible or intangible, owned by or
available to the applicant at the time of application, which can be
applied toward meeting the applicant's need, either directly or by
conversion into money or its equivalent. The department may by rule
designate resources that an applicant may retain and not be ineligible
for public assistance because of such resources. Exempt resources
shall include, but are not limited to:
(a) A home that an applicant, recipient, or their dependents is
living in, including the surrounding property;
(b) Household furnishings and personal effects;
(c) A motor vehicle, other than a motor home, used and useful
having an equity value not to exceed five thousand dollars;
(d) A motor vehicle necessary to transport a household member with
a physical disability. This exclusion is limited to one vehicle per
person with a physical disability;
(e) All other resources, including any excess of values exempted,
not to exceed one thousand dollars or other limit as set by the
department, to be consistent with limitations on resources and
exemptions necessary for federal aid assistance. The department shall
also allow recipients of temporary assistance for needy families to
exempt savings accounts with combined balances of up to an additional
three thousand dollars;
(f) Applicants for or recipients of disability lifeline benefits
shall have their eligibility based on resource limitations consistent
with the temporary assistance for needy families program rules adopted
by the department; and
(g) If an applicant for or recipient of public assistance possesses
property and belongings in excess of the ceiling value, such value
shall be used in determining the need of the applicant or recipient,
except that: (i) The department may exempt resources or income when
the income and resources are determined necessary to the applicant's or
recipient's restoration to independence, to decrease the need for
public assistance, or to aid in rehabilitating the applicant or
recipient or a dependent of the applicant or recipient; and (ii) the
department may provide grant assistance for a period not to exceed nine
months from the date the agreement is signed pursuant to this section
to persons who are otherwise ineligible because of excess real property
owned by such persons when they are making a good faith effort to
dispose of that property: PROVIDED, That:
(A) The applicant or recipient signs an agreement to repay the
lesser of the amount of aid received or the net proceeds of such sale;
(B) If the owner of the excess property ceases to make good faith
efforts to sell the property, the entire amount of assistance may
become an overpayment and a debt due the state and may be recovered
pursuant to RCW 43.20B.630;
(C) Applicants and recipients are advised of their right to a fair
hearing and afforded the opportunity to challenge a decision that good
faith efforts to sell have ceased, prior to assessment of an
overpayment under this section; and
(D) At the time assistance is authorized, the department files a
lien without a sum certain on the specific property.
(12) "Income" -- (a) All appreciable gains in real or personal
property (cash or kind) or other assets, which are received by or
become available for use and enjoyment by an applicant or recipient
during the month of application or after applying for or receiving
public assistance. The department may by rule and regulation exempt
income received by an applicant for or recipient of public assistance
which can be used by him or her to decrease his or her need for public
assistance or to aid in rehabilitating him or her or his or her
dependents, but such exemption shall not, unless otherwise provided in
this title, exceed the exemptions of resources granted under this
chapter to an applicant for public assistance. In addition, for cash
assistance the department may disregard income pursuant to RCW
74.08A.230 and 74.12.350.
(b) If, under applicable federal requirements, the state has the
option of considering property in the form of lump sum compensatory
awards or related settlements received by an applicant or recipient as
income or as a resource, the department shall consider such property to
be a resource.
(13) "Need" -- The difference between the applicant's or recipient's
standards of assistance for himself or herself and the dependent
members of his or her family, as measured by the standards of the
department, and value of all nonexempt resources and nonexempt income
received by or available to the applicant or recipient and the
dependent members of his or her family.
(14) "Authority" means the health care authority.
(15) "Director" means the director of the health care authority.
(16) For purposes of determining eligibility for public assistance
and participation levels in the cost of medical care, the department
shall exempt restitution payments made to people of Japanese and Aleut
ancestry pursuant to the Civil Liberties Act of 1988 and the Aleutian
and Pribilof Island Restitution Act passed by congress, P.L. 100-383,
including all income and resources derived therefrom.
(((15))) (17) In the construction of words and phrases used in this
title, the singular number shall include the plural, the masculine
gender shall include both the feminine and neuter genders and the
present tense shall include the past and future tenses, unless the
context thereof shall clearly indicate to the contrary.
Sec. 63 RCW 74.04.015 and 1981 1st ex.s. c 6 s 2 are each amended
to read as follows:
(1) The secretary of social and health services shall be the
responsible state officer for the administration ((of,)) and ((the))
disbursement of all funds, goods, commodities, and services, which may
be received by the state in connection with programs of public
assistance or services related directly or indirectly to assistance
programs, and all other matters included in the federal social security
act ((approved August 14, 1935)) as amended, or any other federal act
or as the same may be amended ((excepting those specifically required
to be administered by other entities)) except as otherwise provided by
law.
(2) The director shall be the responsible state officer for the
administration and disbursement of funds that the state receives in
connection with the medical services programs established under chapter
74.09 RCW, including the state children's health insurance program,
Titles XIX and XXI of the social security act of 1935, as amended.
((He)) (3) The department and the authority, as appropriate, shall
make such reports and render such accounting as may be required by
((the)) federal ((agency having authority in the premises)) law.
Sec. 64 RCW 74.04.025 and 2010 c 296 s 7 are each amended to read
as follows:
(1) The department, the authority, and the office of administrative
hearings shall ensure that bilingual services are provided to non-English speaking applicants and recipients. The services shall be
provided to the extent necessary to assure that non-English speaking
persons are not denied, or unable to obtain or maintain, services or
benefits because of their inability to speak English.
(2) If the number of non-English speaking applicants or recipients
sharing the same language served by any community service office client
contact job classification equals or exceeds fifty percent of the
average caseload of a full-time position in such classification, the
department shall, through attrition, employ bilingual personnel to
serve such applicants or recipients.
(3) Regardless of the applicant or recipient caseload of any
community service office, each community service office shall ensure
that bilingual services required to supplement the community service
office staff are provided through contracts with language access
providers, local agencies, or other community resources.
(4) The department shall certify, authorize, and qualify language
access providers as needed to maintain an adequate pool of providers.
(5) The department shall require compliance with RCW 41.56.113(2)
through its contracts with third parties.
(6) Initial client contact materials shall inform clients in all
primary languages of the availability of interpretation services for
non-English speaking persons. Basic informational pamphlets shall be
translated into all primary languages.
(7) To the extent all written communications directed to applicants
or recipients are not in the primary language of the applicant or
recipient, the department and the office of administrative hearings
shall include with the written communication a notice in all primary
languages of applicants or recipients describing the significance of
the communication and specifically how the applicants or recipients may
receive assistance in understanding, and responding to if necessary,
the written communication. The department shall assure that sufficient
resources are available to assist applicants and recipients in a timely
fashion with understanding, responding to, and complying with the
requirements of all such written communications.
(8) As used in this section:
(a) "Language access provider" means any independent contractor who
provides spoken language interpreter services for department
appointments or medicaid enrollee appointments, or provided these
services on or after January 1, 2009, and before June 10, 2010, whether
paid by a broker, language access agency, or the department. "Language
access provider" does not mean an owner, manager, or employee of a
broker or a language access agency.
(b) "Primary languages" includes but is not limited to Spanish,
Vietnamese, Cambodian, Laotian, and Chinese.
Sec. 65 RCW 74.04.050 and 1981 1st ex.s. c 6 s 3 are each amended
to read as follows:
(1) The department ((shall serve)) is designated as the single
state agency to administer the following public assistance((. The
department is hereby empowered and authorized to cooperate in the
administration of such federal laws, consistent with the public
assistance laws of this state, as may be necessary to qualify for
federal funds for:)) programs:
(1) Medical assistance;
(2) Aid to dependent children;
(3)
(a) Temporary assistance to needy families;
(b) Child welfare services; and
(((4))) (c) Any other programs of public assistance for which
provision for federal grants or funds may from time to time be made,
except as otherwise provided by law.
(2) The authority is hereby designated as the single state agency
to administer the medical services programs established under chapter
74.09 RCW, including the state children's health insurance program,
Titles XIX and XXI of the federal social security act of 1935, as
amended.
(3) The department and the authority are hereby empowered and
authorized to cooperate in the administration of such federal laws,
consistent with the public assistance laws of this state, as may be
necessary to qualify for federal funds.
(4) The state hereby accepts and assents to all the present
provisions of the federal law under which federal grants or funds,
goods, commodities, and services are extended to the state for the
support of programs ((administered by the department)) referenced in
this section, and to such additional legislation as may subsequently be
enacted as is not inconsistent with the purposes of this title,
authorizing public welfare and assistance activities. The provisions
of this title shall be so administered as to conform with federal
requirements with respect to eligibility for the receipt of federal
grants or funds.
(5) The department and the authority shall periodically make
application for federal grants or funds and submit such plans, reports
and data, as are required by any act of congress as a condition
precedent to the receipt of federal funds for such assistance. The
department and the authority shall make and enforce such rules and
regulations as shall be necessary to insure compliance with the terms
and conditions of such federal grants or funds.
Sec. 66 RCW 74.04.055 and 1991 c 126 s 2 are each amended to read
as follows:
In furtherance of the policy of this state to cooperate with the
federal government in the programs included in this title the secretary
or director, as appropriate, shall issue such rules and regulations as
may become necessary to entitle this state to participate in federal
grants-in-aid, goods, commodities and services unless the same be
expressly prohibited by this title. Any section or provision of this
title which may be susceptible to more than one construction shall be
interpreted in favor of the construction most likely to satisfy federal
laws entitling this state to receive federal matching or other funds
for the various programs of public assistance. If any part of this
chapter is found to be in conflict with federal requirements which are
a prescribed condition to the receipts of federal funds to the state,
the conflicting part of this chapter is hereby inoperative solely to
the extent of the conflict with respect to the agencies directly
affected, and such finding or determination shall not affect the
operation of the remainder of this chapter.
Sec. 67 RCW 74.04.060 and 2006 c 259 s 5 are each amended to read
as follows:
(1)(a) For the protection of applicants and recipients, the
department, the authority, and the county offices and their respective
officers and employees are prohibited, except as hereinafter provided,
from disclosing the contents of any records, files, papers and
communications, except for purposes directly connected with the
administration of the programs of this title. In any judicial
proceeding, except such proceeding as is directly concerned with the
administration of these programs, such records, files, papers and
communications, and their contents, shall be deemed privileged
communications and except for the right of any individual to inquire of
the office whether a named individual is a recipient of welfare
assistance and such person shall be entitled to an affirmative or
negative answer.
(b) Upon written request of a parent who has been awarded
visitation rights in an action for divorce or separation or any parent
with legal custody of the child, the department shall disclose to him
or her the last known address and location of his or her natural or
adopted children. The secretary shall adopt rules which establish
procedures for disclosing the address of the children and providing,
when appropriate, for prior notice to the custodian of the children.
The notice shall state that a request for disclosure has been received
and will be complied with by the department unless the department
receives a copy of a court order which enjoins the disclosure of the
information or restricts or limits the requesting party's right to
contact or visit the other party or the child. Information supplied to
a parent by the department shall be used only for purposes directly
related to the enforcement of the visitation and custody provisions of
the court order of separation or decree of divorce. No parent shall
disclose such information to any other person except for the purpose of
enforcing visitation provisions of the said order or decree.
(c) The department shall review methods to improve the protection
and confidentiality of information for recipients of welfare assistance
who have disclosed to the department that they are past or current
victims of domestic violence or stalking.
(2) The county offices shall maintain monthly at their offices a
report showing the names and addresses of all recipients in the county
receiving public assistance under this title, together with the amount
paid to each during the preceding month.
(3) The provisions of this section shall not apply to duly
designated representatives of approved private welfare agencies, public
officials, members of legislative interim committees and advisory
committees when performing duties directly connected with the
administration of this title, such as regulation and investigation
directly connected therewith: PROVIDED, HOWEVER, That any information
so obtained by such persons or groups shall be treated with such degree
of confidentiality as is required by the federal social security law.
(4) It shall be unlawful, except as provided in this section, for
any person, body, association, firm, corporation or other agency to
solicit, publish, disclose, receive, make use of, or to authorize,
knowingly permit, participate in or acquiesce in the use of any lists
or names for commercial or political purposes of any nature. The
violation of this section shall be a gross misdemeanor.
Sec. 68 RCW 74.04.062 and 1997 c 58 s 1006 are each amended to
read as follows:
Upon written request of a person who has been properly identified
as an officer of the law or a properly identified United States
immigration official the department or authority shall disclose to such
officer the current address and location of a recipient of public
welfare if the officer furnishes the department or authority with such
person's name and social security account number and satisfactorily
demonstrates that such recipient is a fugitive, that the location or
apprehension of such fugitive is within the officer's official duties,
and that the request is made in the proper exercise of those duties.
When the department or authority becomes aware that a public
assistance recipient is the subject of an outstanding warrant, the
department or authority may contact the appropriate law enforcement
agency and, if the warrant is valid, provide the law enforcement agency
with the location of the recipient.
Sec. 69 RCW 74.04.290 and 1983 1st ex.s. c 41 s 22 are each
amended to read as follows:
In carrying out any of the provisions of this title, the secretary,
the director, county administrators, hearing examiners, or other duly
authorized officers of the department or authority shall have power to
subpoena witnesses, administer oaths, take testimony and compel the
production of such papers, books, records and documents as they may
deem relevant to the performance of their duties. Subpoenas issued
under this power shall be under RCW 43.20A.605.
Sec. 70 RCW 7.68.080 and 1990 c 3 s 503 are each amended to read
as follows:
The provisions of chapter 51.36 RCW as now or hereafter amended
govern the provision of medical aid under this chapter to victims
injured as a result of a criminal act, including criminal acts
committed between July 1, 1981, and January 1, 1983, except that:
(1) The provisions contained in RCW 51.36.030, 51.36.040, and
51.36.080 as now or hereafter amended do not apply to this chapter;
(2) The specific provisions of RCW 51.36.020 as now or hereafter
amended relating to supplying emergency transportation do not apply:
PROVIDED, That:
(a) When the injury to any victim is so serious as to require the
victim's being taken from the place of injury to a place of treatment,
reasonable transportation costs to the nearest place of proper
treatment shall be reimbursed from the fund established pursuant to RCW
7.68.090; and
(b) In the case of alleged rape or molestation of a child the
reasonable costs of a colposcope examination shall be reimbursed from
the fund pursuant to RCW 7.68.090. Hospital, clinic, and medical
charges along with all related fees under this chapter shall conform to
regulations promulgated by the director. The director shall set these
service levels and fees at a level no lower than those established by
the ((department of social and health services)) health care authority
under Title 74 RCW. In establishing fees for medical and other health
care services, the director shall consider the director's duty to
purchase health care in a prudent, cost-effective manner. The director
shall establish rules adopted in accordance with chapter 34.05 RCW.
Nothing in this chapter may be construed to require the payment of
interest on any billing, fee, or charge.
Sec. 71 RCW 43.41.160 and 1986 c 303 s 11 are each amended to
read as follows:
(1) It is the purpose of this section to ensure implementation and
coordination of chapter 70.14 RCW as well as other legislative and
executive policies designed to contain the cost of health care that is
purchased or provided by the state. In order to achieve that purpose,
the director may:
(a) Establish within the ((office of financial management)) health
care authority a health care cost containment program in cooperation
with all state agencies;
(b) Implement lawful health care cost containment policies that
have been adopted by the legislature or the governor, including
appropriation provisos;
(c) Coordinate the activities of all state agencies with respect to
health care cost containment policies;
(d) Study and make recommendations on health care cost containment
policies;
(e) Monitor and report on the implementation of health care cost
containment policies;
(f) Appoint a health care cost containment technical advisory
committee that represents state agencies that are involved in the
direct purchase, funding, or provision of health care; and
(g) Engage in other activities necessary to achieve the purposes of
this section.
(2) All state agencies shall cooperate with the director in
carrying out the purpose of this section.
Sec. 72 RCW 43.41.260 and 2009 c 479 s 28 are each amended to
read as follows:
The health care authority((,)) and the office of financial
management((, and the department of social and health services)) shall
together monitor the enrollee level in the basic health plan and the
medicaid caseload of children. The office of financial management
shall adjust the funding levels by interagency reimbursement of funds
between the basic health plan and medicaid and adjust the funding
levels ((between)) for the health care authority ((and the medical
assistance administration of the department of social and health
services)) to maximize combined enrollment.
Sec. 73 RCW 43.70.670 and 2007 c 259 s 38 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)) health care authority
as defined in RCW 74.09.010(((8))) (10) 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.
Sec. 74 RCW 47.06B.020 and 2009 c 515 s 4 are each amended to
read as follows:
(1) The agency council on coordinated transportation is created.
The purpose of the council is to advance and improve accessibility to
and coordination of special needs transportation services statewide.
The council is composed of fourteen voting members and four nonvoting,
legislative members.
(2) The fourteen voting members are the superintendent of public
instruction or a designee, the secretary of transportation or a
designee, the ((secretary of the department of social and health
services)) director of the health care authority or a designee, and
eleven members appointed by the governor as follows:
(a) One representative from the office of the governor;
(b) Three persons who are consumers of special needs transportation
services, which must include:
(i) One person designated by the executive director of the
governor's committee on disability issues and employment; and
(ii) One person who is designated by the executive director of the
developmental disabilities council;
(c) One representative from the Washington association of pupil
transportation;
(d) One representative from the Washington state transit
association;
(e) One of the following:
(i) A representative from the community transportation association
of the Northwest; or
(ii) A representative from the community action council
association;
(f) One person who represents regional transportation planning
organizations and metropolitan planning organizations;
(g) One representative of brokers who provide nonemergency,
medically necessary trips to persons with special transportation needs
under the medicaid program administered by the ((department of social
and health services)) health care authority;
(h) One representative from the Washington state department of
veterans affairs; and
(i) One representative of the state association of counties.
(3) The four nonvoting members are legislators as follows:
(a) Two members from the house of representatives, one from each of
the two largest caucuses, appointed by the speaker of the house of
representatives, including at least one member from the house
transportation policy and budget committee or the house appropriations
committee; and
(b) Two members from the senate, one from each of the two largest
caucuses, appointed by the president of the senate, including at least
one member from the senate transportation committee or the senate ways
and means committee.
(4) Gubernatorial appointees of the council will serve two-year
terms. Members may not receive compensation for their service on the
council, but will be reimbursed for actual and necessary expenses
incurred in performing their duties as members as set forth in RCW
43.03.220.
(5) The council shall vote on an annual basis to elect one of its
voting members to serve as chair. The position of chair must rotate
among the represented agencies, associations, and interest groups at
least every two years. If the position of chair is vacated for any
reason, the secretary of transportation or the secretary's designee
shall serve as acting chair until the next regular meeting of the
council, at which time the members will elect a chair.
(6) The council shall periodically assess its membership to ensure
that there exists a balanced representation of persons with special
transportation needs and providers of special transportation needs
services. Recommendations for modifying the membership of the council
must be included in the council's biennial report to the legislature as
provided in RCW 47.06B.050.
(7) The department of transportation shall provide necessary staff
support for the council.
(8) The council may receive gifts, grants, or endowments from
public or private sources that are made from time to time, in trust or
otherwise, for the use and benefit of the purposes of the council and
spend gifts, grants, or endowments or income from the public or private
sources according to their terms, unless the receipt of the gifts,
grants, or endowments violates RCW 42.17.710.
(9) The meetings of the council must be open to the public, with
the agenda published in advance, and minutes kept and made available to
the public. The public notice of the meetings must indicate that
accommodations for persons with disabilities will be made available
upon request.
(10) All meetings of the council must be held in locations that are
readily accessible to public transportation, and must be scheduled for
times when public transportation is available.
(11) The council shall make an effort to include presentations by
and work sessions including persons with special transportation needs.
Sec. 75 RCW 47.06B.060 and 2009 c 515 s 1 are each amended to
read as follows:
(1) In 2007, the legislature directed the joint transportation
committee to conduct a study of special needs transportation to examine
and evaluate the effectiveness of special needs transportation in the
state. A particular goal of the study was to explore opportunities to
enhance coordination of special needs transportation programs to ensure
that they are delivered efficiently and result in improved access and
increased mobility options for their clients. It is the intent of the
legislature to further consider some of the recommendations, and to
implement many of these recommendations in the form of two pilot
projects that will test the potential for applying these
recommendations statewide in the future.
(2) The legislature is aware that the department of social and
health services submitted an application in December of 2008 to the
federal centers for medicare and medicaid services, seeking approval to
use the medical match system, a federal funding system that has
different requirements from the federal administrative match system
currently used by the department. It is the intent of the legislature
to advance the goals of chapter 515, Laws of 2009 and the
recommendations of the study identified in subsection (1) of this
section without jeopardizing the application made by the department.
(3) By August 15, 2009, the agency council on coordinated
transportation shall appoint a work group for the purpose of
identifying relevant federal requirements related to special needs
transportation, and identifying solutions to streamline the
requirements and increase efficiencies in transportation services
provided for persons with special transportation needs. To advance its
purpose, the work group shall work with relevant federal
representatives and agencies to identify and address various challenges
and barriers.
(4) Membership of the work group must include, but not be limited
to, one or more representatives from:
(a) The departments of transportation, veterans affairs, health,
and ((social and health services)) the health care authority;
(b) Medicaid nonemergency medical transportation brokers;
(c) Public transit agencies;
(d) Regional and metropolitan transportation planning
organizations, including a representative of the regional
transportation planning organization or organizations that provide
staff support to the local coordinating coalition established under RCW
47.06B.070;
(e) Indian tribes;
(f) The agency council on coordinated transportation;
(g) The local coordinating coalitions established under RCW
47.06B.070; and
(h) The office of the superintendent of public instruction.
(5) The work group shall elect one or more of its members to
service as chair or cochairs.
(6) The work group shall immediately contact representatives of the
federal congressional delegation for Washington state and the relevant
federal agencies and coordinating authorities including, but not
limited to, the federal transit administration, the United States
department of health and human services, and the interagency
transportation coordinating council on access and mobility, and invite
the federal representatives to work collaboratively to:
(a) Identify transportation definitions and terminology used in the
various relevant state and federal programs, and establish consistent
transportation definitions and terminology. For purposes of this
subsection, relevant state definitions exclude terminology that
requires a medical determination, including whether a trip or service
is medically necessary;
(b) Identify restrictions or barriers that preclude federal, state,
and local agencies from sharing client lists or other client
information, and make progress towards removing any restrictions or
barriers;
(c) Identify relevant state and federal performance and cost
reporting systems and requirements, and work towards establishing
consistent and uniform performance and cost reporting systems and
requirements; and
(d) Explore, subject to federal approval, opportunities to test
cost allocation models, including the pilot projects established in RCW
47.06B.080, that:
(i) Allow for cost sharing among public paratransit and medicaid
nonemergency medical trips; and
(ii) Capture the value of medicaid trips provided by public transit
agencies for which they are not currently reimbursed with a funding
match by federal medicaid dollars.
(7) By December 1, 2009, the work group shall submit a report to
the joint transportation committee that explains the progress made
towards the goals of this section and identifies any necessary
legislative action that must be taken to implement all the provisions
of this section. A second progress report must be submitted to the
joint transportation committee by June 1, 2010, and a final report must
be submitted to the joint transportation committee by December 1, 2010.
Sec. 76 RCW 47.06B.070 and 2009 c 515 s 9 are each amended to
read as follows:
(1) A local coordinating coalition is created in each nonemergency
medical transportation brokerage region, as designated by the
((department of social and health services)) health care authority,
that encompasses:
(a) A single county that has a population of more than seven
hundred fifty thousand but less than one million; and
(b) Five counties, and is comprised of at least one county that has
a population of more than four hundred thousand.
(2) The purpose of a local coordinating coalition is to advance
local efforts to coordinate and maximize efficiencies in special needs
transportation programs and services, contributing to the overall
objectives and goals of the agency council on coordinated
transportation. The local coordinating coalition shall serve in an
advisory capacity to the agency council on coordinated transportation
by providing the council with a focused and ongoing assessment of the
special transportation needs and services provided within its region.
(3) The composition and size of each local coordinating coalition
may vary by region. Local coordinating coalition members, appointed by
the chair of the agency council on coordinated transportation to two-year terms, must reflect a balanced representation of the region's
providers of special needs transportation services and must include:
(a) Members of existing local coordinating coalitions, with
approval by those members;
(b) One or more representatives of the public transit agency or
agencies serving the region;
(c) One or more representatives of private service providers;
(d) A representative of civic or community-based service providers;
(e) A consumer of special needs transportation services;
(f) A representative of nonemergency medical transportation
medicaid brokers;
(g) A representative of social and human service programs;
(h) A representative of local high school districts; and
(i) A representative from the Washington state department of
veterans affairs.
(4) Each coalition shall vote on an annual basis to elect one of
its members to serve as chair. The position of chair must rotate among
the represented members at least every two years. If the position of
chair is vacated for any reason, the member representing the regional
transportation planning organization described in subsection (6) of
this section shall serve as acting chair until the next regular meeting
of the coalition, at which time the members will elect a chair.
(5) Regular meetings of the local coordinating coalition may be
convened at the call of the chair or by a majority of the members.
Meetings must be open to the public, and held in locations that are
readily accessible to public transportation.
(6) The regional transportation planning organization, as described
in chapter 47.80 RCW, serving the region in which the local
coordinating coalition is created shall provide necessary staff support
for the local coordinating coalition. In regions served by more than
one regional transportation planning organization, unless otherwise
agreed to by the relevant planning organizations, the regional
transportation planning organization serving the largest population
within the region shall provide the necessary staff support.
Sec. 77 RCW 48.01.235 and 2003 c 248 s 2 are each amended to read
as follows:
(1) An issuer and an employee welfare benefit plan, whether insured
or self funded, as defined in the employee retirement income security
act of 1974, 29 U.S.C. Sec. 1101 et seq. may not deny enrollment of a
child under the health plan of the child's parent on the grounds that:
(a) The child was born out of wedlock;
(b) The child is not claimed as a dependent on the parent's federal
tax return; or
(c) The child does not reside with the parent or in the issuer's,
or insured or self funded employee welfare benefit plan's service area.
(2) Where a child has health coverage through an issuer, or an
insured or self funded employee welfare benefit plan of a noncustodial
parent, the issuer, or insured or self funded employee welfare benefit
plan, shall:
(a) Provide such information to the custodial parent as may be
necessary for the child to obtain benefits through that coverage;
(b) Permit the provider or the custodial parent to submit claims
for covered services without the approval of the noncustodial parent.
If the provider submits the claim, the provider will obtain the
custodial parent's assignment of insurance benefits or otherwise secure
the custodial parent's approval.
For purposes of this subsection the ((department of social and
health services)) health care authority as the state medicaid agency
under RCW 74.09.500 may reassign medical insurance rights to the
provider for custodial parents whose children are eligible for services
under RCW 74.09.500; and
(c) Make payments on claims submitted in accordance with (b) of
this subsection directly to the custodial parent, to the provider, or
to the ((department of social and health services)) health care
authority as the state medicaid agency under RCW 74.09.500.
(3) Where a child does not reside in the issuer's service area, an
issuer shall cover no less than urgent and emergent care. Where the
issuer offers broader coverage, whether by policy or reciprocal
agreement, the issuer shall provide such coverage to any child
otherwise covered that does not reside in the issuer's service area.
(4) Where a parent is required by a court order to provide health
coverage for a child, and the parent is eligible for family health
coverage, the issuer, or insured or self funded employee welfare
benefit plan, shall:
(a) Permit the parent to enroll, under the family coverage, a child
who is otherwise eligible for the coverage without regard to any
enrollment season restrictions;
(b) Enroll the child under family coverage upon application of the
child's other parent, ((department of social and health services))
health care authority as the state medicaid agency under RCW 74.09.500,
or child support enforcement program, if the parent is enrolled but
fails to make application to obtain coverage for such child; and
(c) Not disenroll, or eliminate coverage of, such child who is
otherwise eligible for the coverage unless the issuer or insured or
self funded employee welfare benefit plan is provided satisfactory
written evidence that:
(i) The court order is no longer in effect; or
(ii) The child is or will be enrolled in comparable health coverage
through another issuer, or insured or self funded employee welfare
benefit plan, which will take effect not later than the effective date
of disenrollment.
(5) An issuer, or insured or self funded employee welfare benefit
plan, that has been assigned the rights of an individual eligible for
medical assistance under medicaid and coverage for health benefits from
the issuer, or insured or self funded employee welfare benefit plan,
may not impose requirements on the ((department of social and health
services)) health care authority that are different from requirements
applicable to an agent or assignee of any other individual so covered.
Sec. 78 RCW 48.43.008 and 2007 c 259 s 24 are each amended to
read as follows:
When the ((department of social and health services)) health care
authority 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.
Sec. 79 RCW 48.43.517 and 2007 c 5 s 7 are each amended to read
as follows:
When the ((department of social and health services)) health care
authority has determined that it is cost-effective to enroll a child
participating in a medical assistance program under chapter 74.09 RCW
in an employer-sponsored health plan, the carrier shall permit the
enrollment of the participant who is otherwise eligible for coverage in
the health plan without regard to any open enrollment restrictions.
The request for special enrollment shall be made by the ((department))
authority or participant within sixty days of the ((department's))
authority's determination that the enrollment would be cost-effective.
Sec. 80 RCW 69.41.030 and 2010 c 83 s 1 are each amended to read
as follows:
(1) It shall be unlawful for any person to sell, deliver, or
possess any legend drug except upon the order or prescription of a
physician under chapter 18.71 RCW, an osteopathic physician and surgeon
under chapter 18.57 RCW, an optometrist licensed under chapter 18.53
RCW who is certified by the optometry board under RCW 18.53.010, a
dentist under chapter 18.32 RCW, a podiatric physician and surgeon
under chapter 18.22 RCW, a veterinarian under chapter 18.92 RCW, a
commissioned medical or dental officer in the United States armed
forces or public health service in the discharge of his or her official
duties, a duly licensed physician or dentist employed by the veterans
administration in the discharge of his or her official duties, a
registered nurse or advanced registered nurse practitioner under
chapter 18.79 RCW when authorized by the nursing care quality assurance
commission, an osteopathic physician assistant under chapter 18.57A RCW
when authorized by the board of osteopathic medicine and surgery, a
physician assistant under chapter 18.71A RCW when authorized by the
medical quality assurance commission, or any of the following
professionals in any province of Canada that shares a common border
with the state of Washington or in any state of the United States: A
physician licensed to practice medicine and surgery or a physician
licensed to practice osteopathic medicine and surgery, a dentist
licensed to practice dentistry, a podiatric physician and surgeon
licensed to practice podiatric medicine and surgery, a licensed
advanced registered nurse practitioner, or a veterinarian licensed to
practice veterinary medicine: PROVIDED, HOWEVER, That the above
provisions shall not apply to sale, delivery, or possession by drug
wholesalers or drug manufacturers, or their agents or employees, or to
any practitioner acting within the scope of his or her license, or to
a common or contract carrier or warehouseman, or any employee thereof,
whose possession of any legend drug is in the usual course of business
or employment: PROVIDED FURTHER, That nothing in this chapter or
chapter 18.64 RCW shall prevent a family planning clinic that is under
contract with the ((department of social and health services)) health
care authority from selling, delivering, possessing, and dispensing
commercially prepackaged oral contraceptives prescribed by authorized,
licensed health care practitioners.
(2)(a) A violation of this section involving the sale, delivery, or
possession with intent to sell or deliver is a class B felony
punishable according to chapter 9A.20 RCW.
(b) A violation of this section involving possession is a
misdemeanor.
Sec. 81 RCW 69.41.190 and 2009 c 575 s 1 are each amended to read
as follows:
(1)(a) Except as provided in subsection (2) of this section, any
pharmacist filling a prescription under a state purchased health care
program as defined in RCW 41.05.011(2) shall substitute, where
identified, a preferred drug for any nonpreferred drug in a given
therapeutic class, unless the endorsing practitioner has indicated on
the prescription that the nonpreferred drug must be dispensed as
written, or the prescription is for a refill of an antipsychotic,
antidepressant, antiepileptic, chemotherapy, antiretroviral, or
immunosuppressive drug, or for the refill of a
immunomodulator/antiviral treatment for hepatitis C for which an
established, fixed duration of therapy is prescribed for at least
twenty-four weeks but no more than forty-eight weeks, in which case the
pharmacist shall dispense the prescribed nonpreferred drug.
(b) When a substitution is made under (a) of this subsection, the
dispensing pharmacist shall notify the prescribing practitioner of the
specific drug and dose dispensed.
(2)(a) A state purchased health care program may impose limited
restrictions on an endorsing practitioner's authority to write a
prescription to dispense as written only under the following
circumstances:
(i) There is statistical or clear data demonstrating the endorsing
practitioner's frequency of prescribing dispensed as written for
nonpreferred drugs varies significantly from the prescribing patterns
of his or her peers;
(ii) The medical director of a state purchased health program has:
(A) Presented the endorsing practitioner with data that indicates the
endorsing practitioner's prescribing patterns vary significantly from
his or her peers, (B) provided the endorsing practitioner an
opportunity to explain the variation in his or her prescribing patterns
to those of his or her peers, and (C) if the variation in prescribing
patterns cannot be explained, provided the endorsing practitioner
sufficient time to change his or her prescribing patterns to align with
those of his or her peers; and
(iii) The restrictions imposed under (a) of this subsection (2)
must be limited to the extent possible to reduce variation in
prescribing patterns and shall remain in effect only until such time as
the endorsing practitioner can demonstrate a reduction in variation in
line with his or her peers.
(b) A state purchased health care program may immediately designate
an available, less expensive, equally effective generic product in a
previously reviewed drug class as a preferred drug, without first
submitting the product to review by the pharmacy and therapeutics
committee established pursuant to RCW 70.14.050.
(c) For a patient's first course of treatment within a therapeutic
class of drugs, a state purchased health care program may impose
limited restrictions on endorsing practitioners' authority to write a
prescription to dispense as written, only under the following
circumstances:
(i) There is a less expensive, equally effective therapeutic
alternative generic product available to treat the condition;
(ii) The drug use review board established under WAC 388-530-4000
reviews and provides recommendations as to the appropriateness of the
limitation;
(iii) Notwithstanding the limitation set forth in (c)(ii) of this
subsection (2), the endorsing practitioner shall have an opportunity to
request as medically necessary, that the brand name drug be prescribed
as the first course of treatment;
(iv) The state purchased health care program may provide, where
available, prescription, emergency room, diagnosis, and hospitalization
history with the endorsing practitioner; and
(v) Specifically for antipsychotic restrictions, the state
purchased health care program shall effectively guide good practice
without interfering with the timeliness of clinical decision making.
((Department of social and health services)) Health care authority
prior authorization programs must provide for responses within
twenty-four hours and at least a seventy-two hour emergency supply of
the requested drug.
(d) If, within a therapeutic class, there is an equally effective
therapeutic alternative over-the-counter drug available, a state
purchased health care program may designate the over-the-counter drug
as the preferred drug.
(e) A state purchased health care program may impose limited
restrictions on endorsing practitioners' authority to prescribe
pharmaceuticals to be dispensed as written for a purpose outside the
scope of their approved labels only under the following circumstances:
(i) There is a less expensive, equally effective on-label product
available to treat the condition;
(ii) The drug use review board established under WAC 388-530-4000
reviews and provides recommendations as to the appropriateness of the
limitation; and
(iii) Notwithstanding the limitation set forth in (e)(ii) of this
subsection (2), the endorsing practitioner shall have an opportunity to
request as medically necessary, that the drug be prescribed for a
covered off-label purpose.
(f) The provisions of this subsection related to the definition of
medically necessary, prior authorization procedures and patient appeal
rights shall be implemented in a manner consistent with applicable
federal and state law.
(3) Notwithstanding the limitations in subsection (2) of this
section, for refills for an antipsychotic, antidepressant,
antiepileptic, chemotherapy, antiretroviral, or immunosuppressive drug,
or for the refill of an immunomodulator antiviral treatment for
hepatitis C for which an established, fixed duration of therapy is
prescribed for at least twenty-four weeks by no more than forty-eight
weeks, the pharmacist shall dispense the prescribed nonpreferred drug.
Sec. 82 RCW 70.01.010 and 1985 c 213 s 14 are each amended to
read as follows:
In furtherance of the policy of this state to cooperate with the
federal government in the public health programs, the department of
social and health services and the health care authority, as
appropriate, shall adopt such rules and regulations as may become
necessary to entitle this state to participate in federal funds unless
the same be expressly prohibited by law. Any section or provision of
the public health laws of this state which may be susceptible to more
than one construction shall be interpreted in favor of the construction
most likely to satisfy federal laws entitling this state to receive
federal funds for the various programs of public health.
Sec. 83 RCW 70.47.010 and 2009 c 568 s 1 are each amended to read
as follows:
(1)(a) The legislature finds that limitations on access to health
care services for enrollees in the state, such as in rural and
underserved areas, are particularly challenging for the basic health
plan. Statutory restrictions have reduced the options available to the
((administrator)) director to address the access needs of basic health
plan enrollees. It is the intent of the legislature to authorize the
((administrator)) director to develop alternative purchasing strategies
to ensure access to basic health plan enrollees in all areas of the
state, including: (i) The use of differential rating for managed
health care systems based on geographic differences in costs; and (ii)
limited use of self-insurance in areas where adequate access cannot be
assured through other options.
(b) In developing alternative purchasing strategies to address
health care access needs, the ((administrator)) director shall consult
with interested persons including health carriers, health care
providers, and health facilities, and with other appropriate state
agencies including the office of the insurance commissioner and the
office of community and rural health. In pursuing such alternatives,
the ((administrator)) director shall continue to give priority to
prepaid managed care as the preferred method of assuring access to
basic health plan enrollees followed, in priority order, by preferred
providers, fee for service, and self-funding.
(2) The legislature further finds that:
(a) A significant percentage of the population of this state does
not have reasonably available insurance or other coverage of the costs
of necessary basic health care services;
(b) This lack of basic health care coverage is detrimental to the
health of the individuals lacking coverage and to the public welfare,
and results in substantial expenditures for emergency and remedial
health care, often at the expense of health care providers, health care
facilities, and all purchasers of health care, including the state; and
(c) The use of managed health care systems has significant
potential to reduce the growth of health care costs incurred by the
people of this state generally, and by low-income pregnant women, and
at-risk children and adolescents who need greater access to managed
health care.
(3) The purpose of this chapter is to provide or make more readily
available necessary basic health care services in an appropriate
setting to working persons and others who lack coverage, at a cost to
these persons that does not create barriers to the utilization of
necessary health care services. To that end, this chapter establishes
a program to be made available to those residents not eligible for
medicare who share in a portion of the cost or who pay the full cost of
receiving basic health care services from a managed health care system.
(4) It is not the intent of this chapter to provide health care
services for those persons who are presently covered through private
employer-based health plans, nor to replace employer-based health
plans. However, the legislature recognizes that cost-effective and
affordable health plans may not always be available to small business
employers. Further, it is the intent of the legislature to expand,
wherever possible, the availability of private health care coverage and
to discourage the decline of employer-based coverage.
(5)(a) It is the purpose of this chapter to acknowledge the initial
success of this program that has (i) assisted thousands of families in
their search for affordable health care; (ii) demonstrated that low-income, uninsured families are willing to pay for their own health care
coverage to the extent of their ability to pay; and (iii) proved that
local health care providers are willing to enter into a public-private
partnership as a managed care system.
(b) As a consequence, the legislature intends to extend an option
to enroll to certain citizens above two hundred percent of the federal
poverty guidelines within the state who reside in communities where the
plan is operational and who collectively or individually wish to
exercise the opportunity to purchase health care coverage through the
basic health plan if the purchase is done at no cost to the state. It
is also the intent of the legislature to allow employers and other
financial sponsors to financially assist such individuals to purchase
health care through the program so long as such purchase does not
result in a lower standard of coverage for employees.
(c) The legislature intends that, to the extent of available funds,
the program be available throughout Washington state to subsidized and
nonsubsidized enrollees. It is also the intent of the legislature to
enroll subsidized enrollees first, to the maximum extent feasible.
(d) The legislature directs that the basic health plan
((administrator)) director identify enrollees who are likely to be
eligible for medical assistance and assist these individuals in
applying for and receiving medical assistance. ((The administrator and
the department of social and health services shall implement a seamless
system to coordinate eligibility determinations and benefit coverage
for enrollees of the basic health plan and medical assistance
recipients.)) Enrollees receiving medical assistance are not eligible
for the Washington basic health plan.
Sec. 84 RCW 70.47.020 and 2009 c 568 s 2 are each reenacted and
amended to read as follows:
As used in this chapter:
(1) (("Administrator" means the Washington basic health plan
administrator, who also holds the position of administrator))
"Director" means the director of the Washington state health care
authority.
(2) "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.
(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) "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)) director 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).
(5) "Nonsubsidized enrollee" means an individual, or an individual
plus the individual's spouse or dependent children: (a) Who is not
eligible for medicare; (b) who is not confined or residing in a
government-operated institution, unless he or she meets eligibility
criteria adopted by the ((administrator)) director; (c) who is accepted
for enrollment by the ((administrator)) director 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; (e)
who chooses to obtain basic health care coverage from a particular
managed health care system; and (f) who pays or on whose behalf is paid
the full costs for participation in the plan, without any subsidy from
the plan.
(6) "Premium" means a periodic payment, 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.
(7) "Rate" means the amount, negotiated by the ((administrator))
director 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.
(8) "Subsidy" means the difference between the amount of periodic
payment the ((administrator)) director 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) "Subsidized enrollee" means:
(a) An individual, or an individual plus the individual's spouse or
dependent children:
(i) Who is not eligible for medicare;
(ii) Who is not confined or residing in a government-operated
institution, unless he or she meets eligibility criteria adopted by the
((administrator)) director;
(iii) Who is not a full-time student who has received a temporary
visa to study in the United States;
(iv) Who resides in an area of the state served by a managed health
care system participating in the plan;
(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;
(vi) Who chooses to obtain basic health care coverage from a
particular managed health care system in return for periodic payments
to the plan; and
(vii) Who is not receiving medical assistance administered by the
((department of social and health services)) authority;
(b) An individual who meets the requirements in (a)(i) through
(iv), (vi), and (vii) 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, an individual, or
an individual's spouse or dependent children, who meets the
requirements in (a)(i) through (iv), (vi), and (vii) 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.
(10) "Washington basic health plan" or "plan" means the system of
enrollment and payment for basic health care services, administered by
the plan ((administrator)) director through participating managed
health care systems, created by this chapter.
Sec. 85 RCW 70.47.110 and 1991 sp.s. c 4 s 3 are each amended to
read as follows:
The ((department of social and health services)) health care
authority may make payments to ((the administrator or to))
participating managed health care systems on behalf of any enrollee who
is a recipient of medical care under chapter 74.09 RCW, at the maximum
rate allowable for federal matching purposes under Title XIX of the
social security act. Any enrollee on whose behalf the ((department of
social and health services)) health care authority makes such payments
may continue as an enrollee, making premium payments based on the
enrollee's own income as determined under the sliding scale, after
eligibility for coverage under chapter 74.09 RCW has ended, as long as
the enrollee remains eligible under this chapter. Nothing in this
section affects the right of any person eligible for coverage under
chapter 74.09 RCW to receive the services offered to other persons
under that chapter but not included in the schedule of basic health
care services covered by the plan. The ((administrator)) director
shall seek to determine which enrollees or prospective enrollees may be
eligible for medical care under chapter 74.09 RCW and may require these
individuals to complete the eligibility determination process under
chapter 74.09 RCW prior to enrollment or continued participation in the
plan. The ((administrator and the department of social and health
services)) director shall ((cooperatively)) adopt procedures to
facilitate the transition of plan enrollees and payments on their
behalf between the plan and the programs established under chapter
74.09 RCW.
Sec. 86 RCW 70.48.130 and 1993 c 409 s 1 are each amended to read
as follows:
(1) 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)) health care authority, and medical care providers shall
cooperate to achieve the best rates consistent with adequate care.
(2) Payment for emergency or necessary health care shall be by the
governing unit, except that the ((department of social and health
services)) health care authority shall directly reimburse the provider
pursuant to chapter 74.09 RCW, in accordance with the rates and
benefits established by the ((department)) authority, if the confined
person is eligible under the ((department's)) authority's medical care
programs as authorized under chapter 74.09 RCW. After payment by the
((department)) authority, 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)) authority for similar services provided under Title XIX
medicaid, unless additional resources are obtained from the confined
person.
(3) 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)) authority, the governing unit, and any provider of
health care services.
(4) 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.
(5) To the extent that a confined person is unable to be
financially responsible for medical care and is ineligible for the
((department's)) authority'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 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.
(6) There shall be no right of reimbursement to the governing unit
from units of government whose law enforcement officers 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.
(7) 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.
(8) 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.
Sec. 87 RCW 70.168.040 and 2010 c 161 s 1158 are each amended to
read as follows:
The emergency medical services and trauma care system trust account
is hereby created in the state treasury. Moneys shall be transferred
to the emergency medical services and trauma care system trust account
from the public safety education account or other sources as
appropriated, and as collected under RCW 46.63.110(7) and 46.68.440.
Disbursements shall be made by the department subject to legislative
appropriation. Expenditures may be made only for the purposes of the
state trauma care system under this chapter, including emergency
medical services, trauma care services, rehabilitative services, and
the planning and development of related services under this chapter and
for reimbursement by the ((department of social and health services))
health care authority for trauma care services provided by designated
trauma centers.
Sec. 88 RCW 70.225.040 and 2007 c 259 s 45 are each amended to
read as follows:
(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 and the health care authority 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. 89 The purpose of this chapter is to provide
the health care authority with the powers, duties, and authority with
respect to the collection of overpayments and the coordination of
benefits that are currently provided to the department of social and
health services in chapter 43.20B RCW. Providing the health care
authority with these powers is necessary for the authority to
administer medical services programs established under chapter 74.09
RCW currently administered by the department of social and health
services programs but transferred to the authority under this act. The
authority is authorized to collaborate with other state agencies in
carrying out its duties under this chapter and, to the extent
appropriate, may enter into agreements with such other agencies.
Nothing in this chapter may be construed as diminishing the powers,
duties, and authority granted to the department of social and health
services in chapter 43.20B RCW with respect to the programs that will
remain under its jurisdiction following enactment of this act.
NEW SECTION. Sec. 90 The definitions in this section apply
throughout this chapter unless the context clearly requires otherwise:
(1) "Assistance" means all programs administered by the authority.
(2) "Authority" means the Washington state health care authority.
(3) "Director" means the director of the Washington state health
care authority.
(4) "Overpayment" means any payment or benefit to a recipient or to
a vendor in excess of that to which is entitled by law, rule, or
contract, including amounts in dispute.
(5) "Vendor" means a person or entity that provides goods or
services to or for clientele of the authority and that controls
operational decisions.
NEW SECTION. Sec. 91 The authority is authorized to charge fees
for services provided unless otherwise prohibited by law. The fees may
be sufficient to cover the full cost of the service provided if
practical or may be charged on an ability-to-pay basis if practical.
This section does not supersede other statutory authority enabling the
assessment of fees by the authority. Whenever the authority is
authorized by law to collect total or partial reimbursement for the
cost of its providing care of or exercising custody over any person,
the authority shall collect the reimbursement to the extent practical.
NEW SECTION. Sec. 92 (1) Except as otherwise provided by law,
including subsection (2) of this section, there may be no collection of
overpayments and other debts due the authority after the expiration of
six years from the date of notice of such overpayment or other debt
unless the authority has commenced recovery action in a court of law or
unless an administrative remedy authorized by statute is in place.
However, any amount due in a case thus extended ceases to be a debt due
the authority at the expiration of ten years from the date of the
notice of the overpayment or other debt unless a court-ordered remedy
would be in effect for a longer period.
(2) There may be no collection of debts due the authority after the
expiration of twenty years from the date a lien is recorded pursuant to
section 97 of this act.
(3) The authority, at any time, may accept offers of compromise of
disputed claims or may grant partial or total write-off of any debt due
the authority if it is no longer cost-effective to pursue. The
authority shall adopt rules establishing the considerations to be made
in the granting or denial of a partial or total write-off of debts.
NEW SECTION. Sec. 93 The form of the lien in section 95 of this
act must be substantially as follows:
| STATE OF WASHINGTON, HEALTH | ||||
| CARE AUTHORITY | ||||
| By: . . . . . . . . . . . . (Title) | ||||
| STATE OF WASHINGTON | | > | | | |||
| ss. | ||||
| COUNTY OF | ||||
| I, . . . . . ., being first duly sworn, on oath state: That I
am . . . . . . (title); that I have read the foregoing Statement
of Lien, know the contents thereof, and believe the same to
be true. | ||||
| . . . . . . . . . . . . | ||||
| Signed and sworn to or affirmed before me this . . . . day of . . . . . ., . . . . | ||||
| by . . . . . . . . . . . . | ||||
| (name of person making statement). | ||||
| (Seal or stamp) | ||||
| . . . . . . . . . . . . | ||||
| Notary Public in and for the State | ||||
| of Washington | ||||
| My appointment expires: . . . . . . . . . . . . | ||||
NEW SECTION. Sec. 94 (1) No settlement made by and between a
recipient and either the tort feasor or insurer, or both, discharges or
otherwise compromises the lien created in section 95 of this act
without the express written consent of the director or the director's
designee. Discretion to compromise such liens rests solely with the
director or the director's designee.
(2) No settlement or judgment may be entered purporting to
compromise the lien created by section 95 of this act without the
express written consent of the director or the director's designee.
NEW SECTION. Sec. 95 (1) To secure reimbursement of any
assistance paid as a result of injuries to or illness of a recipient
caused by the negligence or wrong of another, the authority is
subrogated to the recipient's rights against a tort feasor or the tort
feasor's insurer, or both.
(2) The authority has the right to file a lien upon any recovery by
or on behalf of the recipient from such tort feasor or the tort
feasor's insurer, or both, to the extent of the value of the assistance
paid by the authority: PROVIDED, That such lien is not effective
against recoveries subject to wrongful death when there are surviving
dependents of the deceased. The lien becomes effective upon filing
with the county auditor in the county where the assistance was
authorized or where any action is brought against the tort feasor or
insurer. The lien may also be filed in any other county or served upon
the recipient in the same manner as a civil summons if, in the
authority's discretion, such alternate filing or service is necessary
to secure the authority's interest. The additional lien is effective
upon filing or service.
(3) The lien of the authority may be against any claim, right of
action, settlement proceeds, money, or benefits arising from an
insurance program to which the recipient might be entitled (a) against
the tort feasor or insurer of the tort feasor, or both, and (b) under
any contract of insurance purchased by the recipient or by any other
person providing coverage for the illness or injuries for which the
assistance is paid or provided by the authority.
(4) If recovery is made by the authority under this section and the
subrogation is fully or partially satisfied through an action brought
by or on behalf of the recipient, the amount paid to the authority must
bear its proportionate share of attorneys' fees and costs.
(a) The determination of the proportionate share to be borne by the
authority must be based upon:
(i) The fees and costs approved by the court in which the action
was initiated; or
(ii) The written agreement between the attorney and client which
establishes fees and costs when fees and costs are not addressed by the
court.
(b) When fees and costs have been approved by a court, after notice
to the authority, the authority has the right to be heard on the matter
of attorneys' fees and costs or its proportionate share.
(c) When fees and costs have not been addressed by the court, the
authority shall receive at the time of settlement a copy of the written
agreement between the attorney and client which establishes fees and
costs and may request and examine documentation of fees and costs
associated with the case. The authority may bring an action in
superior court to void a settlement if it believes the attorneys'
calculation of its proportionate share of fees and costs is
inconsistent with the written agreement between the attorney and client
which establishes fees and costs or if the fees and costs associated
with the case are exorbitant in relation to cases of a similar nature.
(5) The rights and remedies provided to the authority in this
section to secure reimbursement for assistance, including the
authority's lien and subrogation rights, may be delegated to a managed
health care system by contract entered into pursuant to RCW 74.09.522.
A managed health care system may enforce all rights and remedies
delegated to it by the authority to secure and recover assistance
provided under a managed health care system consistent with its
agreement with the authority.
NEW SECTION. Sec. 96 (1) An attorney representing a person who,
as a result of injuries or illness sustained through the negligence or
wrong of another, has received, is receiving, or has applied to receive
shall:
(a) Notify the authority at the time of filing any claim against a
third party, commencing an action at law, negotiating a settlement, or
accepting a settlement offer from the tort feasor or the tort feasor's
insurer, or both; and
(b) Give the authority thirty days' notice before any judgment,
award, or settlement may be satisfied in any action or any claim by the
applicant or recipient to recover damages for such injuries or illness.
(2) The proceeds from any recovery made pursuant to any action or
claim described in section 95 of this act that is necessary to fully
satisfy the authority's lien against recovery must be placed in a trust
account or in the registry of the court until the authority's lien is
satisfied.
NEW SECTION. Sec. 97 (1) The authority shall file liens, seek
adjustment, or otherwise effect recovery for assistance correctly paid
on behalf of an individual consistent with 42 U.S.C. Sec. 1396p. The
authority shall adopt a rule providing for prior notice and hearing
rights to the record title holder or purchaser under a land sale
contract.
(2) Liens may be adjusted by foreclosure in accordance with chapter
61.12 RCW.
(3) In the case of an individual who was fifty-five years of age or
older when the individual received assistance, the authority shall seek
adjustment or recovery from the individual's estate, and from
nonprobate assets of the individual as defined by RCW 11.02.005, but
only for assistance consisting of services that the authority
determines to be appropriate, and related hospital and prescription
drug services. Recovery from the individual's estate, including
foreclosure of liens imposed under this section, must be undertaken as
soon as practicable, consistent with 42 U.S.C. Sec. 1396p.
(4) The authority shall apply the assistance estate recovery law as
it existed on the date that benefits were received when calculating an
estate's liability to reimburse the authority for those benefits.
(5)(a) The authority shall establish procedures consistent with
standards established by the federal department of health and human
services and pursuant to 42 U.S.C. Sec. 1396p to waive recovery when
such recovery would work an undue hardship. The authority shall
recognize an undue hardship for a surviving domestic partner whenever
recovery would not have been permitted if he or she had been a
surviving spouse. The authority is not authorized to pursue recovery
under such circumstances.
(b) Recovery of assistance from a recipient's estate may not
include property made exempt from claims by federal law or treaty,
including exemption for tribal artifacts that may be held by individual
Native Americans.
(6) A lien authorized under this section relates back to attach to
any real property that the decedent had an ownership interest in
immediately before death and is effective as of that date or date of
recording, whichever is earlier.
(7) The authority may enforce a lien authorized under this section
against a decedent's life estate or joint tenancy interest in real
property held by the decedent immediately prior to his or her death.
Such a lien enforced under this subsection may not end and must
continue as provided in this subsection until the authority's lien has
been satisfied.
(a) The value of the life estate subject to the lien is the value
of the decedent's interest in the property subject to the life estate
immediately prior to the decedent's death.
(b) The value of the joint tenancy interest subject to the lien is
the value of the decedent's fractional interest the recipient would
have owned in the jointly held interest in the property had the
recipient and the surviving joint tenants held title to the property as
tenants in common on the date of the recipient's death.
(c) The authority may not enforce the lien provided by this
subsection against a bona fide purchaser or encumbrancer that obtains
an interest in the property after the death of the recipient and before
the authority records either its lien or the request for notice of
transfer or encumbrance as provided by section 116 of this act.
(d) The authority may not enforce a lien provided by this
subsection against any property right that vested prior to July 1,
2005.
(8)(a) Subject to the requirements of 42 U.S.C. Sec. 1396p(a) and
the conditions of this subsection (8), the authority is authorized to
file a lien against the property of an individual prior to his or her
death, and to seek adjustment and recovery from the individual's estate
or sale of the property subject to the lien, if:
(i) The individual is an inpatient in a nursing facility,
intermediate care facility for persons with intellectual disabilities,
or other medical institution; and
(ii) The authority has determined after notice and opportunity for
a hearing that the individual cannot reasonably be expected to be
discharged from the medical institution and to return home.
(b) If the individual is discharged from the medical facility and
returns home, the authority shall dissolve the lien.
(9) The authority is authorized to adopt rules to effect recovery
under this section. The authority may adopt by rule later enactments
of the federal laws referenced in this section.
(10) It is the responsibility of the authority to fully disclose in
advance verbally and in writing, in easy to understand language, the
terms and conditions of estate recovery to all persons offered care
subject to recovery of payments.
(11) In disclosing estate recovery costs to potential clients, and
to family members at the consent of the client, the authority shall
provide a written description of the community service options.
NEW SECTION. Sec. 98 (1) Overpayments of assistance become a
lien against the real and personal property of the recipient from the
time of filing by the authority with the county auditor of the county
in which the recipient resides or owns property, and the lien claim has
preference over the claims of all unsecured creditors.
(2) Debts due the state for overpayments of assistance may be
recovered by the state by deduction from the subsequent assistance
payments to such persons, lien and foreclosure, or order to withhold
and deliver, or may be recovered by civil action.
NEW SECTION. Sec. 99 (1) Any person who owes a debt to the state
for an overpayment of assistance must be notified of that debt by
either personal service or certified mail, return receipt requested.
Personal service, return of the requested receipt, or refusal by the
debtor of such notice is proof of notice to the debtor of the debt
owed. Service of the notice must be in the manner prescribed for the
service of a summons in a civil action. The notice must include a
statement of the debt owed; a statement that the property of the debtor
will be subject to collection action after the debtor terminates from
assistance; a statement that the property will be subject to lien and
foreclosure, distraint, seizure and sale, or order to withhold and
deliver; and a statement that the net proceeds will be applied to the
satisfaction of the overpayment debt. Action to collect the debt by
lien and foreclosure, distraint, seizure and sale, or order to withhold
and deliver, is lawful after ninety days from the debtor's termination
from assistance or the receipt of the notice of debt, whichever is
later. This does not preclude the authority from recovering
overpayments by deduction from subsequent assistance payments, not
exceeding deductions as authorized under federal law with regard to
financial assistance programs: PROVIDED, That subject to federal legal
requirement, deductions may not exceed five percent of the grant
payment standard if the overpayment resulted from error on the part of
the authority or error on the part of the recipient without willful or
knowing intent of the recipient in obtaining or retaining the
overpayment.
(2) A current or former recipient who is aggrieved by a claim that
he or she owes a debt for an overpayment of assistance has the right to
an adjudicative proceeding pursuant to section 53 of this act. If no
application is filed, the debt is subject to collection action as
authorized under this chapter. If a timely application is filed, the
execution of collection action on the debt is stayed pending the final
adjudicative order or termination of the debtor from assistance,
whichever occurs later.
NEW SECTION. Sec. 100 (1) After service of a notice of debt for
an overpayment as provided for in section 99 of this act, stating the
debt accrued, the director may issue to any person, firm, corporation,
association, political subdivision, or department of the state an order
to withhold and deliver property of any kind including, but not
restricted to, earnings which are due, owing, or belonging to the
debtor, when the director has reason to believe that there is in the
possession of such person, firm, corporation, association, political
subdivision, or department of the state property which is due, owing,
or belonging to the debtor. The order to withhold and deliver must
state the amount of the debt, and must state in summary the terms of
this section, RCW 6.27.150 and 6.27.160, chapters 6.13 and 6.15 RCW, 15
U.S.C. Sec. 1673, and other state or federal exemption laws applicable
generally to debtors. The order to withhold and deliver must be served
in the manner prescribed for the service of a summons in a civil action
or by certified mail, return receipt requested. Any person, firm,
corporation, association, political subdivision, or department of the
state upon whom service has been made shall answer the order to
withhold and deliver within twenty days, exclusive of the day of
service, under oath and in writing, and shall make true answers to the
matters inquired of therein. The director may require further and
additional answers to be completed by the person, firm, corporation,
association, political subdivision, or department of the state. If any
such person, firm, corporation, association, political subdivision, or
department of the state possesses any property which may be subject to
the claim of the authority, such property must be withheld immediately
upon receipt of the order to withhold and deliver and must, after the
twenty-day period, upon demand, be delivered forthwith to the director.
The director shall hold the property in trust for application on the
indebtedness involved or for return, without interest, in accordance
with final determination of liability or nonliability. In the
alternative, there may be furnished to the director a good and
sufficient bond, satisfactory to the director, conditioned upon final
determination of liability. Where money is due and owing under any
contract of employment, express or implied, or is held by any person,
firm, corporation, association, political subdivision, or department of
the state subject to withdrawal by the debtor, such money must be
delivered by remittance payable to the order of the director. Delivery
to the director, subject to the exemptions under RCW 6.27.150 and
6.27.160, chapters 6.13 and 6.15 RCW, 15 U.S.C. Sec. 1673, and other
state or federal law applicable generally to debtors, of the money or
other property held or claimed satisfies the requirement of the order
to withhold and deliver. Delivery to the director serves as full
acquittance, and the state warrants and represents that it shall defend
and hold harmless for such actions persons delivering money or property
to the director pursuant to this chapter. The state also warrants and
represents that it shall defend and hold harmless for such actions
persons withholding money or property pursuant to this chapter.
(2) The director shall also, on or before the date of service of
the order to withhold and deliver, mail or cause to be mailed by
certified mail a copy of the order to withhold and deliver to the
debtor at the debtor's last known post office address or, in the
alternative, a copy of the order to withhold and deliver must be served
on the debtor in the same manner as a summons in a civil action on or
before the date of service of the order or within two days thereafter.
The copy of the order must be mailed or served together with a concise
explanation of the right to petition for a hearing on any issue related
to the collection. This requirement is not jurisdictional, but, if the
copy is not mailed or served as provided in this section, or if any
irregularity appears with respect to the mailing or service, the
superior court, on its discretion on motion of the debtor promptly made
and supported by affidavit showing that the debtor has suffered
substantial injury due to the failure to mail the copy, may set aside
the order to withhold and deliver and award to the debtor an amount
equal to the damages resulting from the director's failure to serve on
or mail to the debtor the copy.
NEW SECTION. Sec. 101 If any person, firm, corporation,
association, political subdivision, or department of the state fails to
answer an order to withhold and deliver within the time prescribed in
section 100 of this act, or fails or refuses to deliver property
pursuant to the order, or after actual notice of filing of a lien as
provided for in this chapter, pays over, releases, sells, transfers, or
conveys real or personal property subject to such lien to or for the
benefit of the debtor or any other person, or fails or refuses to
surrender upon demand property distrained under section 100 of this
act, or fails or refuses to honor an assignment of wages presented by
the director, such person, firm, corporation, association, political
subdivision, or department of the state is liable to the authority in
an amount equal to one hundred percent of the value of the debt which
is the basis of the lien, order to withhold and deliver, distraint, or
assignment of wages, together with costs, interest, and reasonable
attorneys' fees.
NEW SECTION. Sec. 102 Any person, firm, corporation,
association, political subdivision, or department employing a person
owing a debt for overpayment of assistance received shall honor,
according to its terms, a duly executed assignment of earnings
presented to the employer by the director as a plan to satisfy or
retire an overpayment debt. This requirement to honor the assignment
of earnings is applicable whether the earnings are to be paid presently
or in the future and continues in force and effect until released in
writing by the director. Payment of moneys pursuant to an assignment
of earnings presented to the employer by the director serves as full
acquittance under any contract of employment, and the state warrants
and represents it shall defend and hold harmless such action taken
pursuant to the assignment of earnings. The director is released from
liability for improper receipt of moneys under assignment of earnings
upon return of any moneys so received.
NEW SECTION. Sec. 103 If an improper real property transfer is
made as defined in RCW 74.08.331 through 74.08.338, the authority may
request the attorney general to file suit to rescind the transaction
except as to subsequent bona fide purchasers for value. If it is
established by judicial proceedings that a fraudulent conveyance
occurred, the value of any assistance which has been furnished may be
recovered in any proceedings from the recipient or the recipient's
estate.
NEW SECTION. Sec. 104 When the authority provides assistance to
persons who possess excess real property under RCW 74.04.005(11)(g),
the authority may file a lien against or otherwise perfect its interest
in such real property as a condition of granting such assistance, and
the authority has the status of a secured creditor.
NEW SECTION. Sec. 105 (1) When the authority determines that a
vendor was overpaid by the authority for either goods or services, or
both, provided to authority clients, except nursing homes under chapter
74.46 RCW, the authority shall give written notice to the vendor. The
notice must include the amount of the overpayment, the basis for the
claim, and the rights of the vendor under this section.
(2) The notice may be served upon the vendor in the manner
prescribed for the service of a summons in civil action or be mailed to
the vendor at the last known address by certified mail, return receipt
requested, demanding payment within twenty days of the date of receipt.
(3) The vendor has the right to an adjudicative proceeding governed
by the administrative procedure act, chapter 34.05 RCW, and the rules
of the authority. The vendor's application for an adjudicative
proceeding must be in writing, state the basis for contesting the
overpayment notice, and include a copy of the authority's notice. The
application must be served on and received by the authority within
twenty-eight days of the vendor's receipt of the notice of overpayment.
The vendor must serve the authority in a manner providing proof of
receipt.
(4) Where an adjudicative proceeding has been requested, the
presiding or reviewing office shall determine the amount, if any, of
the overpayment received by the vendor.
(5) If the vendor fails to attend or participate in the
adjudicative proceeding, upon a showing of valid service, the presiding
or reviewing officer may enter an administrative order declaring the
amount claimed in the notice to be assessed against the vendor and
subject to collection action by the authority.
(6) Failure to make an application for an adjudicative proceeding
within twenty-eight days of the date of notice results in the
establishment of a final debt against the vendor in the amount asserted
by the authority and that amount is subject to collection action. The
authority may also charge the vendor with any costs associated with the
collection of any final overpayment or debt established against the
vendor.
(7) The authority may enforce a final overpayment or debt through
lien and foreclosure, distraint, seizure and sale, order to withhold
and deliver, or other collection action available to the authority to
satisfy the debt due.
(8) Debts determined under this chapter are subject to collection
action without further necessity of action by a presiding or reviewing
officer. The authority may collect the debt in accordance with
sections 100, 101, and 106 of this act. In addition, a vendor lien may
be subject to distraint and seizure and sale in the same manner as
prescribed for support liens in RCW 74.20A.130.
(9) Chapter 66, Laws of 1998 applies to overpayments for goods or
services provided on or after July 1, 1998.
(10) The authority may adopt rules consistent with this section.
NEW SECTION. Sec. 106 (1) The authority may, at the director's
discretion, secure the repayment of any outstanding overpayment, plus
interest, if any, through the filing of a lien against the vendor's
real property, or by requiring the posting of a bond, assignment of
deposit, or some other form of security acceptable to the authority, or
by doing both.
(a) Any lien is effective from the date of filing for record with
the county auditor of the county in which the property is located and
the lien claim has preference over the claims of all unsecured
creditors.
(b) The authority shall review and determine the acceptability of
all other forms of security.
(c) Any bond must be issued by a company licensed as a surety in
the state of Washington.
(d) This subsection does not apply to nursing homes licensed under
chapter 18.51 RCW or portions of hospitals licensed under chapter 70.41
RCW and operating as a nursing home, if those facilities are subject to
chapter 74.46 RCW.
(2) The authority may recover any overpayment, plus interest, if
any, by setoff or recoupment against subsequent payments to the vendor.
NEW SECTION. Sec. 107 Liens created under section 106 of this
act bind the affected property for a period of ten years after the lien
has been recorded or ten years after the resolution of all good faith
disputes as to the overpayment, whichever is later. Any civil action
by the authority to enforce such lien must be timely commenced before
the ten-year period expires or the lien is released. A civil action to
enforce such lien is not timely commenced unless the summons and
complaint are filed within the ten-year period in a court having
jurisdiction and service of the summons and complaint is made upon all
parties in the manner prescribed by appropriate civil court rules.
NEW SECTION. Sec. 108 Any action to enforce a vendor overpayment
debt must be commenced within six years from the date of the
authority's notice to the vendor.
NEW SECTION. Sec. 109 The remedies under sections 106 and 107 of
this act are nonexclusive and nothing contained in this chapter may be
construed to impair or affect the right of the authority to maintain a
civil action or to pursue any other remedies available to it under the
laws of this state to recover such debt.
NEW SECTION. Sec. 110 (1) Except as provided in subsection (4)
of this section, vendors shall pay interest on overpayments at the rate
of one percent per month or portion thereof. Where partial repayment
of an overpayment is made, interest accrues on the remaining balance.
Interest must not accrue when the overpayment occurred due to authority
error.
(2) If the overpayment is discovered by the vendor prior to
discovery and notice by the authority, the interest begins accruing
ninety days after the vendor notifies the authority of such
overpayment.
(3) If the overpayment is discovered by the authority prior to
discovery and notice by the vendor, the interest begins accruing thirty
days after the date of notice by the authority to the vendor.
(4) This section does not apply to:
(a) Interagency or intergovernmental transactions; and
(b) Contracts for public works, goods and services procured for the
exclusive use of the authority, equipment, or travel.
NEW SECTION. Sec. 111 (1) To avoid a duplicate payment of
benefits, a recipient of assistance from the authority is deemed to
have subrogated the authority to the recipient's right to recover
temporary total disability compensation due to the recipient and the
recipient's dependents under Title 51 RCW, to the extent of such
assistance or compensation, whichever is less. However, the amount to
be repaid to the authority must bear its proportionate share of
attorneys' fees and costs, if any, incurred under Title 51 RCW by the
recipient or the recipient's dependents.
(2) The authority may assert and enforce a lien and notice to
withhold and deliver to secure reimbursement. The authority shall
identify in the lien and notice to withhold and deliver the recipient
of assistance and temporary total disability compensation and the
amount claimed by the authority.
NEW SECTION. Sec. 112 The effective date of the lien and notice
to withhold and deliver provided in section 111 of this act is the day
that it is received by the department of labor and industries or a
self-insurer as defined in chapter 51.08 RCW. Service of the lien and
notice to withhold and deliver may be made personally, by regular mail
with postage prepaid, or by electronic means. A statement of lien and
notice to withhold and deliver must be mailed to the recipient at the
recipient's last known address by certified mail, return receipt
requested, no later than two business days after the authority mails,
delivers, or transmits the lien and notice to withhold and deliver to
the department of labor and industries or a self-insurer.
NEW SECTION. Sec. 113 The director of labor and industries or
the director's designee, or a self-insurer as defined in chapter 51.08
RCW, following receipt of the lien and notice to withhold and deliver,
shall deliver to the director of the authority or the director's
designee any temporary total disability compensation payable to the
recipient named in the lien and notice to withhold and deliver up to
the amount claimed. The director of labor and industries or
self-insurer shall withhold and deliver from funds currently in the
director's or self-insurer's possession or from any funds that may at
any time come into the director's or self-insurer's possession on
account of temporary total disability compensation payable to the
recipient named in the lien and notice to withhold and deliver.
NEW SECTION. Sec. 114 (1) A recipient feeling aggrieved by the
action of the authority in recovering his or her temporary total
disability compensation as provided in sections 111 through 115 of this
act has the right to an adjudicative proceeding.
(2) A recipient seeking an adjudicative proceeding shall file an
application with the director within twenty-eight days after the
statement of lien and notice to withhold and deliver was mailed to the
recipient. If the recipient files an application more than
twenty-eight days after, but within one year of, the date the statement
of lien and notice to withhold and deliver was mailed, the recipient is
entitled to a hearing if the recipient shows good cause for the
recipient's failure to file a timely application. The filing of a late
application does not affect prior collection action pending the final
adjudicative order. Until good cause for failure to file a timely
application is decided, the authority may continue to collect under the
lien and notice to withhold and deliver.
(3) The proceeding shall be governed by chapter 34.05 RCW, the
administrative procedure act.
NEW SECTION. Sec. 115 Sections 111 through 114 of this act and
this section do not apply to persons whose eligibility for benefits
under Title 51 RCW is based upon an injury or illness occurring prior
to July 1, 1972.
NEW SECTION. Sec. 116 (1) When an individual receives assistance
subject to recovery under this chapter and the individual is the holder
of record title to real property or the purchaser under a land sale
contract, the authority may present to the county auditor for recording
in the deed and mortgage records of a county a request for notice of
transfer or encumbrance of the real property. The authority shall
adopt a rule providing prior notice and hearing rights to the record
title holder or purchaser under a land sale contract.
(2) The authority shall present to the county auditor for recording
a termination of request for notice of transfer or encumbrance when, in
the judgment of the authority, it is no longer necessary or appropriate
for the authority to monitor transfers or encumbrances related to the
real property.
(3) The authority shall adopt by rule a form for the request for
notice of transfer or encumbrance and the termination of request for
notice of transfer or encumbrance that, at a minimum:
(a) Contains the name of the assistance recipient and a case
identifier or other appropriate information that links the individual
who is the holder of record title to real property or the purchaser
under a land sale contract to the individual's assistance records;
(b) Contains the legal description of the real property;
(c) Contains a mailing address for the authority to receive the
notice of transfer or encumbrance; and
(d) Complies with the requirements for recording in RCW 36.18.010
for those forms intended to be recorded.
(4) The authority shall pay the recording fee required by the
county clerk under RCW 36.18.010.
(5) The request for notice of transfer or encumbrance described in
this section does not affect title to real property and is not a lien
on, encumbrance of, or other interest in the real property.
NEW SECTION. Sec. 117 (1) By December 10, 2011, the department
of social and health services and the health care authority shall
provide a preliminary report, and by December 1, 2012, provide a final
implementation plan, to the governor and the legislature with
recommendations regarding the role of the health care authority in the
state's purchasing of mental health treatment, substance abuse
treatment, and long-term care services, including services for those
with developmental disabilities.
(2) The reports shall:
(a) Consider options for effectively coordinating the purchase and
delivery of care for people who need long-term care, developmental
disabilities, mental health, or chemical dependency services. Options
considered may include, but are not limited to, transitioning purchase
of these services from the department of social and health services to
the health care authority, and strategies for the agencies to
collaborate seamlessly while purchasing services separately; and
(b) Address the following components:
(i) Incentives to improve prevention efforts;
(ii) Service delivery approaches, including models for care
management and care coordination and benefit design;
(iii) Rules to assure that those requiring long-term care services
and supports receive that care in the least restrictive setting
appropriate to their needs;
(iv) Systems to measure cost savings;
(v) Mechanisms to measure health outcomes and consumer
satisfaction;
(vi) The designation of a single point of entry for financial and
functional eligibility determinations for long-term care services; and
(vii) Process for collaboration with local governments.
(3) In developing these recommendations, the agencies shall:
(a) Consult with tribal governments and with interested
stakeholders, including consumers, health care and other service
providers, health insurance carriers, and local governments; and
(b) Cooperate with the joint select committee on health reform
implementation established in House Concurrent Resolution No. 4404 and
any of its advisory committees. The agencies shall strongly consider
the guidance and input received from these forums in the development of
its recommendations.
(4) The agencies shall submit a progress report to the governor and
the legislature by November 15, 2013, that provides details on the
agencies' progress on purchasing coordination to date.
Sec. 118 RCW 74.09A.005 and 2007 c 179 s 1 are each amended to
read as follows:
The legislature finds that:
(1) Simplification in the administration of payment of health
benefits is important for the state, providers, and health insurers;
(2) The state, providers, and health insurers should take advantage
of all opportunities to streamline operations through automation and
the use of common computer standards;
(3) It is in the best interests of the state, providers, and health
insurers to identify all third parties that are obligated to cover the
cost of health care coverage of joint beneficiaries; and
(4) Health insurers, as a condition of doing business in
Washington, must increase their effort to share information with the
((department)) authority and accept the ((department's)) authority's
timely claims consistent with 42 U.S.C. 1396a(a)(25).
Therefore, the legislature declares that to improve the
coordination of benefits between the ((department of social and health
services)) health care authority and health insurers to ensure that
medical insurance benefits are properly utilized, a transfer of
information between the ((department)) authority and health insurers
should be instituted, and the process for submitting requests for
information and claims should be simplified.
Sec. 119 RCW 74.09A.010 and 2007 c 179 s 2 are each amended to
read as follows:
For the purposes of this chapter:
(1) (("Department")) "Authority" means the ((department of social
and health services)) Washington state health care authority.
(2) "Health insurance coverage" includes any policy, contract, or
agreement under which health care items or services are provided,
arranged, reimbursed, or paid for by a health insurer.
(3) "Health insurer" means any party that is, by statute, policy,
contract, or agreement, legally responsible for payment of a claim for
a health care item or service, including, but not limited to, a
commercial insurance company providing disability insurance under
chapter 48.20 or 48.21 RCW, a health care service contractor providing
health care coverage under chapter 48.44 RCW, a health maintenance
organization providing comprehensive health care services under chapter
48.46 RCW, an employer or union self-insured plan, any private insurer,
a group health plan, a service benefit plan, a managed care
organization, a pharmacy benefit manager, and a third party
administrator.
(4) "Computerized" means online or batch processing with
standardized format via magnetic tape output.
(5) "Joint beneficiary" is an individual who has health insurance
coverage and is a recipient of public assistance benefits under chapter
74.09 RCW.
Sec. 120 RCW 74.09A.020 and 2007 c 179 s 3 are each amended to
read as follows:
(1) The ((department)) authority shall provide routine and periodic
computerized information to health insurers regarding client
eligibility and coverage information. Health insurers shall use this
information to identify joint beneficiaries. Identification of joint
beneficiaries shall be transmitted to the ((department)) authority.
The ((department)) authority shall use this information to improve
accuracy and currency of health insurance coverage and promote improved
coordination of benefits.
(2) To the maximum extent possible, necessary data elements and a
compatible database shall be developed by affected health insurers and
the ((department)) authority. The ((department)) authority shall
establish a representative group of health insurers and state agency
representatives to develop necessary technical and file specifications
to promote a standardized database. The database shall include
elements essential to the ((department)) authority and its population's
health insurance coverage information.
(3) If the state and health insurers enter into other agreements
regarding the use of common computer standards, the database identified
in this section shall be replaced by the new common computer standards.
(4) The information provided will be of sufficient detail to
promote reliable and accurate benefit coordination and identification
of individuals who are also eligible for ((department)) authority
programs.
(5) The frequency of updates will be mutually agreed to by each
health insurer and the ((department)) authority based on frequency of
change and operational limitations. In no event shall the computerized
data be provided less than semiannually.
(6) The health insurers and the ((department)) authority shall
safeguard and properly use the information to protect records as
provided by law, including but not limited to chapters 42.48, 74.09,
74.04, 70.02, and 42.56 RCW, and 42 U.S.C. Sec. 1396a and 42 C.F.R.
Sec. 43 et seq. The purpose of this exchange of information is to
improve coordination and administration of benefits and ensure that
medical insurance benefits are properly utilized.
(7) The ((department)) authority shall target implementation of
this section to those health insurers with the highest probability of
joint beneficiaries.
Sec. 121 RCW 74.09A.030 and 2007 c 179 s 4 are each amended to
read as follows:
Health insurers, as a condition of doing business in Washington,
must:
(1) Provide, with respect to individuals who are eligible for, or
are provided, medical assistance under chapter 74.09 RCW, upon the
request of the ((department)) authority, information to determine
during what period the individual or their spouses or their dependants
may be, or may have been, covered by a health insurer and the nature of
coverage that is or was provided by the health insurer, including the
name, address, and identifying number of the plan, in a manner
prescribed by the ((department)) authority;
(2) Accept the ((department's)) authority's right to recovery and
the assignment to the ((department)) authority of any right of an
individual or other entity to payment from the party for an item or
service for which payment has been made under chapter 74.09 RCW;
(3) Respond to any inquiry by the ((department)) authority
regarding a claim for payment for any health care item or service that
is submitted not later than three years after the date of the provision
of such health care item or service;
(4) Agree not to deny a claim submitted by the ((department))
authority solely on the basis of the date of submission of the claim,
the type or format of the claim form, or a failure to present proper
documentation at the point-of-sale that is the basis of the claim, if:
(a) The claim is submitted by the ((department)) authority within
the three-year period beginning on the date the item or service was
furnished; and
(b) Any action by the ((department)) authority to enforce its
rights with respect to such claim is commenced within six years of the
((department's)) authority's submission of such claim; and
(5) Agree that the prevailing party in any legal action to enforce
this section receives reasonable attorneys' fees as well as related
collection fees and costs incurred in the enforcement of this section.
NEW SECTION. Sec. 122 The following acts or parts of acts are
each repealed:
(1) RCW 74.09.085 (Contracts -- Performance measures -- Financial
incentives) and 2005 c 446 s 3;
(2) RCW 74.09.110 (Administrative personnel -- Professional
consultants and screeners) and 1979 c 141 s 339 & 1959 c 26 s
74.09.110;
(3) RCW 74.09.5221 (Medical assistance -- Federal standards -- Waivers -- Application) and 1997 c 231 s 112;
(4) RCW 74.09.5227 (Implementation date -- Payments for services
provided by rural hospitals) and 2001 2nd sp.s. c 2 s 3;
(5) RCW 74.09.755 (AIDS -- Community-based care -- Federal social
security act waiver) and 1989 c 427 s 12;
(6) RCW 43.20A.860 (Requirement to seek federal waivers and state
law changes to medical assistance program) and 1995 c 265 s 26; and
(7) RCW 74.04.270 (Audit of accounts -- Uniform accounting system)
and 1979 c 141 s 304 & 1959 c 26 s 74.04.270.
Sec. 123 RCW 74.09.015 and 2007 c 259 s 16 are each amended 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 RCW 41.05.037 and this section, which
may include use of the 211 system established in chapter 43.211 RCW.
NEW SECTION. Sec. 124 A new section is added to chapter 43.20A
RCW to read as follows:
The secretary shall enter into agreements with the director of the
health care authority, in his or her capacity as the director of the
designated single state agency to administer medical services programs
under Titles XIX and XXI of the social security act, to establish the
division of responsibilities between the agencies with respect to
mental health, chemical dependency, and long-term care services,
including services for people with developmental disabilities. The
agreements shall be revised, as necessary, to comply with the final
implementation plan adopted in section 117 of this act.
NEW SECTION. Sec. 125 (1) All powers, duties, and functions of
the department of social and health services pertaining to the medical
assistance program and the medicaid purchasing administration are
transferred to the health care authority to the extent necessary to
carry out the purposes of this act. All references to the secretary or
the department of social and health services in the Revised Code of
Washington shall be construed to mean the director or the health care
authority when referring to the functions transferred in this section.
(2)(a) All reports, documents, surveys, books, records, files,
papers, or written material in the possession of the department of
social and health services pertaining to the powers, functions, and
duties transferred shall be delivered to the custody of the health care
authority. All cabinets, furniture, office equipment, motor vehicles,
and other tangible property employed by the department of social and
health services in carrying out the powers, functions, and duties
transferred shall be made available to the health care authority. All
funds, credits, or other assets held in connection with the powers,
functions, and duties transferred shall be assigned to the health care
authority.
(b) Any appropriations made to the department of social and health
services for carrying out the powers, functions, and duties transferred
shall, on the effective date of this section, be transferred and
credited to the health care authority.
(c) Whenever any question arises as to the transfer of any
personnel, funds, books, documents, records, papers, files, equipment,
or other tangible property used or held in the exercise of the powers
and the performance of the duties and functions transferred, the
director of financial management shall make a determination as to the
proper allocation and certify the same to the state agencies concerned.
(3) All employees of the medicaid purchasing administration at the
department of social and health services are transferred to the
jurisdiction of the health care authority. All employees classified
under chapter 41.06 RCW, the state civil service law, are assigned to
the health care authority to perform their usual duties upon the same
terms as formerly, without any loss of rights, subject to any action
that may be appropriate thereafter in accordance with the laws and
rules governing state civil service.
(4) All rules and all pending business before the department of
social and health services pertaining to the powers, functions, and
duties transferred shall be continued and acted upon by the health care
authority. All existing contracts and obligations shall remain in full
force and shall be performed by the health care authority.
(5) The transfer of the powers, duties, functions, and personnel of
the department of social and health services shall not affect the
validity of any act performed before the effective date of this
section.
(6) If apportionments of budgeted funds are required because of the
transfers directed by this section, the director of financial
management shall certify the apportionments to the agencies affected,
the state auditor, and the state treasurer. Each of these shall make
the appropriate transfer and adjustments in funds and appropriation
accounts and equipment records in accordance with the certification.
(7) A nonsupervisory medicaid purchasing unit bargaining unit is
created at the health care authority. All nonsupervisory civil service
employees of the medicaid purchasing administration at the department
of social and health services assigned to the health care authority
under this section whose positions are within the existing bargaining
unit description at the department of social and health services shall
become a part of the nonsupervisory medicaid purchasing unit bargaining
unit at the health care authority under the provisions of chapter 41.80
RCW. The exclusive bargaining representative of the existing
bargaining unit at the department of social and health services is
certified as the exclusive bargaining representative of the
nonsupervisory medicaid purchasing unit bargaining unit at the health
care authority without the necessity of an election.
(8) A supervisory medicaid purchasing unit bargaining unit is
created at the health care authority. All supervisory civil service
employees of the medicaid purchasing administration at the department
of social and health services assigned to the health care authority
under this section whose positions are within the existing bargaining
unit description at the department of social and health services shall
become a part of the supervisory medicaid purchasing unit bargaining
unit at the health care authority under the provisions of chapter 41.80
RCW. The exclusive bargaining representative of the existing
bargaining unit at the department of social and health services is
certified as the exclusive bargaining representative of the supervisory
medicaid purchasing unit bargaining unit at the health care authority
without the necessity of an election.
(9) The bargaining units of employees created under this section
are appropriate units under the provisions of chapter 41.80 RCW.
However, nothing contained in this section shall be construed to alter
the authority of the public employment relations commission under the
provisions of chapter 41.80 RCW to amend or modify the bargaining
units.
(10) Positions from the department of social and health services
central administration are transferred to the jurisdiction of the
health care authority. Employees classified under chapter 41.06 RCW,
the state civil service law, are assigned to the health care authority
to perform their usual duties upon the same terms as formerly, without
any loss of rights, subject to any action that may be appropriate
thereafter in accordance with the laws and rules governing state civil
service.
(11) All classified employees of the department of social and
health services central administration assigned to the health care
authority under subsection (10) of this section whose positions are
within an existing bargaining unit description at the health care
authority shall become a part of the existing bargaining unit at the
health care authority and shall be considered an appropriate inclusion
or modification of the existing bargaining unit under the provisions of
chapter 41.80 RCW.
NEW SECTION. Sec. 126 The code reviser shall note wherever
"administrator" is used or referred to in the Revised Code of
Washington as the head of the health care authority that the title of
the agency head has been changed to "director." The code reviser shall
prepare legislation for the 2012 regular session that changes all
statutory references to "administrator" of the health care authority to
"director" of the health care authority.
NEW SECTION. Sec. 127 RCW 43.20A.365 is recodified as a section
in chapter 74.09 RCW.
NEW SECTION. Sec. 128 Sections 89 through 116 of this act
constitute a new chapter in Title
NEW SECTION. Sec. 129 Sections 74 through 76 of this act expire
June 30, 2012.
NEW SECTION. Sec. 130 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. 131 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
July 1, 2011.