WSR 10-22-039

PERMANENT RULES

HEALTH CARE AUTHORITY


(Health Insurance Partnership)

[ Order 10-04 -- Filed October 27, 2010, 11:47 a.m. , effective November 27, 2010 ]


Effective Date of Rule: Thirty-one days after filing.

Purpose: To amend chapter 182-26 WAC to increase the age of an eligible dependent for health insurance partnership (HIP) insurance coverage and to add an exception to the HIP employer premium payment deadline.

Citation of Existing Rules Affected by this Order: Amending WAC 182-26-100, 182-26-305, 182-26-340, and 182-26-350.

Statutory Authority for Adoption: RCW 41.05.160 and chapter 70.47A RCW.

Adopted under notice filed as WSR 10-18-010 on August 19, 2010.

Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

Number of Sections Adopted on the Agency's Own Initiative: New 1, Amended 4, Repealed 0.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 1, Amended 4, Repealed 0.

Number of Sections Adopted Using Negotiated Rule Making: New 1, Amended 4, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 0, Repealed 0.

Date Adopted: October 27, 2010.

Jason Siems

Rules Coordinator

OTS-3358.1


AMENDATORY SECTION(Amending Order 08-02, filed 10/31/08, effective 12/1/08)

WAC 182-26-100   Definitions.   "Administrator" means the administrator of the Washington state health care authority established under chapter 41.05 RCW.

"Appeal" means a formal written request to the HIP or its designee for resolution of problems or concerns that cannot be resolved informally. For the purposes of this chapter, "appeal" applies only to HIP decisions regarding subsidy determinations and employer eligibility for the HIP.

"Applicant" means:

An ((individual)) eligible partnership participant who applies for a premium subsidy through the HIP on behalf of the ((individual)) eligible partnership participant and his or her dependents; or

((A)) An eligible partnership participant who applies or reapplies for premium subsidy through the HIP on behalf of the eligible partnership participant and his or her dependents during the annual subsidy application and renewal period as described in WAC 182-26-320.

"Application" means a form developed by the administrator that an applicant must sign, complete, and submit to the administrator to apply for a premium subsidy through the HIP. To be considered complete, the application must be accompanied by all supporting documents as required and determined by the administrator.

"Benchmark health benefit plan" or "benchmark plan" means a health benefit plan selected by the board and upon which the subsidy scale shall be determined and from which the administrator will calculate ((a)) an eligible partnership participant's premium subsidy.

"Board" or "HIP board" means the health insurance partnership board established under RCW 70.47A.100.

"Carrier" or "insurance carrier" means the same as defined in RCW 48.43.005.

"The department of social and health services" or "DSHS" means the department of social and health services as defined in RCW 43.20A.020.

"Dependent," for the purpose of determining subsidy eligibility, "dependent" means:

(((1) A)) (a) An eligible partnership participant's ((lawful)) spouse, ((not legally separated, who shares a home with the partnership participant)) as defined under RCW 70.47A.901; or

(((2))) (b) The ((unmarried)) child of the partnership participant or participant's dependent spouse, whether by birth, adoption, legal guardianship, or placement pending adoption, and not given up for adoption, who is:

(((a))) (i) Younger than age ((twenty-five)) twenty-six; or

(((b))) (ii) Is of any age, is not able to take care of himself or herself due to disability, and is under legal guardianship of the partnership participant or the participant's dependent spouse.

(((3))) (c) A dependent may be placed on only one HIP account at any given time.

"Designated health benefit plan" means a health benefit plan selected by the board as eligible for offer through the HIP.

"Disenroll" or "disenrollment" means the termination of a partnership participants' enrollment in the HIP program. Decisions regarding eligibility or enrollment status for insurance coverage will be made by the carrier.

"Eligible partnership participant" means a partnership participant who:

Is a resident of the state of Washington;

Has a family income that does not exceed two hundred percent of the federal poverty level, as determined annually by the federal Department of Health and Human Services; and

Is a health plan eligible employee as defined in this section that is enrolled or is applying to enroll in the participating small employer's offered coverage.

"Employee" has the same meaning as defined in RCW 48.43.005.

"Employer agreement" means a form developed by the administrator that a small employer must complete, sign, and submit to the administrator to request enrollment in the HIP.

"Health insurance partnership" or "HIP" means the health insurance partnership established in RCW 70.47A.030.

"Health plan eligible employee" means an individual who meets the participating small employer's enrollment criteria.

"HIP account" means an account maintained by the administrator for each partnership participant that includes but is not limited to:

Demographic information for participants and dependents, if any;

Subsidy status;

Carrier and plan enrollment status; and

Other information as required by the administrator.

"Income" or "family gross income" means total cash receipts, as defined in WAC 182-26-345, before taxes, for participants and all dependents.

"Individual health benefit plan selection." Reserved.

The "office of the insurance commissioner" or "OIC" means the insurance commissioner as defined in RCW 48.02.010.

"Open enrollment" means a designated time period during which partnership participants may enroll additional dependents or make other changes to their employer-sponsored health benefit plan coverage.

"Participating small employer" means a small employer who:

Enters into a written agreement with the HIP to purchase a designated health benefit plan through the HIP;

Attests at the date of the agreement that the employer does not currently offer coverage, including insurance purchased through the small group and association health plan markets, self-funded plans, and multiple employer welfare arrangements; and

Attests at the date of the agreement that at least fifty percent of its employees are low-wage workers, as defined by the board.

"Partnership participant" means:

A participating small employer as defined in this section;

An employee of a participating small employer;

A former employee of a participating small employer who chooses to continue coverage through the HIP following separation from employment, to the extent the employee is eligible for continuation of coverage under 29 U.S.C. Sec. 1161 et seq.; and

A former employee of a participating small employer who chooses to continue coverage through HIP following separation from employment, to the extent determined by the board.

"Philanthropy" means a person, organization or other entity, approved by the administrator that is responsible for payment of all or part of the monthly premium obligation on behalf of a partnership participant.

"Premium" has the same meaning as described in RCW 48.43.005.

"Premium subsidy" or "subsidy" means payment to or reimbursement by the HIP on behalf of an eligible partnership participant toward the purchase of a designated health benefit plan.

"Qualifying change in family status" is defined in WAC 182-26-325.

"Section 125 plan" means a cafeteria plan compliant with section 125 of the federal Internal Revenue Code that enables employees to use pretax dollars to pay their share of their health benefit plan premium.

"Small employer" or "employer" as used in this chapter means an employer who meets the definition of "small employer" in RCW 48.43.005.

"Subsidy application and renewal period" means an annual period that lasts at least sixty days, during which:

All partnership participants may apply for premium subsidies for themselves and their dependents; and

All partnership participants receiving a subsidy are required to provide proof of their continuing eligibility for a premium subsidy.

The subsidy application and renewal period will begin ninety days before the employer-sponsored health benefit plan open enrollment period begins.

"Surcharge" means an amount, determined by the administrator, that may be added to a partnership participant's premium as provided for in WAC 182-26-500. The surcharge is not part of the premium and applies only to coverage purchased through the HIP.

"Washington state resident" means:

(a) A person who physically resides in and maintains a residence in the state of Washington.

(b) To be considered a Washington resident, individuals who are temporarily out of Washington state for any reason may be required to demonstrate their intent to return to Washington state.

(c) "Residence" may include, but is not limited to:

(i) A home the person owns or is purchasing or renting;

(ii) A shelter or other physical location where the person stays; or

(iii) Another person's home.

[Statutory Authority: RCW 70.47A.060. 08-22-041 (Order 08-02), 182-26-100, filed 10/31/08, effective 12/1/08.]


NEW SECTION
WAC 182-26-230   Small employer one-time exception to monthly group premium payment deadline.   The HIP program may grant small employers a one-time exception to the monthly group premium payment deadline as specified and agreed upon in the HIP employer agreement. Small employers are allowed to utilize the exception only once. To utilize the one-time exception, the small employer must satisfy all of the following three steps:

(1) The participating small employer must make a request to the HIP, in writing or over the phone, of its intent to utilize the one-time exception to the monthly group premium payment deadline.

(2) The participating small employer receives written acknowledgment from the HIP that its one-time payment deadline is approved; the exception must be received and approved by the last business day of the month preceding coverage.

(3) The participating small employer makes the full monthly group premium payment to the HIP by the 10th day of the month of coverage.

[]


AMENDATORY SECTION(Amending Order 08-02, filed 10/31/08, effective 12/1/08)

WAC 182-26-305   Applying for a HIP premium subsidy.   (1) To receive a HIP subsidy, an applicant must submit a complete application and all supporting documents as described in WAC 182-26-310 to the HIP.

(2) On a subsidy application, an applicant must list all eligible dependents up to age nineteen. The applicant must also provide other information and documents as required by the HIP.

(3) An applicant is not required to list dependents aged nineteen or over and under ((twenty-five)) twenty-six on the application, but if they are listed on the application, the HIP will include the dependents' income for purposes of subsidy eligibility and calculation.

(4) An applicant is not required to apply for a subsidy for all of his or her dependents. However, any dependent that does not apply for a subsidy at the same time that the other family members apply must wait to apply as a dependent until the next subsidy application and renewal period.

[Statutory Authority: RCW 70.47A.060. 08-22-041 (Order 08-02), 182-26-305, filed 10/31/08, effective 12/1/08.]


AMENDATORY SECTION(Amending Order 08-02, filed 10/31/08, effective 12/1/08)

WAC 182-26-340   How does the HIP determine the premium subsidy amount?   (1) The HIP will apply a sliding scale subsidy schedule based on the partnership participant's family gross income and family size to determine the percentage of the employee's premium obligation the state will pay.

(2) The percentage in subsection (1) of this section will be applied to the health benefit plan employee premium share, including the amount due for dependents' coverage, remaining after deducting the employer contribution and a philanthropic contribution if applicable from the total premium amount for that participant.

(3) If a participating small employer chooses a health benefit plan with a higher premium than the benchmark plan, the subsidy will not exceed the amount applicable to the benchmark plan.

(4) In no case will the subsidy percentage exceed ninety percent of the ((benchmark)) plan ((employee)) employee's premium share after all contributions.

(5) Once enrolled in the HIP, the subsidy percentage will not change until the next subsidy application and renewal period, even if the total premium share changes because of a qualifying change in family status.

[Statutory Authority: RCW 70.47A.060. 08-22-041 (Order 08-02), 182-26-340, filed 10/31/08, effective 12/1/08.]


AMENDATORY SECTION(Amending Order 08-02, filed 10/31/08, effective 12/1/08)

WAC 182-26-350   What does the HIP count as income?   Income includes all of the following, before any deductions (gross income):


Source Received by the participant, spouse, child dependent aged nineteen or over and under ((twenty-five)) twenty-six, or adult dependent Received by a dependent child under age nineteen
Wages, tips, and salaries Yes No
Taxable interest Yes Yes
Ordinary dividends Yes Yes
Taxable refunds, credits, or offsets of state and local income taxes Yes Yes
Alimony received Yes N/A
Business income or loss Yes Yes
Capital gain or loss Yes Yes
Other gains or losses Yes Yes
IRA distributions Yes Yes
Pensions and annuities Yes N/A
Rental real estate, royalties, partnerships, S corporations Yes Yes
Farm income Yes Yes
Unemployment compensation Yes No
Social Security benefits Yes Yes
Other income Yes Yes

[Statutory Authority: RCW 70.47A.060. 08-22-041 (Order 08-02), 182-26-350, filed 10/31/08, effective 12/1/08.]

Washington State Code Reviser's Office