HEALTH CARE AUTHORITY
(Basic Health Plan)
[Filed February 28, 1997, 11:35 a.m.]
Date of Adoption: February 28, 1997.
Purpose: Revisions of current Basic Health Plan rules to implement a reservation list for reduced premium enrollees.
Citation of Existing Rules Affected by this Order: Amending WAC 182-25-030, 182-25-040, and 182-25-090.
Statutory Authority for Adoption: RCW 70.47.050.
Under RCW 34.05.350 the agency for good cause finds that immediate adoption, amendment, or repeal of a rule is necessary for the preservation of the public health, safety, or general welfare, and that observing the time requirements of notice and opportunity to comment upon adoption of a permanent rule would be contrary to the public interest.
Reasons for this Finding: State law requires immediate rules on Basic Health Plan reservation list when funds are not available for continued subsidized enrollment.
Number of Sections Adopted in Order to Comply with Federal Statute: New 0, amended 0, repealed 0; Federal Rules or Standards: New 0, amended 0, repealed 0; or Recently Enacted State Statutes: New 0, amended 0, repealed 0.
Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, amended 0, repealed 0.
Number of Sections Adopted on the Agency's own Initiative: New 0, amended 2, repealed 0.
Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, amended 2, repealed 0.
Number of Sections Adopted using Negotiated Rule Making: New 0, amended 0, repealed 0; Pilot Rule Making: New 0, amended 0, repealed 0; or Other Alternative Rule Making: New 0, amended 0, repealed 0.
Effective Date of Rule: Immediately.
February 28, 1997
AMENDATORY SECTION (Amending WSR 96-15-024, filed 7/9/96, effective
WAC 182-25-030 Eligibility. (1) To be eligible for enrollment in BHP, an individual must:
(a) Not be eligible for Medicare; and
(b) Reside within the state of Washington.
Persons not meeting these criteria, as evidenced by information submitted on the application for enrollment or otherwise obtained by BHP, will not be enrolled. An enrollee who subsequently fails to meet these criteria, or who is later determined to have failed to meet the criteria at the time of enrollment, will be disenrolled from the plan as provided in WAC 182-25-090.
(2) To be eligible for subsidized enrollment in BHP, an individual must have a gross family income that does not exceed two hundred percent of federal poverty level as adjusted for family size and determined annually by the U.S. Department of Health and Human Services, and must pay, or have paid on their behalf, the monthly BHP premium.
(3) To be eligible for nonsubsidized enrollment in BHP, an individual may have any income level and must pay, or have paid on their behalf, the full costs for participation in BHP, including the cost of administration, without subsidy from the HCA.
(4) An individual otherwise eligible for enrollment in BHP may be
denied enrollment if the administrator has determined that acceptance of
additional enrollment would exceed limits established by the legislature,
would jeopardize the orderly development of BHP or would result in an
overexpenditure of BHP funds. In the event that the administrator closes
or limits enrollment and to the extent funding is available, BHP will
continue to accept and process applications for enrollment((
, but will
not process those applications for determination of eligibility. BHP
will place the names of applicants on a waiting list in the order in
which applications are received, and will so notify the applicants))
(a) Applicants who will pay the full premium;
(b) Children eligible for BHP Plus;
(c) Pregnant women who, prior to April 1, 1997, apply to BHP, are referred and qualify for maternity benefits through DSHS;
(d) Children eligible for subsidized BHP, who were referred to DSHS for BHP Plus coverage, but were found ineligible for BHP Plus;
(e) Employees of a home care agency group enrolled or applying for coverage under WAC 182-25-060;
(f) Eligible individual home care providers;
(g) Licensed foster care workers; and
(h) Limited enrollment of new employer groups.
Subject to availability of funding, additional space for enrollment
may be reserved for other applicants as determined by the administrator,
in order to ensure continuous coverage and service for individual and
group accounts currently or previously enrolled in BHP. (For example:
Transferring enrollees enrolled prior to the implementation of the
reservation list from nonsubsidized to subsidized BHP; adding new family
members to an existing account; transferring enrollees between group and
individual accounts; reinstating enrollees who are otherwise eligible
under WAC 182-25-090 to return to BHP after a limited break in coverage
due to late payment or other coverage; adding newly hired employees to
an existing employer group; or adding new or returning members of
federally recognized native American tribes to that tribe's currently
approved financial sponsor group.) Applicants for subsidized BHP who are
not in any of these categories may reserve space on a reservation list
to be processed according to the date the reservation or application is
received by BHP. In the event that enrollment is reopened by the
administrator, applicants whose names appear on the ((
reservation list will be notified by BHP of the opportunity to enroll.
BHP may require new application forms and documentation from applicants
on the (( waiting)) reservation list, or may contact applicants to verify
continued interest in applying, prior to determining their eligibility.
[Statutory Authority: RCW 70.47.050. 96-15-024, 182-25-030, filed
7/9/96, effective 8/9/96.]
AMENDATORY SECTION (Amending WSR 96-15-024, filed 7/9/96, effective
WAC 182-25-040 Enrollment in the plan. (1) Any individual applying for enrollment in BHP must submit a signed, completed BHP application for enrollment. Applications for enrollment of children under the age of eighteen must be signed by the child's parent or legal guardian, who shall also be held responsible for payment of premiums due on behalf of the child. If an applicant is accepted for enrollment, the applicant's signature acknowledges the applicant's obligation to pay the monthly premium in accordance with the terms and conditions identified in the member handbook. Applications for subsidized enrollment on behalf of children under the age of nineteen shall be referred to the department of social and health services for Medicaid eligibility determination, unless the family chooses not to access this option.
(2) Each applicant shall list all eligible dependents to be enrolled and supply other information and documentation as required by BHP and, where applicable, DSHS medical assistance.
(a) Documentation will be required, showing the amount and sources of the applicant's gross family income. Acceptable documentation will include a copy of the applicant's most recently filed federal income tax form, and/or other documentation that shows year-to-date income, or income for the most recent thirty days or complete calendar month as of the date of application. An average of documented income received over a period of several months may be used for purposes of eligibility determination. Income documentation shall be required for the subscriber and dependents, with the exceptions listed under WAC 182-25-010 (17)(b).
(b) Documentation of Washington state residency shall also be required, displaying the applicant's name and address. Other documentation may be accepted if the applicant does not have a physical residence.
(c) BHP may request additional information from applicants for purposes of establishing or verifying eligibility, premium responsibility or managed health care system selection.
(d) Submission of incomplete or inaccurate information may delay or prevent an applicant's enrollment in BHP. Intentional submission of false information may result in disenrollment of the subscriber and all enrolled dependents.
(3) Each family applying for enrollment must designate a managed health care system from which the applicant and all enrolled dependents will receive covered services. All applicants from the same family must receive covered services from the same managed health care system (with the exception of cases in which a subscriber who is paying child support for his/her dependents lives in a different service area). No applicant will be enrolled for whom designation of a managed health care system has not been made as part of the application for enrollment. The administrator will establish procedures for the selection of managed health care systems, which will include conditions under which an enrollee may change from one managed health care system to another. Such procedures will allow enrollees to change from one managed health care system to another during open enrollment, or otherwise upon showing of good cause for the transfer.
(4) Managed health care systems may assist BHP applicants in the enrollment process, but must provide them with the toll-free number for BHP, information on all MHCS available within the applicant's county of residence and an estimate of the premium the applicant would pay for each available MHCS.
(5) Insurance brokers or agents who have met all statutory and regulatory requirements of the office of the insurance commissioner, are currently licensed through the office of the insurance commissioner, and who have completed BHP's training program, will be paid a commission for assisting eligible applicants to enroll in BHP.
(a) Individual policy commission: Subject to availability of funds, and as a pilot program, BHP will pay a one-time fee to any currently licensed insurance broker or agent who sells BHP to an eligible individual applicant if that applicant has never been a BHP member in the past.
(b) Group policy commission: Subject to availability of funds, and as a pilot program, fees paid for the sale of BHP group coverage to an eligible employer will be based on the number of employees in the group for the first and second months of the group's enrollment.
(c) Insurance brokers or agents must provide the prospective applicant with the BHP toll-free information number and inform them of BHP benefits, limitations, exclusions, waiting periods, co-payments, all managed health care systems available to the applicant within his/her county of residence and the estimated premium for each of them.
(d) All statutes and regulations of the office of the insurance commissioner will apply to brokers or agents who sell BHP, except they will not be required to be appointed by the MHCS.
(e) BHP will not pay renewal commissions.
(6) Except as provided in WAC 182-25-030(4), applications for enrollment will be reviewed by BHP within thirty days of receipt and those applicants satisfying the eligibility criteria and who have provided all required information, documentation and premium payments will be notified of their effective date of enrollment.
(7) Eligible applicants will be enrolled in BHP in the order in which their completed applications, including all required documentation, have been received by BHP, provided that the applicant also remits full payment of the first premium bill to BHP by the due date specified by BHP. In the event a reservation list is implemented, eligible applicants will be enrolled in accordance with WAC 182-25-030(4).
(8) Not all family members are required to apply for enrollment in BHP; however, any family member for whom application for enrollment is not made at the same time that other family members apply, may not subsequently enroll as a family member until the next open enrollment period, unless the subscriber has experienced a qualifying change in family status:
(a) The loss of other continuous health care coverage, for family members who have previously waived coverage, upon proof of continuous medical coverage from the date the subscriber enrolled;
(b) Marriage; or
(c) Birth, adoption or change in dependency or custody of a child or adult dependent. Eligible newborn or newly adopted children may be enrolled effective from the date of birth or physical placement for adoption provided that application for enrollment is submitted to BHP within sixty days of the date of birth or such placement for adoption.
(9) Any enrollee who voluntarily disenrolls from BHP for reasons other than ineligibility or enrollment in other health care coverage may not reenroll for a period of twelve months from the effective date of disenrollment. After the twelve-month period, or if the enrollee disenrolled for reasons of ineligibility or enrollment in other health care coverage, he/she may reenroll in BHP, subject to enrollment limits and portability and preexisting condition policies as referenced in WAC 182-25-020(1) and 182-25-030(4) and specified in the member handbook, provided he/she is determined by BHP to be otherwise eligible for enrollment as of the date of application. With the exception of enrollees under group coverage, enrollees who are disenrolled from BHP for nonpayment, in accordance with WAC 182-25-090(2), more than twice in a twelve-month period, and who have a lapse in coverage of one month or more, may not reenroll for a period of twelve months from the effective date of the third disenrollment. If a reservation list has been implemented, an enrollee who was disenrolled in accordance with WAC 182-25-090(2) and is eligible to enroll from the reservation list prior to the end of the required twelve-month wait for reenrollment, will not be reenrolled until the end of the twelve-month period. If an enrollee who was disenrolled in accordance with WAC 182-25-090(2) satisfies the required twelve-month wait for reenrollment while on the reservation list, enrollment will not be completed until funding is available to enroll him or her from the reservation list.
(10) On a schedule approved by the administrator, BHP will request
verification of information from all or a subset of enrollees
("recertification"), requiring new documentation of income if the
enrollee has had a change in income that would result in a different
subsidy level. For good cause, BHP may require recertification on a more
widespread or more frequent basis. Enrollees who fail to comply with a
recertification request will be disenrolled from BHP. Each enrollee is
responsible for notifying BHP within thirty days of any changes which
could affect the enrollee's eligibility or premium responsibility. If,
as a result of recertification, BHP determines that a subsidized
enrollee's income exceeds twice the poverty level according to the
federal income guidelines, and that the enrollee knowingly failed to
inform BHP of such increase in income, BHP may bill the enrollee for the
subsidy paid on the enrollee's behalf during the period of time that the
enrollee's income exceeded twice the poverty level.
[Statutory Authority: RCW 70.47.050. 96-15-024, 182-25-040, filed
7/9/96, effective 8/9/96.]
AMENDATORY SECTION (Amending WSR 96-15-024, filed 7/9/96, effective
WAC 182-25-090 Disenrollment from BHP. (1) An enrollee or employer group may disenroll effective the first day of any month by giving BHP at least ten days prior written notice of the intention to disenroll. Reenrollment in BHP shall be subject to the provisions of WAC 182-25-040(9). The administrator shall also establish procedures for notice by an enrollee of a disenrollment decision, including the date upon which disenrollment shall become effective. Nonpayment of premium by an enrollee shall be considered an indication of the enrollee's intention to disenroll from BHP.
(2) BHP may disenroll any enrollee or group from BHP for good cause, which shall include:
(a) Failure to meet the eligibility requirements set forth in WAC 182-25-030, 182-25-050, 182-25-060, and 182-25-070;
(b) Nonpayment of premium;
(c) Repeated failure to pay co-payments in full on a timely basis;
(d) Fraud or knowingly providing false information;
(e) Abuse or intentional misconduct; and
(f) Refusal to accept or follow procedures or treatment determined by a MHCS to be essential to the health of the enrollee, where the managed health care system demonstrates to the satisfaction of BHP that no professionally acceptable alternative form of treatment is available from the managed health care system, and the enrollee has been so advised by the managed health care system.
In the event that an employer group, a home care agency group or a financial sponsor group is disenrolled under these provisions, the employer or sponsor and all members of that group will be notified of the disenrollment and the enrollees will be offered coverage under individual accounts. BHP will make every effort to transfer the enrollees to individual accounts without a break in coverage; however, the enrollee will be responsible for ensuring that payment is received by BHP prior to the final disenrollment date for that month.
Enrollees who are disenrolled from BHP in accordance with (c), (d), (e) or (f) of this subsection may not reenroll for a period of twelve months from the effective date of disenrollment. With the exception of enrollees under group coverage, enrollees who are disenrolled from BHP for nonpayment, in accordance with (b) of this subsection, more than twice in a twelve-month period, and who have a lapse in coverage of one month or more, may not reenroll for a period of twelve months from the effective date of the third disenrollment. If a reservation list has been implemented, an enrollee who was disenrolled in accordance with WAC 182-25-090(2) and is eligible to enroll from the reservation list prior to the end of the required twelve-month wait for reenrollment, will not be reenrolled until the end of the twelve-month period. If an enrollee who was disenrolled in accordance with WAC 182-25-090(2) satisfies the required twelve-month wait for reenrollment while on the reservation list, enrollment will not be completed until funding is available to enroll him or her from the reservation list.
BHP shall provide the enrollee or the parent, legal guardian or sponsor of an enrolled dependent with advance written notice of its intent to disenroll the enrollee. Such notice shall specify an effective date of disenrollment, which shall be at least ten days from the date of the notice, and shall describe the procedures for disenrollment, including the enrollee's right to appeal the disenrollment decision as set forth in WAC 182-25-100 and 182-25-105. Prior to the effective date specified, if the enrollee submits an appeal to BHP contesting the disenrollment decision, as provided in WAC 182-25-105, disenrollment shall not become effective until the date, if any, established as a result of BHP's appeal procedure, provided that the enrollee otherwise remains eligible and continues to make all premium payments when due; and further provided that the enrollee does not create a risk of violent, aggressive or harassing behavior, assault or battery or purposeful damage to or theft of managed health care system property, or the property of staff or providers, patients or visitors while on the property of the managed health care system or one of its participating providers.
(3) Any enrollee who knowingly provides false information to BHP or
to a participating managed health care system may be disenrolled by BHP
and may be held financially responsible for any covered services
fraudulently obtained through BHP.
[Statutory Authority: RCW 70.47.050. 96-15-024, 182-25-090, filed 7/9/96, effective 8/9/96.]