(1)(a) The
following persons who are residents of this state are eligible
for pool coverage:
(i) 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;
(ii) 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;
(iii) 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;
(iv) Any person becoming eligible for medicare before August
1, 2009, who provides evidence of (A) a rejection for medical
reasons, (B) a requirement of restrictive riders, (C) an up-rated
premium, (D) a preexisting conditions limitation, or (E) lack of
access to or for a comprehensive medicare supplemental insurance
policy under chapter 48.66 RCW, the effect of any 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;
(v) Any person becoming eligible for medicare on or after
August 1, 2009, who does not have access to a reasonable choice
of comprehensive medicare part C plans, as defined in (b) of this
subsection, and who provides evidence of (A) a rejection for
medical reasons, (B) a requirement of restrictive riders, (C) an
up-rated premium, (D) a preexisting conditions limitation, or (E)
lack of access to or for a comprehensive medicare supplemental
insurance policy under chapter 48.66 RCW, the effect of any 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; and
(vi) Any person under the age of nineteen who does not have
access to individual plan open enrollment or special enrollment,
as defined in RCW 48.43.005, or the federal preexisting condition
insurance pool, at the time of application to the pool is
eligible for the pool coverage.
(b) For purposes of (a)(v) of this subsection (1), a person
does not have access to a reasonable choice of plans unless the
person has a choice of health maintenance organization or
preferred provider organization medicare part C plans offered by
at least three different carriers that have had provider networks
in the person's county of residence for at least five years. The
plan options must include coverage at least as comprehensive as a
plan F medicare supplement plan combined with medicare parts A
and B. The plan options must also provide access to adequate and
stable provider networks that make up-to-date provider
directories easily accessible on the carrier web site, and will
provide them in hard copy, if requested. In addition, if no
health maintenance organization or preferred provider
organization plan includes the health care provider with whom the
person has an established care relationship and from whom he or
she has received treatment within the past twelve months, the
person does not have reasonable access.
(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) 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));
(c) 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)(a)(iv) 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)(a)(iii) of
this section in that county shall no longer be eligible for
coverage under that plan pursuant to subsection (1)(a)(iii) 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)(a)(iii) 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)(i), (ii), or (iv) 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)(a)(ii) 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.
[2011 c 315 § 5; 2011 c 314 § 15; 2009 c 555 § 3; 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:
Reviser's note: This section was amended by 2011 c 314 § 15 and by 2011 c 315 § 5, each without reference to the other. Both amendments are incorporated in the publication of this section under RCW 1.12.025(2). For rule of construction, see RCW 1.12.025(1).
Effective date -- 2011 c 315 §§ 5 and 6: "Sections 5 and 6 of this act are necessary for the immediate preservation of the public peace, health, or safety, or support of the state government and its existing public institutions, and take effect immediately [May 11, 2011]." [2011 c 315 § 7.]
Intent -- 2011 c 315: See note following RCW 48.43.005.
Contingent effective date -- 2009 c 555 § 3: "Section 3 of this act takes effect if section 4, chapter 317, Laws of 2008 is null and void on July 26, 2009; otherwise section 3 of this act is null and void." [2009 c 555 § 6.]
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.