Current through Register Vol. 24-18, September 15, 2024
(1)
Eligibility. To be eligible for the premium payment program (PPP):
(a) A member of the client's medical
assistance unit, as described in chapter 182-506 WAC, must be receiving
benefits under the medicaid agency's:
(i)
Alternative benefits plan coverage;
(ii) Categorically needy coverage;
or
(iii) Medically needy
coverage.
(b) The client
must provide the medicaid agency with proof of:
(i) Enrollment in a comprehensive individual
or comprehensive employer-sponsored health insurance plan;
(ii) A Social Security Number or tax
identification number for the policy holder; and
(iii) Premium expenditures.
(c) A client enrolled in a
qualified individual health insurance plan purchased through the Washington
health benefit exchange must complete an eligibility telephone consultation
with the medicaid agency within 30 calendar days of submitting a completed
application.
(i) The telephone consultation
must occur between the agency and the client, or the client's legal
representative, or both.
(A) Within seven
business days of receipt of the client's completed application, the agency
attempts to schedule the consultation with the client by telephone. If the
client is not reached within two business days from the first attempt, the
agency attempts to reach the client in the manner in which the application was
received (i.e., mail or email).
(B)
The client must schedule their telephone consultation by responding to the
agency by telephone or email within 10 business days of the agency's
outreach.
(C) Upon completion of
the telephone consultation, premium payment enrollment begins as outlined in
subsection (7) of this section.
(ii) The agency may deny the client's
application if the client fails to timely complete their telephone
consultation.
(d) If the
agency suspects that a client has been encouraged by any entity into enrollment
in the premium payment program for the purpose of maximizing the revenue of a
provider or a health plan, the agency immediately informs the client of their
right to disenroll from the program. The agency may take other legal actions,
as appropriate, which could result in the exclusion of a provider from the
medicaid program under chapter 182-502 WAC.
(2)
Comprehensive health insurance
plans. A comprehensive health insurance plan includes:
(a) An individual health insurance plan
purchased from the Washington health benefit exchange, also known as a
qualified health plan (QHP);
(b) An
employer-sponsored group health insurance plan; or
(c) A qualified employer-sponsored group
health insurance plan.
(3)
Comprehensive health insurance plan
exclusions. A comprehensive health insurance plan does not include:
(a) A health savings account, flexible health
spending arrangement, or other surcharge deductions (i.e., tobacco and spousal
deductions);
(b) A high-deductible
plan;
(c) A high-risk plan,
including a Washington state health insurance pool (WSHIP) plan;
(d) A medicare advantage or supplemental
plan, including medicare Part C;
(e) A QHP purchased through the Washington
health benefit exchange with a premium tax credit;
(f) A plan that is the legal obligation of a
noncustodial parent, or any other liable party under
RCW
74.09.185; or
(g) Any individual health insurance plan that
was not purchased through the Washington health benefit exchange.
(4)
Exceptions to
comprehensive health insurance plan requirement:
(a) The agency allows an exception to the
comprehensive health insurance requirement for clients enrolled in the PPP
based on a plan as described in subsection (3)(d) and (e) of this section when
the client:
(i) Has been enrolled in the same
plan continuously since January 1, 2012;
(ii) Was approved for and continuously
enrolled in the PPP since January 1, 2012; and
(iii) Remained eligible for a medicaid
program identified in subsection (1)(a) of this section continuously since
January 1, 2012.
(b) If
a client's medicaid eligibility for a program identified in subsection (1)(a)
of this section or their enrollment in their health plan changes or terminates,
the exception to the comprehensive health insurance requirement
terminates.
(5)
Cost-effective comprehensive health insurance plan. A
comprehensive health insurance plan must be cost-effective as defined in WAC
182-558-0020.
(6)
Comprehensive health insurance
premium above average cost.
(a) If the
agency determines that a client's comprehensive health insurance premium is
more than the average cost per user, the agency pays a greater amount for a
medicaid client on the health insurance plan if the following criteria are met:
(i) The client must provide the following
completed information to the agency:
(A) A
written request that the agency pay a greater amount than the average cost per
user for a medicaid client on the health insurance plan.
(I) The client must currently have a medical
condition or conditions requiring ongoing medical care.
(II) The request must include the cost of the
premium for each member on the comprehensive health insurance.
(B) Written documentation from the
client's provider of a medical condition or conditions that require ongoing
medical care. (For example, a client's providers could submit treatment plans,
medication or durable medical equipment lists, or other
documentation.)
(ii) The
agency reviews the submitted documentation and determines that the cost of the
greater premium is less than the cost of covering the client under medicaid.
(A) The agency's clinical staff reviews the
written documentation from the client's providers to determine if the client
has a medical condition or conditions requiring ongoing medical care.
(B) The agency notifies the client within 60
days of the initial request if additional documentation is required.
(b) The agency notifies
the client in writing of the approval or denial of the client's request within
90 calendar days from the date the agency received:
(i) All requested information from the
client; or
(ii) The client's
written request.
(c) The
agency may deny the request if the client fails to submit all requested
information in (a)(i) of this subsection within 90 calendar days of the
client's request or fails to participate in consultation as required in
subsection (1)(c) of this section.
(d) The agency determines the updated premium
amount based on the client's portion of the total premium using the information
submitted by the client under (a)(i) of this subsection.
(e) If approved, the effective date of the
increased premium amount is the date the client submitted the written request
to the agency.
(7)
Premium limit. The agency pays no more than one premium per
client, per month. PPP enrollment begins no sooner than the date on which:
(a) A client is approved for a medicaid
program identified in subsection (1)(a) of this section;
(b) The agency receives and accepts the
completed Application for HCA Premium Payment Program (HCA 13-705)
form;
(c) A client's apple health
managed care enrollment, if applicable, ends; and
(d) A client completes the telephone
eligibility phone consultation, if applicable under subsection (1)(c) of this
section.
(8)
Integrated managed care exemption. A client enrolled in the PPP is
exempt from integrated managed care under chapter 182-538 WAC.
(9)
Premium assistance subsidy.
The agency's premium assistance subsidy may not exceed the minimum amount
required to maintain comprehensive health insurance for the medicaid-eligible
client.
(10)
Proof of premium
expenditures. Proof of premium expenditures must be submitted to the
agency by the client or the client's representative no later than the end of
the third month following the last month of coverage.
(11)
Cost-sharing benefit
limitations. The agency's cost-sharing benefit for copays, coinsurance,
and deductibles is limited to services covered under the medicaid state
plan.
(12)
Proof of
cost-sharing required. Proof of cost-sharing must be submitted to the
agency no later than the end of the sixth month following the date of
service.
(13)
Client
eligibility review.
(a) The agency
reviews a client's eligibility annually for the PPP or when the client's:
(i) Health insurance plan has an annual open
enrollment;
(ii) Medicaid
eligibility for a program identified in subsection (1)(a) of this section
changes or ends;
(iii) Medical
assistance unit changes;
(iv)
Premium changes; or
(v) Private
health insurance coverage changes or ends.
(b) If the agency finds that the client's
premiums or medicaid eligibility have changed, the agency may adjust the
premium reimbursement or terminate eligibility for the PPP. The agency notifies
the client of any changes in PPP eligibility under this subsection.
