PERMANENT RULES
SOCIAL AND HEALTH SERVICES
(Medical Assistance Administration)
Purpose: The following cost-saving changes to the SCHIP program are being proposed:
| • | The monthly premium for a child will increase from $10 to $15. |
| • | The maximum monthly premium paid per family will increase from $30 to $45. |
| • | A client's eligibility for the program will end after three consecutive months of nonpayment of premiums; the current rule allows four consecutive months. |
| • | The wait period before SCHIP coverage can be reinstated for a client, whose coverage was terminated for not paying the premiums for three consecutive months, is being reduced from four months to three months. |
Citation of Existing Rules Affected by this Order: Repealing WAC 388-542-0100, 388-542-0125, 388-542-0150, 388-542-0200, 388-542-0220, 388-542-0250, 388-542-0275 and 388-542-0500; and amending WAC 388-505-0211, 388-542-0050, and 388-542-0300.
Statutory Authority for Adoption: RCW 74.08.090, 74.09.510, 74.09.522, and 74.09.450.
Other Authority: 2003-05 Revised Omnibus Operating Budget - 2004 Supplement (ESSB 2459, chapter 276, Laws of 2004).
Adopted under notice filed as WSR 04-13-140 on June 22, 2004.
Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 1, Repealed 0.
Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.
Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.
Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 2, Amended 2, Repealed 8.
Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 2, Amended 3, Repealed 8.
Date Adopted: July 28, 2004.
Brian H. Lindgren, Manager
Rules and Policies Assistance Unit
3423.2STATE CHILDREN'S HEALTH INSURANCE ((PLAN (CHIP))) PROGRAM
(SCHIP)
[]
(1) Chapter 388-538 WAC, Managed care (except WAC 388-538-065);
(2) WAC 388-505-0210 (3) and (8), Children's medical eligibility;
(3) WAC 388-505-0211, Premium requirements for SCHIP children;
(4) WAC 388-416-0015(10), Certification periods; and
(5) WAC 388-418-0025 (4) and (5), Change of circumstance.
[]
(("Children's health insurance program (CHIP)" means the
health insurance program authorized by Title XXI of the Social
Security Act and administered by the department of social and
health services (DSHS). This program also is referred to as
the state children's health insurance program (SCHIP).
"Client premium" means a monthly payment a client makes to the department of social and health services (DSHS) for CHIP coverage.))
"Creditable coverage" means most types of public and
private health coverage, except Indian health services, that
provides access to physicians, hospitals, laboratory services,
and radiology services. This term applies to the coverage
whether or not the coverage is equivalent to that offered
under ((CHIP)) SCHIP. "Creditable coverage" is described in
42 U.S.C. Sec. 1397jj.
"Employer-sponsored dependent coverage" means creditable health coverage for dependents offered by a family member's employer or union, for which the employer or union may contribute in whole or part towards the premium. Extensions of such coverage (e.g., COBRA extensions) also qualify as employer-sponsored dependent coverage as long as there remains a contribution toward the premiums by the employer or union.
(("Finance division" means the division of the department
of social and health services that sends out billing
statements, monitors accounts, and collects the CHIP client
premiums.))
[Statutory Authority: RCW 74.09.080, 74.08.510, [74.08.]522, 74.09.450, 1115 Waiver, 42 U.S.C. 1396. 02-01-075, § 388-542-0050, filed 12/14/01, effective 1/14/02. Statutory Authority: RCW 74.08.090, 74.09.450. 00-07-103, § 388-542-0050, filed 3/17/00, effective 4/17/00.]
(a) Chooses to end employer sponsored dependent coverage.
The waiting period begins the day after the employment-based
coverage ends((, and ends on the last day of the fourth full
month of noncoverage)); or
(b) Fails to exercise an optional coverage extension (e.g., COBRA) that meets the following conditions. The waiting period begins on the day there is a documented refusal of the coverage extension when the extended coverage is:
(i) Subsidized in part or in whole by the employer or union;
(ii) Available and accessible to the applicant or family; and
(iii) At a monthly cost to the family meeting the limitation of subsection (2)(b)(iv).
(2) MAA does not require a waiting period prior to
((CHIP)) SCHIP coverage when:
(a) The client or family member has a medical condition that, without treatment, would be life-threatening or cause serious disability or loss of function; or
(b) The loss of employer sponsored dependent coverage is due to any of the following:
(i) Loss of employment with no post-employment subsidized coverage as described in subsection (1)(b);
(ii) Death of the employee;
(iii) The employer discontinues employer-sponsored dependent coverage;
(iv) The family's total out-of-pocket maximum for employer-sponsored dependent coverage is fifty dollars per month or more;
(v) The plan terminates employer-sponsored dependent coverage for the client because the client reached the maximum lifetime coverage amount;
(vi) Coverage under a COBRA extension period expired;
(vii) Employer-sponsored dependent coverage is not reasonably available (e.g., client would have to travel to another city or state to access care); or
(viii) Domestic violence caused the loss of coverage for the victim.
[Statutory Authority: RCW 74.09.080, 74.08.510, [74.08.]522, 74.09.450, 1115 Waiver, 42 U.S.C. 1396. 02-01-075, § 388-542-0300, filed 12/14/01, effective 1/14/02. Statutory Authority: RCW 74.08.090, 74.09.450. 00-07-103, § 388-542-0300, filed 3/17/00, effective 4/17/00.]
The following sections of the Washington Administrative Code are repealed:
| WAC 388-542-0100 | CHIP scope of care. |
| WAC 388-542-0125 | Access to care. |
| WAC 388-542-0150 | Client eligibility requirements for CHIP. |
| WAC 388-542-0200 | CHIP enrollment. |
| WAC 388-542-0220 | Ending CHIP client eligibility. |
| WAC 388-542-0250 | CHIP client costs. |
| WAC 388-542-0275 | Reimbursement. |
| WAC 388-542-0500 | Managed care rules that apply to CHIP. |
(a) "Mandatory children" means all states are required by federal rule to provide Medicaid coverage for these children; and
(b) "Optional children" means the state of Washington chose to provide Medicaid coverage to children that are not included in the mandatory population.
(c))), "premium" means an amount paid for medical coverage.
(2) ((Optional children include:
(a) A child under the age of one year, whose assistance unit's net available income exceeds one hundred eighty-five percent FPL as described in WAC 388-478-0075;
(b) A child over age one but who has not yet attained age six whose assistance unit's net available income exceeds one hundred thirty-three percent FPL as described in WAC 388-478-0075; and
(c) A child over age six whose assistance unit's net available income exceeds one hundred percent FPL as described in WAC 388-478-0075.
(3) For optional children found eligible for Medicaid coverage under WAC 388-505-0210(2), payment of a premium is required as a condition of eligibility. See subsection (6) of this section for exemptions for optional children.
(4) A child found eligible for Medicaid coverage under WAC 388-505-0210(2) that does not meet the conditions of subsection (2) of this section is a mandatory recipient of Medicaid and is not subject to the premium requirement.
(5))) For a child found eligible for the state children's health insurance program (SCHIP) under WAC 388-505-0210(3), payment of a premium is required as a condition of eligibility.
(((6) An optional))
(3) A child is exempt from the premium requirement if the child meets one of the following:
(a) The child is pregnant; or
(b) The child is an American Indian or Alaska native((;
(c) A child whose assistance unit's net available income is equal to or less than one hundred fifty percent FPL. An optional child exempted from the premium requirement under this subsection is treated as if the child is a mandatory child)).
(((7))) (4) The premium requirement begins the first of
the month following the determination of eligibility. There
is no premium requirement for medical coverage received in a
month or months before the determination of eligibility.
(((8))) (5) The premium amount for the assistance unit is
based on the net available income as described in WAC 388-450-0005. If the household includes more than one
assistance unit, the premium amount billed for the assistance
units may be different amounts.
(((9) The premium amount for each optional Medicaid child
is:
(a) Zero dollars per month when the assistance unit's net available income is above one hundred percent FPL and equal to or less than one hundred fifty percent FPL; or
(b) Ten dollars per month when the assistance unit's net available income is above one hundred fifty percent FPL and equal to or less than two hundred percent FPL.
(10))) (6) The premium amount for each SCHIP child is fifteen dollars per month.
(((11))) (7) The department bills the family for the
lesser of:
(a) A maximum of forty-five dollars per month; or
(b) The total of the highest premiums, for up to three children in the assistance unit.
(((12))) (8) Premium payment is a condition of
eligibility for assistance units that include ((optional))
SCHIP children. All ((optional)) SCHIP children in an
assistance unit are ineligible for medical coverage when the
head of household's premium payments are three months in
arrears. Three months in arrears means a balance exists for
three months.
(((13))) (9) When the department terminates the medical
coverage of ((an optional)) a SCHIP child due to nonpayment of
premiums, the child has a three-month period of ineligibility
beginning the first of the following month. The three month
period of ineligibility is rescinded only when the:
(a) Past due premiums are paid in full prior to the begin date of the period of ineligibility; or
(b) ((Optional)) SCHIP child has a change in
circumstances such that the child becomes ((a mandatory
child)) eligible for Medicaid. The department cannot rescind
the three-month period of ineligibility for reasons other than
the criteria described in this subsection (((13) of this
section)).
(((14))) (10) The department writes off past-due premiums
after twelve months.
(((15))) (11) When the designated three-month period of
ineligibility is over, all past due premiums that are an
obligation of the head of household must be paid or written
off before ((an optional)) a child can become eligible for
((medical coverage)) SCHIP.
(((16))) (12) A family cannot designate partial payment
of the billed premium amount as payment for a specific child
in the assistance unit. The full amount of the premium bill
is the obligation of the head of household of the assistance
unit. A family can decide to request medical coverage only
for certain children in the assistance unit, if they want to
reduce premium obligation.
(((17))) (13) A change that affects the premium amount is
effective the month after the change is reported and
processed.
(((18))) (14) A sponsor or other third party may pay the
premium on behalf of the child or children in the assistance
unit. The premium payment requirement remains the obligation
of head of household of the assistance unit. The failure of a
sponsor or other third party to pay the premium does not
eliminate the:
(a) Establishment of the period of ineligibility
described in subsection (((13))) (9) of this section; or
(b) Obligation of the head of household to pay past-due premiums.
[Statutory Authority: RCW 74.08.090, 74.09.055, 2004 c 276. 04-08-125, § 388-505-0211, filed 4/7/04, effective 5/8/04.]