SOCIAL AND HEALTH SERVICES
(Medical Assistance Administration)
Date of Adoption: March 17, 2000.
Purpose: To codify policies regulating the new children's federal/state health insurance program known as CHIP or SCHIP. This program is authorized under Title XXI of the Social Security Act, and is intended to cover children under the age of nineteen whose family income is from 200% to 250% of the federal poverty level (FPL).
Statutory Authority for Adoption: RCW 74.08.090, 74.09.450.
Adopted under notice filed as WSR 00-03-061 on January 18, 2000.
Changes Other than Editing from Proposed to Adopted Version: WAC 388-542-0050 Definitions for children's health insurance program (CHIP).
"Creditable coverage" means most types of public and private
health coverage, except Indian Health Services, that provides
access to physicians ((
doctors)), hospitals, laboratory services,
and radiology services. This applies regardless of whether the
coverage is equivalent to that offered under CHIP. "Creditable
coverage" is more completely defined in 42 U.S.C. 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
s)) in whole or part towards the premium.
WAC 388-542-0150 Client eligibility requirements for CHIP.
(5) When MAA ends a client's eligibility according to
(3))) (4) of this section.
WAC 388-542-0200 CHIP managed care enrollment.
(2)(b) Enroll with a CHIP Indian or tribal primary care case manager (PCCM) provider by calling MAA's toll-free enrollment line, or sending a completed CHIP enrollment form to MAA; or.
WAC 388-542-0250 CHIP client costs.
(1) The finance division charges ten dollars per covered child, per month, for the client premium. The family maximum, for CHIP premiums, is thirty dollars per month.
(3)(g) Mental health services (including services with psychiatrists or psychologists);
(h) Occupational, physical, or speech therapy,
(h))) (i) Office visits with age appropriate immunizations
or for EPSDT (well-child check) screening;
(6) For those clients who are required to make copays,
C))lients make copays to the health care provider, not MAA.
(7)(c)(iii) Provide receipts as proof ((
or)) of payment.
Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.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 8, Amended 0, Repealed 0.
Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 0, 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 8, Amended 0, Repealed 0. Effective Date of Rule: Thirty-one days after filing.
March 17, 2000
Marie Myerchin-Redifer, Manager
Rules and Policies Assistance Unit2677.11
CHILDREN'S HEALTH INSURANCE PLAN (CHIP)
The following definitions and abbreviations and those found in WAC 388-500-0005, Medical definitions apply to this chapter. Defined words and phrases are bolded the first time they are used in the text.
"Age appropriate immunizations" means the recommended childhood immunization schedule as approved by the Advisory Committee on Immunization Practices (ACIP), the American Academy of Pediatrics (AAP), and the American Academy of Family Physicians (AAFP).
"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). Also referred to as state children's health insurance program (S-CHIP).
"Client copay" or "copay" means an amount a CHIP client pays to health care providers for specific services.
"Client premium" means a monthly payment a client must make to 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 applies whether or not the coverage is equivalent to that offered under CHIP. "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.
"Finance division" means the division of the department of social and health services that sends out, monitors, and collects the CHIP client premiums.
(1) CHIP clients are eligible for the same scope of medical care as Medicaid categorically needy clients as described in WAC 388-529-0100.
(2) The following WACs apply to CHIP clients enrolled in managed care:
(a) WAC 388-538-095; and
(b) WAC 388-538-100.
(3) Except for American Indian/Alaska Native (AI/AN) clients who have chosen primary care case management (PCCM) or fee-for-service as described in WAC 388-542-0200(3), CHIP clients must receive medical services from managed care plans in counties where two or more managed care plans are available.
(1) MAA provides fee-for-service coverage between the time a client becomes eligible for CHIP services and the time the client is enrolled in managed care.
(2) Not all CHIP clients are required to enroll in managed care. See WAC 388-542-0150 (1)(c).
(1) To be eligible for CHIP a client must meet all of the following. The client:
(a) Cannot have other creditable coverage. If MAA finds out after eligibility determination that a CHIP client had creditable coverage at the time of application, MAA ends the client's eligibility the first of the following month.
(b) Must agree to pay both of the following:
(i) A monthly client premium as described in WAC 388-542-250(1); and
(ii) A service copay as described in WAC 388-542-250(3).
(c) Must make a choice concerning how to receive services. The choices vary depending on where the client lives (except as provided for AI/AN in WAC 388-542-0200). In counties with:
(i) Two or more managed care plans, the client must choose a managed care plan;
(ii) One managed care plan, the client must choose between a managed care plan and MAA's fee-for-service program; or
(iii) No managed care plan, the only option is MAA's fee-for-service program.
(2) The following WACs describe additional eligibility requirements and conditions for a CHIP client:
(a) WAC 388-505-0210 describes requirements related to children's medical eligibility;
(b) WACs 388-424-0005 and 388-424-0010 describe requirements related to citizenship and alien status;
(c) WAC 388-478-0075 describes monthly income standards;
(d) WAC 388-416-0015 describes eligibility certification periods; and
(e) WAC 388-418-0025 describes effects of changes on eligibility.
(3) MAA does not require a client to pay the client premium in advance to be eligible for CHIP.
(4) MAA ends a client's eligibility for CHIP when the client owes four months of premiums, based on the due dates listed on the bill for the client premium.
(5) When MAA ends a client's eligibility according to subsection (4) of this section, to become eligible for CHIP again, the client must meet both of the following:
(a) Pay all unforgiven past due premiums; and
(b) Serve a waiting period of four consecutive months as described in WAC 388-542-0300. The client does not have CHIP coverage during the waiting period.
(6) MAA forgives client premiums that are more than twelve months overdue. MAA does not require clients to pay overdue premiums that it has forgiven.
(7) Unless specifically stated in chapter 388-542 WAC, the department's administrative rules covering children's medical programs apply to CHIP.
(1) MAA enrolls clients in managed care prospectively only.
(2) American Indian/Alaska Native (AI/AN) clients who meet the provisions of 25 U.S.C. 1603 (c)-(d) for federally-recognized tribal members and their descendants, may choose one of the following:
(a) Enroll with a CHIP plan available in their area;
(b) Enroll with a CHIP Indian or tribal PCCM provider by calling MAA's toll-free enrollment line, or sending a completed CHIP enrollment form to MAA; or
(c) MAA's fee-for-service program.
(3) Clients who are required to enroll in managed care may change plans during the two-month period after enrollment and during an annual open enrollment period. Clients may not change plans otherwise, unless they have "good cause." The "good cause" reasons are any of the following:
(a) The client is American Indian/Alaska Native (AI/AN);
(b) The client moves out of the plan's service area;
(c) To assure all family members are in the same plan;
(d) To protect the client from a perpetrator of domestic violence, abuse or neglect;
(e) To rectify a documented department error;
(f) An administrative law judge orders MAA to disenroll the client; or
(g) The client's plan stops offering service in the client's county.
(1) The finance division charges ten dollars per covered child, per month, for the client premium. The family maximum for CHIP premiums is thirty dollars per month.
(2) The finance division sends bills for client premiums at the beginning of each month of coverage. Client premiums begin the first of the month in which the bill was sent, not the date that the client became eligible for services.
(3) MAA requires a copay for certain services, as follows:
(a) Five dollars for office visits with physicians, physician assistants, or advanced registered nurse practitioners (ARNP) (i.e., CPT codes 99201 - 99215);
(b) Five dollars for nongeneric (i.e., brand name, whether single or multiple source) drugs; and
(c) Twenty-five dollars for emergency department visits that do not result in hospital admission.
(4) MAA does not require a copay for the following services:
(a) Consultations (i.e., CPT codes 99241 - 99275);
(b) Deliveries (births);
(d) Drug and alcohol treatment;
(e) Generic drugs;
(f) Inpatient and outpatient surgery;
(g) Mental health services (including services with psychiatrists or psychologists);
(h) Occupational, physical, or speech therapy;
(i) Office visits with age appropriate immunizations or exams for an EPSDT (well-child check) screening;
(j) Radiology; or
(k) Visits to the emergency room that result in an inpatient hospital admission.
(5) Clients are responsible for client copays from the first day the client is eligible for CHIP.
(6) For clients who are required to make copays, clients make copays to the health care provider, not MAA. A provider may refuse service to CHIP clients when the copay is not paid at the time of service.
(7) Client out-of-pocket expenses are subject to a twelve-month maximum. All of the following apply to twelve-month, out-of-pocket expenses for CHIP clients:
(a) Only client premiums and copays for covered services count towards the twelve-month maximum;
(b) For those children who incur client premiums and copays, the twelve-month maximums are as follows:
(i) For one child, three hundred dollars;
(ii) For two children, six hundred dollars; and
(iii) For three or more children, nine hundred dollars. The family maximum is nine hundred dollars.
(c) The client and/or family must do the following:
(i) Track and document out-of-pocket expenses;
(ii) Notify MAA when the maximum has been reached; and
(iii) Provide receipts as proof of payment.
(8) MAA's starting date for determining twelve-month, out-of-pocket maximum expenses is the date that the first child in a family became eligible for CHIP services. For example, if a family has:
(a) One child, and that child became eligible for services on April first, the twelve-month period starts on April first;
(b) Two children, and first child became eligible for services on April first and the second child started three months later on July first, the twelve-month period for both children starts on April first;
(c) Three or more children, and the first child became eligible for services on April first, and the last child became eligible on November first (within the same twelve-month period), the twelve-month period starts on April first for all the children.
(9) MAA exempts American Indian/Alaska Native (AI/AN) clients from paying client premiums or service copays.
(1) MAA deducts the twenty-five dollar copay from hospitals' outpatient reimbursement for emergency services provided to CHIP clients, unless the emergency department visit results in a hospital admission.
(2) MAA does not deduct the five dollar copay from providers' reimbursement.
(1) If the client or family chooses to end employer sponsored dependent coverage, the client must serve a waiting period of four, full, consecutive months before becoming eligible to enroll in CHIP. The waiting period begins the day after the coverage ends, and ends on the last day of the fourth full month of noncoverage by the employer.
(2) MAA does not require a waiting period prior to CHIP 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;
(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 that leads to loss of coverage for the victim.