Source: https://www.lawserver.com/law/state/washington/wa-code/washington_code_70-47-020
Timestamp: 2020-05-27 22:03:06
Document Index: 278559054

Matched Legal Cases: ['§ 70', '§ 4', '§ 1', '§ 4', '§ 2', '§ 3', '§ 1', '§ 6']

» Washington Code 70.47.020 – Definitions (as amended by 2011 c 284)LawServer
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Washington Code 70.47.020 – Definitions (as amended by 2011 c 284)
Terms Used In Washington Code 70.47.020
(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:
(vii) Who is not receiving1 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;
(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.
*Reviser’s note: RCW 70.47.100 was amended by 2011 1st sp.s. c 9 § 4, changing subsection (7) to subsection (9).
(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 writtencontract 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:
(((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.
Findings—Intent—2011 1st sp.s. c 9: “(1) The legislature finds that:
(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.]
(1)2 “Director” means the director of the Washington state health care authority.
(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 the3 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 the4 director; (c) who is accepted for enrollment by the5 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.
(7) “Rate” means the amount, negotiated by the6 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 the7 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).
(ii) Who is not confined or residing in a government-operated institution, unless he or she meets eligibility criteria adopted by the8 director;
(vii) Who is not receiving medical assistance administered by the9 authority; and
(10) “Washington basic health plan” or “plan” means the system of enrollment and payment for basic health care services, administered by the plan10 director through participating managed health care systems, created by this chapter.
Reviser’s note: *(1) RCW 70.47.100 was amended by 2011 1st sp.s. c 9 § 4, changing subsection (7) to subsection (9).
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.]
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.]
medical assistance administered by the department of social and health services [↩]
“Administrator” means the Washington basic health plan administrator, who also holds the position of administrator [↩]
administrator [↩]
department of social and health services [↩]
Chapter 70.47 Contents