WSR 00-19-101

PROPOSED RULES

HEALTH CARE AUTHORITY


(Basic Health Plan)

[ Order 00-05 -- Filed September 20, 2000, 11:30 a.m. ]

Original Notice.

Preproposal statement of inquiry was filed as WSR 00-16-136.

Title of Rule: WAC 182-25-020 BHP benefits.

Purpose: Changes the waiting period for treatment of preexisting conditions to nine months, rather than three.

Other Identifying Information: Initially, the agency had proposed to also amend the list of benefits but, because of stakeholder comments, that change will not be made at this time.

Statutory Authority for Adoption: RCW 70.47.050.

Statute Being Implemented: RCW 70.47.060.

Summary: Changes the waiting period for treatment of preexisting conditions to nine months, rather than three.

Reasons Supporting Proposal: During contracting with managed health care systems for 2001, the health plans bid much higher rates for a three-month waiting period than for a nine-month waiting period, which would limit the number of persons basic health could cover within budget.

Name of Agency Personnel Responsible for Drafting: Rosanne Reynolds, Lacey, Washington, (360) 923-2948; Implementation and Enforcement: Becky Loomis, Lacey, Washington, (360) 923-2996.

Name of Proponent: Health Care Authority, governmental.

Rule is not necessitated by federal law, federal or state court decision.

Explanation of Rule, its Purpose, and Anticipated Effects: Changes the three-month waiting period for treatment of preexisting conditions to nine months.

Proposal Changes the Following Existing Rules: Changes the three-month waiting period to nine months.

No small business economic impact statement has been prepared under chapter 19.85 RCW. Impacts to small businesses will be minimal.

RCW 34.05.328 does not apply to this rule adoption. RCW 34.05.328 does not apply to Health Care Authority rules unless requested by the Joint Administrative Rules Review Committee or applied voluntarily.

Hearing Location: Health Care Authority, 676 Woodland Square Loop S.E., Building B, 3rd Floor Conference Room, Lacey, WA 98504, on October 27, 2000, at 10:00 a.m.

Assistance for Persons with Disabilities: Contact Nikki Johnson by October 20, 2000, TDD (888) 923-5622, or (360) 923-2805.

Submit Written Comments to: Rosanne Reynolds, fax (360) 412-4276, by October 27, 2000.

Date of Intended Adoption: November 3, 2000.

September 20, 2000

Melodie Bankers

Rules Coordinator

OTS-4391.1


AMENDATORY SECTION(Amending WSR 98-07-002, filed 3/5/98, effective 4/5/98)

WAC 182-25-020
BHP benefits.

(1) The administrator shall design and from time to time may revise BHP benefits, according to the requirements of chapter 70.47 RCW, as amended. These benefits will include physician services, prescription drugs and medications, and inpatient and outpatient hospital services, limited mental health care services, limited chemical dependency services, limited organ transplant services, and all services necessary for prenatal, postnatal and well-child care, and will emphasize proven preventive and primary care services. The Medicaid scope of benefits may be provided by BHP as the BHP plus program through coordination with DSHS for children under the age of nineteen, who are found to be Medicaid eligible. BHP benefits may include co-payments, waiting periods, limitations and exclusions which the administrator determines are appropriate and consistent with the goals and objectives of the plan. BHP benefits will be subject to a ((three-month)) nine-month waiting period for preexisting conditions. Exceptions (for example, maternity, prescription drugs, services for a newborn or newly adopted child) are outlined in the schedule of benefits. Credit toward the waiting period will be given for any continuous period of time for which an enrollee was covered under similar health coverage if that coverage was in effect at any time during the three-month period immediately preceding the date of reservation or application for coverage under BHP. Similar coverage includes BHP; all DSHS programs administered by the medical assistance administration which have the Medicaid scope of benefits; the DSHS program for the medically indigent; Indian health services; most coverages offered by health carriers; and most self-insured health plans. A list of BHP benefits, including co-payments, waiting periods, limitations and exclusions, will be provided to the subscriber.

(2) In designing and revising BHP benefits, the administrator will consider the effects of particular benefits, co-payments, limitations and exclusions on access to necessary health care services, as well as the cost to the enrollees and to the state, and will also consider generally accepted practices of the health insurance and managed health care industries.

(3) Prior to enrolling in BHP, each applicant will be given a written description of covered benefits, including all co-payments, waiting periods, limitations and exclusions, and be advised how to access information on the services, providers, facilities, hours of operation, and other information descriptive of the managed health care system(s) available to enrollees in a given service area.

(4) BHP will mail to all subscribers written notice of any changes in the amount and scope of benefits provided under BHP, or policy changes regarding premiums and co-payments at least thirty days prior to the due date of the premium payment for the month in which such revisions are to take effect. The administrator may make available a separate schedule of benefits for children, eighteen years of age and younger, for those dependent children in the plan.

[Statutory Authority: RCW 70.47.050. 98-07-002, 182-25-020, filed 3/5/98, effective 4/5/98; 97-15-003, 182-25-020, filed 7/3/97, effective 8/3/97; 96-15-024, 182-25-020, filed 7/9/96, effective 8/9/96.]

Washington State Code Reviser's Office