As
used in this chapter:
(1) "Administrator" means the Washington basic health plan
administrator, who also holds the position of administrator of
the Washington state health care authority.
(2) "Health coverage tax credit eligible enrollee" means
individual workers and their qualified family members who lose
their jobs due to the effects of international trade and are
eligible for certain trade adjustment assistance benefits; or are
eligible for benefits under the alternative trade adjustment
assistance program; or are people who receive benefits from the
pension benefit guaranty corporation and are at least fifty-five
years old.
(3) "Health coverage tax credit program" means the program
created by the Trade Act of 2002 (P.L. 107-210) that provides a
federal tax credit that subsidizes private health insurance
coverage for displaced workers certified to receive certain trade
adjustment assistance benefits and for individuals receiving
benefits from the pension benefit guaranty corporation.
(4) "Managed health care system" means: (a) Any health care
organization, including health care providers, insurers, health
care service contractors, health maintenance organizations, or
any combination thereof, that provides directly or by contract
basic health care services, as defined by the administrator and
rendered by duly licensed providers, to a defined patient
population enrolled in the plan and in the managed health care
system; or (b) a self-funded or self-insured method of providing
insurance coverage to subsidized enrollees provided under RCW 41.05.140 and subject to the limitations under *RCW 70.47.100(7).
(5) "Nonsubsidized enrollee" means an individual, or an
individual plus the individual's spouse or dependent children:
(a) Who is not eligible for medicare; (b) who is not confined or
residing in a government-operated institution, unless he or she
meets eligibility criteria adopted by the administrator; (c) who
is accepted for enrollment by the administrator as provided in
RCW 48.43.018, either because the potential enrollee cannot be
required to complete the standard health questionnaire under RCW 48.43.018, or, based upon the results of the standard health
questionnaire, the potential enrollee would not qualify for
coverage under the Washington state health insurance pool; (d)
who resides in an area of the state served by a managed health
care system participating in the plan; (e) who chooses to obtain
basic health care coverage from a particular managed health care
system; and (f) who pays or on whose behalf is paid the full
costs for participation in the plan, without any subsidy from the
plan.
(6) "Premium" means a periodic payment, which an individual,
their employer or another financial sponsor makes to the plan as
consideration for enrollment in the plan as a subsidized
enrollee, a nonsubsidized enrollee, or a health coverage tax
credit eligible enrollee.
(7) "Rate" means the amount, negotiated by the administrator
with and paid to a participating managed health care system, that
is based upon the enrollment of subsidized, nonsubsidized, and
health coverage tax credit eligible enrollees in the plan and in
that system.
(8) "Subsidy" means the difference between the amount of
periodic payment the administrator makes to a managed health care
system on behalf of a subsidized enrollee plus the administrative
cost to the plan of providing the plan to that subsidized
enrollee, and the amount determined to be the subsidized
enrollee's responsibility under RCW 70.47.060(2).
(9) "Subsidized enrollee" means:
(a) An individual, or an individual plus the individual's
spouse or dependent children:
(i) Who is not eligible for medicare;
(ii) Who is not confined or residing in a
government-operated institution, unless he or she meets
eligibility criteria adopted by the administrator;
(iii) Who is not a full-time student who has received a
temporary visa to study in the United States;
(iv) Who resides in an area of the state served by a managed
health care system participating in the plan;
(v) Whose gross family income at the time of enrollment does
not exceed two hundred percent of the federal poverty level as
adjusted for family size and determined annually by the federal
department of health and human services;
(vi) Who chooses to obtain basic health care coverage from a
particular managed health care system in return for periodic
payments to the plan; and
(vii) Who is not receiving ((medical assistance administered
by the department of social and health services)) or has not been
determined to be currently eligible for federally financed
categorically needy or medically needy programs under chapter 74.09 RCW, except as provided under RCW 70.47.110;
(b) An individual who meets the requirements in (a)(i)
through (iv), (vi), and (vii) of this subsection and who is a
foster parent licensed under chapter 74.15 RCW and whose gross
family income at the time of enrollment does not exceed three
hundred percent of the federal poverty level as adjusted for
family size and determined annually by the federal department of
health and human services; and
(c) To the extent that state funds are specifically
appropriated for this purpose, with a corresponding federal
match, an individual, or an individual's spouse or dependent
children, who meets the requirements in (a)(i) through (iv),
(vi), and (vii) of this subsection and whose gross family income
at the time of enrollment is more than two hundred percent, but
less than two hundred fifty-one percent, of the federal poverty
level as adjusted for family size and determined annually by the
federal department of health and human services.
(10) "Washington basic health plan" or "plan" means the
system of enrollment and payment for basic health care services,
administered by the plan administrator through participating
managed health care systems, created by this chapter.
[2011 c 284 § 1. Prior: 2009 c 568 § 2; 2007 c 259 § 35; 2005 c 188 § 2; 2004 c 192 § 1; 2000 c 79 § 43; 1997 c 335 § 1; 1997 c 245 § 5; prior: 1995 c 266 § 2; 1995 c 2 § 3; 1994 c 309 § 4; 1993 c 492 § 209; 1987 1st ex.s. c 5 § 4.]
NOTES:
*Reviser's note: RCW 70.47.100 was amended by 2011 1st sp.s. c 9 § 4, changing subsection (7) to subsection (9).
RCW 70.47.020
Definitions (as amended by 2011 1st sp.s. c
9).
As used in this chapter:
(1) "Administrator" means the Washington basic health plan
administrator, who also holds the position of administrator of
the Washington state health care authority.
(2) "Health coverage tax credit eligible enrollee" means
individual workers and their qualified family members who lose
their jobs due to the effects of international trade and are
eligible for certain trade adjustment assistance benefits; or are
eligible for benefits under the alternative trade adjustment
assistance program; or are people who receive benefits from the
pension benefit guaranty corporation and are at least fifty-five
years old.
(3) "Health coverage tax credit program" means the program
created by the Trade Act of 2002 (P.L. 107-210) that provides a
federal tax credit that subsidizes private health insurance
coverage for displaced workers certified to receive certain trade
adjustment assistance benefits and for individuals receiving
benefits from the pension benefit guaranty corporation.
(4) "Managed health care system" means: (a) Any health care
organization, including health care providers, insurers, health
care service contractors, health maintenance organizations, or
any combination thereof, that provides directly or by contract
basic health care services, as defined by the administrator and
rendered by duly licensed providers, to a defined patient
population enrolled in the plan and in the managed health care
system; or (b) a self-funded or self-insured method of providing
insurance coverage to subsidized enrollees provided under RCW 41.05.140 and subject to the limitations under RCW 70.47.100(((7))) (9).
(5) "Nonparticipating provider" means a person, health care
provider, practitioner, facility, or entity, acting within their
authorized scope of practice or licensure, that does not have a
written contract to participate in a managed health care system's
provider network, but provides services to plan enrollees who
receive coverage through the managed health care system.
(6) "Nonsubsidized enrollee" means an individual, or an
individual plus the individual's spouse or dependent children:
(a) Who is not eligible for medicare; (b) who is not confined or
residing in a government-operated institution, unless he or she
meets eligibility criteria adopted by the administrator; (c) who
is accepted for enrollment by the administrator as provided in
RCW 48.43.018, either because the potential enrollee cannot be
required to complete the standard health questionnaire under RCW 48.43.018, or, based upon the results of the standard health
questionnaire, the potential enrollee would not qualify for
coverage under the Washington state health insurance pool; (d)
who resides in an area of the state served by a managed health
care system participating in the plan; (e) who chooses to obtain
basic health care coverage from a particular managed health care
system; and (f) who pays or on whose behalf is paid the full
costs for participation in the plan, without any subsidy from the
plan.
(((6))) (7) "Premium" means a periodic payment, which an
individual, their employer or another financial sponsor makes to
the plan as consideration for enrollment in the plan as a
subsidized enrollee, a nonsubsidized enrollee, or a health
coverage tax credit eligible enrollee.
(((7))) (8) "Rate" means the amount, negotiated by the
administrator with and paid to a participating managed health
care system, that is based upon the enrollment of subsidized,
nonsubsidized, and health coverage tax credit eligible enrollees
in the plan and in that system.
(((8))) (9) "Subsidy" means the difference between the
amount of periodic payment the administrator makes to a managed
health care system on behalf of a subsidized enrollee plus the
administrative cost to the plan of providing the plan to that
subsidized enrollee, and the amount determined to be the
subsidized enrollee's responsibility under RCW 70.47.060(2).
(((9))) (10) "Subsidized enrollee" means:
(a) An individual, or an individual plus the individual's
spouse or dependent children:
(i) Who is not eligible for medicare;
(ii) Who is not confined or residing in a
government-operated institution, unless he or she meets
eligibility criteria adopted by the administrator;
(iii) Who is not a full-time student who has received a
temporary visa to study in the United States;
(iv) Who resides in an area of the state served by a managed
health care system participating in the plan;
(v) Until March 1, 2011, whose gross family income at the
time of enrollment does not exceed two hundred percent of the
federal poverty level as adjusted for family size and determined
annually by the federal department of health and human services;
(vi) Who chooses to obtain basic health care coverage from a
particular managed health care system in return for periodic
payments to the plan;
(vii) Who is not receiving medical assistance administered
by the department of social and health services; and
(viii) After February 28, 2011, who is in the basic health
transition eligibles population under 1115 medicaid demonstration
project number 11-W-00254/10;
(b) An individual who meets the requirements in (a)(i)
through (iv), (vi), and (vii) of this subsection and who is a
foster parent licensed under chapter 74.15 RCW and whose gross
family income at the time of enrollment does not exceed three
hundred percent of the federal poverty level as adjusted for
family size and determined annually by the federal department of
health and human services; and
(c) To the extent that state funds are specifically
appropriated for this purpose, with a corresponding federal
match, an individual, or an individual's spouse or dependent
children, who meets the requirements in (a)(i) through (iv),
(vi), and (vii) of this subsection and whose gross family income
at the time of enrollment is more than two hundred percent, but
less than two hundred fifty-one percent, of the federal poverty
level as adjusted for family size and determined annually by the
federal department of health and human services.
(((10))) (11) "Washington basic health plan" or "plan" means
the system of enrollment and payment for basic health care
services, administered by the plan administrator through
participating managed health care systems, created by this
chapter.
[2011 1st sp.s. c 9 § 3. Prior: 2011 c 205 § 1; prior: 2009 c 568 § 2; 2007 c 259 § 35; 2005 c 188 § 2; 2004 c 192 § 1; 2000 c 79 § 43; 1997 c 335 § 1; 1997 c 245 § 5; prior: 1995 c 266 § 2; 1995 c 2 § 3; 1994 c 309 § 4; 1993 c 492 § 209; 1987 1st ex.s. c 5 § 4.]
NOTES:
Findings -- Intent -- 2011 1st sp.s. c 9: "(1) The legislature
finds that:
(a) There is an increasing level of dispute and uncertainty
regarding the amount of payment nonparticipating providers may
receive for health care services provided to enrollees of state
purchased health care programs designed to serve low-income
individuals and families, such as basic health and the medicaid
managed care programs;
(b) The dispute has resulted in litigation, including a
recent Washington superior court ruling that determined
nonparticipating providers were entitled to receive billed
charges from a managed health care system for services provided
to medicaid and basic health plan enrollees. The decision would
allow a nonparticipating provider to demand and receive payment
in an amount exceeding the payment managed health care system
network providers receive for the same services. Similar
provider lawsuits have now been filed in other jurisdictions in
the state;
(c) In the biennial operating budget, the legislature has
previously indicated its intent that payment to nonparticipating
providers for services provided to medicaid managed care
enrollees should be limited to amounts paid to medicaid
fee-for-service providers. The duration of these provisions is
limited to the period during which the operating budget is in
effect. A more permanent resolution of these issues is needed;
and
(d) Continued failure to resolve this dispute will have
adverse impacts on state purchased health care programs serving
low-income enrollees, including: (i) Diminished ability for the
state to negotiate cost-effective contracts with managed health
care systems; (ii) a potential for significant reduction in the
willingness of providers to participate in managed health care
system provider networks; (iii) a reduction in providers
participating in the managed health care systems; and (iv)
increased exposure for program enrollees to balance billing
practices by nonparticipating providers. Ultimately, fewer
eligible people will get the care they need as state purchased
health care programs will operate with less efficiency and
reduced access to cost-effective and quality health care coverage
for program enrollees.
(2) It is the intent of the legislature to create a
legislative solution that reduces the cost borne by the state to
provide public health care coverage to low-income enrollees in
managed health care systems, protects enrollees and state
purchased health care programs from balance billing by
nonparticipating providers, provides appropriate payment to
health care providers for services provided to enrollees of state
purchased health care programs, and limits the risk for managed
health care systems that contract with the state programs."
[2011 1st sp.s. c 9 § 1.]
RCW 70.47.020
Definitions (as amended by 2011 1st sp.s. c
15).
As used in this chapter:
(1) (("Administrator" means the Washington basic health plan
administrator, who also holds the position of administrator))
"Director" means the director of the Washington state health care
authority.
(2) "Health coverage tax credit eligible enrollee" means
individual workers and their qualified family members who lose
their jobs due to the effects of international trade and are
eligible for certain trade adjustment assistance benefits; or are
eligible for benefits under the alternative trade adjustment
assistance program; or are people who receive benefits from the
pension benefit guaranty corporation and are at least fifty-five
years old.
(3) "Health coverage tax credit program" means the program
created by the Trade Act of 2002 (P.L. 107-210) that provides a
federal tax credit that subsidizes private health insurance
coverage for displaced workers certified to receive certain trade
adjustment assistance benefits and for individuals receiving
benefits from the pension benefit guaranty corporation.
(4) "Managed health care system" means: (a) Any health care
organization, including health care providers, insurers, health
care service contractors, health maintenance organizations, or
any combination thereof, that provides directly or by contract
basic health care services, as defined by the ((administrator))
director and rendered by duly licensed providers, to a defined
patient population enrolled in the plan and in the managed health
care system; or (b) a self-funded or self-insured method of
providing insurance coverage to subsidized enrollees provided
under RCW 41.05.140 and subject to the limitations under *RCW 70.47.100(7).
(5) "Nonsubsidized enrollee" means an individual, or an
individual plus the individual's spouse or dependent children:
(a) Who is not eligible for medicare; (b) who is not confined or
residing in a government-operated institution, unless he or she
meets eligibility criteria adopted by the ((administrator))
director; (c) who is accepted for enrollment by the
((administrator)) director as provided in RCW 48.43.018, either
because the potential enrollee cannot be required to complete the
standard health questionnaire under RCW 48.43.018, or, based upon
the results of the standard health questionnaire, the potential
enrollee would not qualify for coverage under the Washington
state health insurance pool; (d) who resides in an area of the
state served by a managed health care system participating in the
plan; (e) who chooses to obtain basic health care coverage from a
particular managed health care system; and (f) who pays or on
whose behalf is paid the full costs for participation in the
plan, without any subsidy from the plan.
(6) "Premium" means a periodic payment, which an individual,
their employer or another financial sponsor makes to the plan as
consideration for enrollment in the plan as a subsidized
enrollee, a nonsubsidized enrollee, or a health coverage tax
credit eligible enrollee.
(7) "Rate" means the amount, negotiated by the
((administrator)) director with and paid to a participating
managed health care system, that is based upon the enrollment of
subsidized, nonsubsidized, and health coverage tax credit
eligible enrollees in the plan and in that system.
(8) "Subsidy" means the difference between the amount of
periodic payment the ((administrator)) director makes to a
managed health care system on behalf of a subsidized enrollee
plus the administrative cost to the plan of providing the plan to
that subsidized enrollee, and the amount determined to be the
subsidized enrollee's responsibility under RCW 70.47.060(2).
(9) "Subsidized enrollee" means:
(a) An individual, or an individual plus the individual's
spouse or dependent children:
(i) Who is not eligible for medicare;
(ii) Who is not confined or residing in a
government-operated institution, unless he or she meets
eligibility criteria adopted by the ((administrator)) director;
(iii) Who is not a full-time student who has received a
temporary visa to study in the United States;
(iv) Who resides in an area of the state served by a managed
health care system participating in the plan;
(v) Until March 1, 2011, whose gross family income at the
time of enrollment does not exceed two hundred percent of the
federal poverty level as adjusted for family size and determined
annually by the federal department of health and human services;
(vi) Who chooses to obtain basic health care coverage from a
particular managed health care system in return for periodic
payments to the plan;
(vii) Who is not receiving medical assistance administered
by the ((department of social and health services)) authority;
and
(viii) After February 28, 2011, who is in the basic health
transition eligibles population under 1115 medicaid demonstration
project number 11-W-00254/10;
(b) An individual who meets the requirements in (a)(i)
through (iv), (vi), and (vii) of this subsection and who is a
foster parent licensed under chapter 74.15 RCW and whose gross
family income at the time of enrollment does not exceed three
hundred percent of the federal poverty level as adjusted for
family size and determined annually by the federal department of
health and human services; and
(c) To the extent that state funds are specifically
appropriated for this purpose, with a corresponding federal
match, an individual, or an individual's spouse or dependent
children, who meets the requirements in (a)(i) through (iv),
(vi), and (vii) of this subsection and whose gross family income
at the time of enrollment is more than two hundred percent, but
less than two hundred fifty-one percent, of the federal poverty
level as adjusted for family size and determined annually by the
federal department of health and human services.
(10) "Washington basic health plan" or "plan" means the
system of enrollment and payment for basic health care services,
administered by the plan ((administrator)) director through
participating managed health care systems, created by this
chapter.
[2011 1st sp.s. c 15 § 83; 2011 c 205 § 1; 2009 c 568 § 2; 2007 c 259 § 35; 2005 c 188 § 2; 2004 c 192 § 1; 2000 c 79 § 43; 1997 c 335 § 1; 1997 c 245 § 5. Prior: 1995 c 266 § 2; 1995 c 2 § 3; 1994 c 309 § 4; 1993 c 492 § 209; 1987 1st ex.s. c 5 § 4.]
NOTES:
Reviser's note: *(1) RCW 70.47.100 was amended by 2011 1st
sp.s. c 9 § 4, changing subsection (7) to subsection (9).
(2) RCW 70.47.020 was amended three times during the 2011
legislative session, each without reference to the other. For
rule of construction concerning sections amended more than once
during the same legislative session, see RCW 1.12.025.
Effective date -- Findings -- Intent -- Report -- Agency transfer -- References to head of health care authority -- Draft legislation -- 2011 1st sp.s. c 15: See notes following RCW 74.09.010.
Intent -- 2011 c 205: "The legislature intends to define eligibility for the basic health plan for periods subsequent to expiration of the 1115 medicaid demonstration project based upon recommendations from its joint select committee on health reform regarding whether the basic health plan should be offered as an enrollment option for persons who qualify for federal premium subsidies under the federal patient protection and affordable care act of 2010." [2011 c 205 § 2.]
Effective date -- 2011 c 205: "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 [April 29, 2011]." [2011 c 205 § 3.]
Severability -- Subheadings not law -- 2007 c 259: See notes following RCW 41.05.033.
Findings -- 2005 c 188: "The legislature finds that the basic health plan is a valuable means of providing access to affordable health insurance coverage for low-income families and individuals in Washington state. The legislature further finds that persons studying in the United States as full-time students under temporary visas must show, as a condition of receiving their temporary visa, that they have sufficient funds available for self-support during their entire proposed course of study. For this reason, the legislature finds that it is not appropriate to provide subsidized basic health plan coverage to this group of students." [2005 c 188 § 1.]
Effective date -- 2004 c 192: "This act takes effect January 1, 2005." [2004 c 192 § 6.]
Effective date -- Severability -- 2000 c 79: See notes following RCW 48.04.010.
Effective date -- 1995 c 266: See note following RCW 70.47.060.
Effective date -- 1995 c 2: See note following RCW 43.72.090.
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.