The
administrator has the following powers and duties:
(1) To design and from time to time revise a schedule of
covered basic health care services, including physician services,
inpatient and outpatient hospital services, prescription drugs
and medications, and other services that may be necessary for
basic health care. In addition, the administrator may, to the
extent that funds are available, offer as basic health plan
services chemical dependency services, mental health services and
organ transplant services; however, no one service or any
combination of these three services shall increase the actuarial
value of the basic health plan benefits by more than five percent
excluding inflation, as determined by the office of financial
management. All subsidized and nonsubsidized enrollees in any
participating managed health care system under the Washington
basic health plan shall be entitled to receive covered basic
health care services in return for premium payments to the plan.
The schedule of services shall emphasize proven preventive and
primary health care and shall include all services necessary for
prenatal, postnatal, and well-child care. However, with respect
to coverage for subsidized enrollees who are eligible to receive
prenatal and postnatal services through the medical assistance
program under chapter 74.09 RCW, the administrator shall not
contract for such services except to the extent that such
services are necessary over not more than a one-month period in
order to maintain continuity of care after diagnosis of pregnancy
by the managed care provider. The schedule of services shall
also include a separate schedule of basic health care services
for children, eighteen years of age and younger, for those
subsidized or nonsubsidized enrollees who choose to secure basic
coverage through the plan only for their dependent children. In
designing and revising the schedule of services, the
administrator shall consider the guidelines for assessing health
services under the mandated benefits act of 1984, RCW 48.47.030,
and such other factors as the administrator deems appropriate.
(2)(a) To design and implement a structure of periodic
premiums due the administrator from subsidized enrollees that is
based upon gross family income, giving appropriate consideration
to family size and the ages of all family members. The
enrollment of children shall not require the enrollment of their
parent or parents who are eligible for the plan. The structure
of periodic premiums shall be applied to subsidized enrollees
entering the plan as individuals pursuant to subsection (11) of
this section and to the share of the cost of the plan due from
subsidized enrollees entering the plan as employees pursuant to
subsection (12) of this section.
(b) To determine the periodic premiums due the administrator
from subsidized enrollees under RCW 70.47.020(6)(b). Premiums
due for foster parents with gross family income up to two hundred
percent of the federal poverty level shall be set at the minimum
premium amount charged to enrollees with income below sixty-five
percent of the federal poverty level. Premiums due for foster
parents with gross family income between two hundred percent and
three hundred percent of the federal poverty level shall not
exceed one hundred dollars per month.
(c) To determine the periodic premiums due the administrator
from nonsubsidized enrollees. Premiums due from nonsubsidized
enrollees shall be in an amount equal to the cost charged by the
managed health care system provider to the state for the plan
plus the administrative cost of providing the plan to those
enrollees and the premium tax under RCW 48.14.0201.
(d) To determine the periodic premiums due the administrator
from health coverage tax credit eligible enrollees. Premiums due
from health coverage tax credit eligible enrollees must be in an
amount equal to the cost charged by the managed health care
system provider to the state for the plan, plus the
administrative cost of providing the plan to those enrollees and
the premium tax under RCW 48.14.0201. The administrator will
consider the impact of eligibility determination by the
appropriate federal agency designated by the Trade Act of 2002
(P.L. 107-210) as well as the premium collection and remittance
activities by the United States internal revenue service when
determining the administrative cost charged for health coverage
tax credit eligible enrollees.
(e) An employer or other financial sponsor may, with the
prior approval of the administrator, pay the premium, rate, or
any other amount on behalf of a subsidized or nonsubsidized
enrollee, by arrangement with the enrollee and through a
mechanism acceptable to the administrator. The administrator
shall establish a mechanism for receiving premium payments from
the United States internal revenue service for health coverage
tax credit eligible enrollees.
(f) To develop, as an offering by every health carrier
providing coverage identical to the basic health plan, as
configured on January 1, 2001, a basic health plan model plan
with uniformity in enrollee cost-sharing requirements.
(3) To evaluate, with the cooperation of participating
managed health care system providers, the impact on the basic
health plan of enrolling health coverage tax credit eligible
enrollees. The administrator shall issue to the appropriate
committees of the legislature preliminary evaluations on June 1,
2005, and January 1, 2006, and a final evaluation by June 1,
2006. The evaluation shall address the number of persons
enrolled, the duration of their enrollment, their utilization of
covered services relative to other basic health plan enrollees,
and the extent to which their enrollment contributed to any
change in the cost of the basic health plan.
(4) To end the participation of health coverage tax credit
eligible enrollees in the basic health plan if the federal
government reduces or terminates premium payments on their behalf
through the United States internal revenue service.
(5) To design and implement a structure of enrollee
cost-sharing due a managed health care system from subsidized,
nonsubsidized, and health coverage tax credit eligible enrollees.
The structure shall discourage inappropriate enrollee utilization
of health care services, and may utilize copayments, deductibles,
and other cost-sharing mechanisms, but shall not be so costly to
enrollees as to constitute a barrier to appropriate utilization
of necessary health care services.
(6) To limit enrollment of persons who qualify for subsidies
so as to prevent an overexpenditure of appropriations for such
purposes. Whenever the administrator finds that there is danger
of such an overexpenditure, the administrator shall close
enrollment until the administrator finds the danger no longer
exists. Such a closure does not apply to health coverage tax
credit eligible enrollees who receive a premium subsidy from the
United States internal revenue service as long as the enrollees
qualify for the health coverage tax credit program.
(7) To limit the payment of subsidies to subsidized
enrollees, as defined in RCW 70.47.020. The level of subsidy
provided to persons who qualify may be based on the lowest cost
plans, as defined by the administrator.
(8) To adopt a schedule for the orderly development of the
delivery of services and availability of the plan to residents of
the state, subject to the limitations contained in RCW 70.47.080
or any act appropriating funds for the plan.
(9) To solicit and accept applications from managed health
care systems, as defined in this chapter, for inclusion as
eligible basic health care providers under the plan for
subsidized enrollees, nonsubsidized enrollees, or health coverage
tax credit eligible enrollees. The administrator shall endeavor
to assure that covered basic health care services are available
to any enrollee of the plan from among a selection of two or more
participating managed health care systems. In adopting any rules
or procedures applicable to managed health care systems and in
its dealings with such systems, the administrator shall consider
and make suitable allowance for the need for health care services
and the differences in local availability of health care
resources, along with other resources, within and among the
several areas of the state. Contracts with participating managed
health care systems shall ensure that basic health plan enrollees
who become eligible for medical assistance may, at their option,
continue to receive services from their existing providers within
the managed health care system if such providers have entered
into provider agreements with the department of social and health
services.
(10) To receive periodic premiums from or on behalf of
subsidized, nonsubsidized, and health coverage tax credit
eligible enrollees, deposit them in the basic health plan
operating account, keep records of enrollee status, and authorize
periodic payments to managed health care systems on the basis of
the number of enrollees participating in the respective managed
health care systems.
(11) To accept applications from individuals residing in
areas served by the plan, on behalf of themselves and their
spouses and dependent children, for enrollment in the Washington
basic health plan as subsidized, nonsubsidized, or health
coverage tax credit eligible enrollees, to give priority to
members of the Washington national guard and reserves who served
in Operation Enduring Freedom, Operation Iraqi Freedom, or
Operation Noble Eagle, and their spouses and dependents, for
enrollment in the Washington basic health plan, to establish
appropriate minimum-enrollment periods for enrollees as may be
necessary, and to determine, upon application and on a reasonable
schedule defined by the authority, or at the request of any
enrollee, eligibility due to current gross family income for
sliding scale premiums. Funds received by a family as part of
participation in the adoption support program authorized under
RCW 26.33.320 and 74.13.100 through 74.13.145 shall not be
counted toward a family's current gross family income for the
purposes of this chapter. When an enrollee fails to report
income or income changes accurately, the administrator shall have
the authority either to bill the enrollee for the amounts
overpaid by the state or to impose civil penalties of up to two
hundred percent of the amount of subsidy overpaid due to the
enrollee incorrectly reporting income. The administrator shall
adopt rules to define the appropriate application of these
sanctions and the processes to implement the sanctions provided
in this subsection, within available resources. No subsidy may
be paid with respect to any enrollee whose current gross family
income exceeds twice the federal poverty level or, subject to RCW 70.47.110, who is a recipient of medical assistance or medical
care services under chapter 74.09 RCW. If a number of enrollees
drop their enrollment for no apparent good cause, the
administrator may establish appropriate rules or requirements
that are applicable to such individuals before they will be
allowed to reenroll in the plan.
(12) To accept applications from business owners on behalf
of themselves and their employees, spouses, and dependent
children, as subsidized or nonsubsidized enrollees, who reside in
an area served by the plan. The administrator may require all or
the substantial majority of the eligible employees of such
businesses to enroll in the plan and establish those procedures
necessary to facilitate the orderly enrollment of groups in the
plan and into a managed health care system. The administrator
may require that a business owner pay at least an amount equal to
what the employee pays after the state pays its portion of the
subsidized premium cost of the plan on behalf of each employee
enrolled in the plan. Enrollment is limited to those not
eligible for medicare who wish to enroll in the plan and choose
to obtain the basic health care coverage and services from a
managed care system participating in the plan. The administrator
shall adjust the amount determined to be due on behalf of or from
all such enrollees whenever the amount negotiated by the
administrator with the participating managed health care system
or systems is modified or the administrative cost of providing
the plan to such enrollees changes.
(13) To determine the rate to be paid to each participating
managed health care system in return for the provision of covered
basic health care services to enrollees in the system. Although
the schedule of covered basic health care services will be the
same or actuarially equivalent for similar enrollees, the rates
negotiated with participating managed health care systems may
vary among the systems. In negotiating rates with participating
systems, the administrator shall consider the characteristics of
the populations served by the respective systems, economic
circumstances of the local area, the need to conserve the
resources of the basic health plan trust account, and other
factors the administrator finds relevant.
(14) To monitor the provision of covered services to
enrollees by participating managed health care systems in order
to assure enrollee access to good quality basic health care, to
require periodic data reports concerning the utilization of
health care services rendered to enrollees in order to provide
adequate information for evaluation, and to inspect the books and
records of participating managed health care systems to assure
compliance with the purposes of this chapter. In requiring
reports from participating managed health care systems, including
data on services rendered enrollees, the administrator shall
endeavor to minimize costs, both to the managed health care
systems and to the plan. The administrator shall coordinate any
such reporting requirements with other state agencies, such as
the insurance commissioner and the department of health, to
minimize duplication of effort.
(15) To evaluate the effects this chapter has on private
employer-based health care coverage and to take appropriate
measures consistent with state and federal statutes that will
discourage the reduction of such coverage in the state.
(16) To develop a program of proven preventive health
measures and to integrate it into the plan wherever possible and
consistent with this chapter.
(17) To provide, consistent with available funding,
assistance for rural residents, underserved populations, and
persons of color.
(18) In consultation with appropriate state and local
government agencies, to establish criteria defining eligibility
for persons confined or residing in government-operated
institutions.
(19) To administer the premium discounts provided under RCW 48.41.200(3)(a) (i) and (ii) pursuant to a contract with the
Washington state health insurance pool.
(20) To give priority in enrollment to persons who
disenrolled from the program in order to enroll in medicaid, and
subsequently became ineligible for medicaid coverage.
[2007 c 259 § 36; 2006 c 343 § 9; 2004 c 192 § 3; 2001 c 196 § 13; 2000 c 79 § 34. Prior: 1998 c 314 § 17; 1998 c 148 § 1; prior: 1997 c 337 § 2; 1997 c 335 § 2; 1997 c 245 § 6; 1997 c 231 § 206; prior: 1995 c 266 § 1; 1995 c 2 § 4; 1994 c 309 § 5; 1993 c 492 § 212; 1992 c 232 § 908; prior: 1991 sp.s. c 4 § 2; 1991 c 3 § 339; 1987 1st ex.s. c 5 § 8.]
NOTES:
Severability -- Subheadings not law -- 2007 c 259: See notes following RCW 41.05.033.
Findings -- 2006 c 343: See note following RCW 43.60A.160.
Effective date -- 2004 c 192: See note following RCW 70.47.020.
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.
Effective date -- 1997 c 337 §§ 1 and 2: See note following RCW 70.47.015.
Short title -- Part headings and captions not law -- Severability -- Effective dates -- 1997 c 231: See notes following RCW 48.43.005.
Effective date -- 1995 c 266: "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 shall take effect July 1, 1995." [1995 c 266 § 5.]
Effective date -- 1995 c 2: See note following RCW 43.72.090.
Contingency -- 1994 c 309 §§ 5 and 6: "If a court in a permanent injunction, permanent order, or final decision determines that the amendments made by sections 5 and 6, chapter 309, Laws of 1994, must be submitted to the people for their adoption and ratification, or rejection, as a result of section 13, chapter 2, Laws of 1994, the amendments made by sections 5 and 6, chapter 309, Laws of 1994, shall be null and void." [1994 c 309 § 7.]
Findings--Intent -- 1993 c 492: See notes following RCW 43.20.050.
Short title -- Severability -- Savings -- Captions not law -- Reservation of legislative power -- Effective dates -- 1993 c 492: See RCW 43.72.910 through 43.72.915.
Severability -- 1992 c 232: See note following RCW 43.33A.180.
Effective date -- 1991 sp.s. c 4: See note following RCW 70.47.030.