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Medicaid, SCHIP, & Federal Authority

  • Deficit Reduction Act of 2005 (DRA)In June 2007, the Centers for Medicare and Medicaid Services (CMS) approved Washington’s submission of a benchmark state plan amendment under the DRA to offer Medicaid and disease management services to beneficiaries with certain chronic medical conditions. The chronic care coordination program, identifies high-risk and high-cost individuals with multiple chronic care needs and seeks to improve access and health outcomes while controlling costs.    Enrollment in the program is voluntary.[1] The program has two components:  a statewide care management program and a local care program.  In addition to state plan services, all enrollees receive condition-specific education; access to a nurse call line; care coordination including feedback to the primary care physician; and regularly-scheduled telephonic care management. All traditional Medicaid services will be administered on a fee-for-service basis, and a prepaid ambulatory health plan will provide the disease management.  

    During the 2007 legislative session, Washington passed legislation to provide access to coverage for all children in the state by 2010.  Starting July 2007, it funds intensive education, outreach, and administrative simplification efforts to enroll all currently eligible children, covering over one-half of Washington 's uninsured children. Beginning in January 2009, the legislation authorizes the state to expand the State Children's Health Insurance Program (SCHIP) to children who have family incomes up to 300 percent FPL; the current eligibility level is 250 percent FPL. The department is authorized to seek federal financial participation for the expansion population. In addition, children in families with incomes above 300 percent FPL will have access to SCHIP at full-cost. Premiums would apply to children above 200 percent FPL. The legislation also includes a premium assistance program, if cost-effective, for those families with access to employer-sponsored insurance.


    [1] All categorically needy aged, blind, or disabled adults ages 21 and over in Medicaid fee-for-service have the opportunity to enroll.

High-Risk Pools

  • The Washington State Health Insurance Pool first became operational in 1988. The pool is financed through premiums and assessments to insurers. The premium cap is 150 percent of the standard risk rate in general but 125 percent for the Pool’s preferred provider plan. At the end of 2006, approximately 3100 persons were enrolled in the program.

Limited-Benefit Plans

  • In 2004, Washington passed legislation redefining the small group market, changing group size to 2 to 50, from 1 to 50. The legislation also streamlines some administrative costs, protects portability of policies, and implements new rating factors for health insurance plans. Carriers are permitted to offer a limited- benefit package (replacing the previous requirement to offer a prescribed limited-benefit package that mirrored the Basic Health package.)

Dependent Coverage

  • S.B 5930 requires any commercial health plan offering health insurance coverage to allow the option of covering unmarried dependents up until age 25. Additional premiums may be charged to cover these young adult dependents. If the dependent meets certain disability criteria, parents may continue to cover the dependent irrespective of age for the same premium as dependents under age 20. These requirements also apply to the state employee program.

State Specific Strategies

  • The Washington Health Insurance Partnership

    In 2007, House Bill 1569 authorized the creation of a Massachusetts-style Connector called the Washington Health Insurance Partnership (HIP) under the direction of a seven member Board. HIP is initially targeting small employers with low-income workers. For a small employer to designate HIP as its health benefits administrator, the employer has to have at least one eligible employee (a Washington resident earning less than 200 percent FPL) and set up a cafeteria plan as defined by Section 125 of the federal income tax code. Cafeteria plans allow pre-tax premium payments by both an employer and an employee. If a small employer meets these two conditions, all of its employees regardless of income can purchase through HIP (even after leaving employment).
    In addition, the legislation establishes sliding scale premium subsidies for individuals who earn less than 200 percent FPL based on gross family income on a similar schedule as that currently used by the Washington Basic Health Plan.
    In 2008, House Bill 2537 made several technical changes as requested by the HIP board. Two provisions of the original bill, employee choice and portability, are delayed by a start up phase of up to two years. It also narrowed eligibility requirements for employers, who must now attest to the fact that: (a) the employer does not currently offer health insurance to its employees, and (b) at least 50 percent of the employer's employees are low-wage workers. HIP will now begin to accept enrollments January 1, 2009, with coverage to begin March 1, 2009 (2537 delayed implementation three months).
    Basic Health - Created in 1988, Basic Health (BH) is a state-sponsored program that provides health care coverage to WashingtonState residents with family incomes below 200 percent FPL. Monthly premiums are based on family size, income, age, and health plan choice, with a sliding scale state subsidy. Member cost-sharing comes in the form of copays, coinsurance, and deductibles. A standardized benefits package is offered through private insurance carriers offering a “managed care plan.” To qualify, applicants must meet BH's income guidelines, live in Washington state, not be eligible for Medicare, not be a full-time student in the United States on a student visa, and not be institutionalized at the time of enrollment. As of Fall of 2006, the program covered approximately 100,000 subsidized enrollees. BH and Medicaid coordinate coverage to support family unity for low-income families. Close to 15,000 additional children receive coverage via BH and Medicaid covers approximately 22,000 children. Medicaid coverage is delivered through BH contracted health plans.
    In addition, there are several small sub-programs included in BH and that are included in the total enrollment figure of approximately 100,000 subsidized BH enrollees. The “financial sponsors” program allows a third party to pay the BH premium. As of the Fall of 2006 about 28,000 BH enrollees had financial sponsors. Employers may also sponsor coverage for their employees who meet BH eligibility criteria. As of Fall of 2006, about 250 BH enrollees were enrolled in the employer-sponsored program. BH is also available to foster parents and homecare agency workers or individual providers employed by clients of the state’s Medicaid Aging and Disability program.

    Coverage for Non-Citizen Children - In January 2006, the Washington State Children’s Health Program (CHP) was re-instated in Medicaid to provide health coverage for non-citizen children in families up to 100 percent of federal povertyFunding has been provided to cover about 14,000 CHP enrollees. In addition, non-citizen children in families up to 200 percent of federal poverty may enroll in Basic Health.