RCW 48.41.100
Eligibility for coverage. (Contingent
expiration date.)
(1) The following persons who are residents of
this state are eligible for pool coverage:
(a) Any person who provides evidence of a carrier's decision
not to accept him or her for enrollment in an individual health
benefit plan as defined in RCW 48.43.005 based upon, and within
ninety days of the receipt of, the results of the standard health
questionnaire designated by the board and administered by health
carriers under RCW 48.43.018;
(b) Any person who continues to be eligible for pool
coverage based upon the results of the standard health
questionnaire designated by the board and administered by the
pool administrator pursuant to subsection (3) of this section;
(c) Any person who resides in a county of the state where no
carrier or insurer eligible under chapter 48.15 RCW offers to the
public an individual health benefit plan other than a
catastrophic health plan as defined in RCW 48.43.005 at the time
of application to the pool, and who makes direct application to
the pool; and
(d) Any medicare eligible person upon providing evidence of
rejection for medical reasons, a requirement of restrictive
riders, an up-rated premium, or a preexisting conditions
limitation on a medicare supplemental insurance policy under
chapter 48.66 RCW, the effect of which is to substantially reduce
coverage from that received by a person considered a standard
risk by at least one member within six months of the date of
application.
(2) The following persons are not eligible for coverage by
the pool:
(a) Any person having terminated coverage in the pool unless
(i) twelve months have lapsed since termination, or (ii) that
person can show continuous other coverage which has been
involuntarily terminated for any reason other than nonpayment of
premiums. However, these exclusions do not apply to eligible
individuals as defined in section 2741(b) of the federal health
insurance portability and accountability act of 1996 (42 U.S.C.
Sec. 300gg-41(b));
(b) Any person on whose behalf the pool has paid out two
million dollars in benefits;
(c) Inmates of public institutions and persons whose
benefits are duplicated under public programs. However, these
exclusions do not apply to eligible individuals as defined in
section 2741(b) of the federal health insurance portability and
accountability act of 1996 (42 U.S.C. Sec. 300gg-41(b));
(d) Any person who resides in a county of the state where
any carrier or insurer regulated under chapter 48.15 RCW offers
to the public an individual health benefit plan other than a
catastrophic health plan as defined in RCW 48.43.005 at the time
of application to the pool and who does not qualify for pool
coverage based upon the results of the standard health
questionnaire, or pursuant to subsection (1)(d) of this section.
(3) When a carrier or insurer regulated under chapter 48.15 RCW begins to offer an individual health benefit plan in a county
where no carrier had been offering an individual health benefit
plan:
(a) If the health benefit plan offered is other than a
catastrophic health plan as defined in RCW 48.43.005, any person
enrolled in a pool plan pursuant to subsection (1)(c) of this
section in that county shall no longer be eligible for coverage
under that plan pursuant to subsection (1)(c) of this section,
but may continue to be eligible for pool coverage based upon the
results of the standard health questionnaire designated by the
board and administered by the pool administrator. The pool
administrator shall offer to administer the questionnaire to each
person no longer eligible for coverage under subsection (1)(c) of
this section within thirty days of determining that he or she is
no longer eligible;
(b) Losing eligibility for pool coverage under this
subsection (3) does not affect a person's eligibility for pool
coverage under subsection (1)(a), (b), or (d) of this section;
and
(c) The pool administrator shall provide written notice to
any person who is no longer eligible for coverage under a pool
plan under this subsection (3) within thirty days of the
administrator's determination that the person is no longer
eligible. The notice shall: (i) Indicate that coverage under
the plan will cease ninety days from the date that the notice is
dated; (ii) describe any other coverage options, either in or
outside of the pool, available to the person; (iii) describe the
procedures for the administration of the standard health
questionnaire to determine the person's continued eligibility for
coverage under subsection (1)(b) of this section; and (iv)
describe the enrollment process for the available options outside
of the pool.
(4) The board shall ensure that an independent analysis of
the eligibility standards for the pool coverage is conducted,
including examining the eight percent eligibility threshold,
eligibility for medicaid enrollees and other publicly sponsored
enrollees, and the impacts on the pool and the state budget. The
board shall report the findings to the legislature by December 1,
2007.
[2007 c 259 § 30; 2001 c 196 § 3; 2000 c 79 § 12; 1995 c 34 § 5; 1989 c 121 § 7; 1987 c 431 § 10.]
NOTES:
Effective date -- 2007 c 259 § 30: "Section 30 of this act is necessary for the immediate preservation of the public peace, health, or safety, or support of the state government and its existing public institutions, and takes effect immediately [May 2, 2007]." [2007 c 259 § 75.]
Severability -- Subheadings not law -- 2007 c 259: See notes following RCW 41.05.033.
Effective date -- 2001 c 196: See note following RCW 48.20.025.
Effective date -- Severability -- 2000 c 79: See notes following RCW 48.04.010.
RCW 48.41.100
Eligibility for coverage. (Contingent
effective date.)
(1) The following persons who are residents of
this state are eligible for pool coverage:
(a) Any person who provides evidence of a carrier's decision
not to accept him or her for enrollment in an individual health
benefit plan as defined in RCW 48.43.005 based upon, and within
ninety days of the receipt of, the results of the standard health
questionnaire designated by the board and administered by health
carriers under RCW 48.43.018;
(b) Any person who continues to be eligible for pool
coverage based upon the results of the standard health
questionnaire designated by the board and administered by the
pool administrator pursuant to subsection (3) of this section;
(c) Any person who resides in a county of the state where no
carrier or insurer eligible under chapter 48.15 RCW offers to the
public an individual health benefit plan other than a
catastrophic health plan as defined in RCW 48.43.005 at the time
of application to the pool, and who makes direct application to
the pool; and
(d) Any medicare eligible person upon providing evidence of
rejection for medical reasons, a requirement of restrictive
riders, an up-rated premium, or a preexisting conditions
limitation on a medicare supplemental insurance policy under
chapter 48.66 RCW, the effect of which is to substantially reduce
coverage from that received by a person considered a standard
risk by at least one member within six months of the date of
application.
(2) The following persons are not eligible for coverage by
the pool:
(a) Any person having terminated coverage in the pool unless
(i) twelve months have lapsed since termination, or (ii) that
person can show continuous other coverage which has been
involuntarily terminated for any reason other than nonpayment of
premiums. However, these exclusions do not apply to eligible
individuals as defined in section 2741(b) of the federal health
insurance portability and accountability act of 1996 (42 U.S.C.
Sec. 300gg-41(b));
(b) Any person on whose behalf the pool has paid out two
million dollars in benefits;
(c) Inmates of public institutions, and those persons who
become eligible for medical assistance after June 30, 2008, as
defined in RCW 74.09.010. However, these exclusions do not apply
to eligible individuals as defined in section 2741(b) of the
federal health insurance portability and accountability act of
1996 (42 U.S.C. Sec. 300gg-41(b));
(d) Any person who resides in a county of the state where
any carrier or insurer regulated under chapter 48.15 RCW offers
to the public an individual health benefit plan other than a
catastrophic health plan as defined in RCW 48.43.005 at the time
of application to the pool and who does not qualify for pool
coverage based upon the results of the standard health
questionnaire, or pursuant to subsection (1)(d) of this section.
(3) When a carrier or insurer regulated under chapter 48.15 RCW begins to offer an individual health benefit plan in a county
where no carrier had been offering an individual health benefit
plan:
(a) If the health benefit plan offered is other than a
catastrophic health plan as defined in RCW 48.43.005, any person
enrolled in a pool plan pursuant to subsection (1)(c) of this
section in that county shall no longer be eligible for coverage
under that plan pursuant to subsection (1)(c) of this section,
but may continue to be eligible for pool coverage based upon the
results of the standard health questionnaire designated by the
board and administered by the pool administrator. The pool
administrator shall offer to administer the questionnaire to each
person no longer eligible for coverage under subsection (1)(c) of
this section within thirty days of determining that he or she is
no longer eligible;
(b) Losing eligibility for pool coverage under this
subsection (3) does not affect a person's eligibility for pool
coverage under subsection (1)(a), (b), or (d) of this section;
and
(c) The pool administrator shall provide written notice to
any person who is no longer eligible for coverage under a pool
plan under this subsection (3) within thirty days of the
administrator's determination that the person is no longer
eligible. The notice shall: (i) Indicate that coverage under
the plan will cease ninety days from the date that the notice is
dated; (ii) describe any other coverage options, either in or
outside of the pool, available to the person; (iii) describe the
procedures for the administration of the standard health
questionnaire to determine the person's continued eligibility for
coverage under subsection (1)(b) of this section; and (iv)
describe the enrollment process for the available options outside
of the pool.
(4) The board shall ensure that an independent analysis of
the eligibility standards for the pool coverage is conducted,
including examining the eight percent eligibility threshold,
eligibility for medicaid enrollees and other publicly sponsored
enrollees, and the impacts on the pool and the state budget. The
board shall report the findings to the legislature by December 1,
2007.
[2008 c 317 § 4; 2007 c 259 § 30; 2001 c 196 § 3; 2000 c 79 § 12; 1995 c 34 § 5; 1989 c 121 § 7; 1987 c 431 § 10.]
NOTES:
Report -- Contingent effective date -- 2008 c 317: See notes following RCW 74.09.510.
Effective date -- 2007 c 259 § 30: "Section 30 of this act is necessary for the immediate preservation of the public peace, health, or safety, or support of the state government and its existing public institutions, and takes effect immediately [May 2, 2007]." [2007 c 259 § 75.]
Severability -- Subheadings not law -- 2007 c 259: See notes following RCW 41.05.033.
Effective date -- 2001 c 196: See note following RCW 48.20.025.
Effective date -- Severability -- 2000 c 79: See notes following RCW 48.04.010.