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PDFWAC 182-558-0030

Overview of eligibility.

(1) 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:
(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.
(2) A comprehensive health insurance plan includes:
(a) An individual health insurance plan;
(b) An employer-sponsored group health insurance plan; or
(c) A qualified employer-sponsored group health insurance plan.
(3) A comprehensive health insurance plan does not include:
(a) A health savings account or flexible health spending arrangement;
(b) A high-deductible plan;
(c) A high-risk plan, including a Washington state health insurance pool (WSHIP) plan;
(d) A limited or supplemental plan, including a medicare supplemental plan;
(e) A medicare advantage plan (medicare Part C);
(f) A qualified health plan (QHP) purchased through the health benefit exchange with a premium tax credit; or
(g) A plan that is the legal obligation of a noncustodial parent, or any other liable party under RCW 74.09.185.
(4) Exception to comprehensive insurance 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)(c), (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 or their enrollment in their health plan changes or terminates, the exception to the comprehensive health insurance requirement terminates.
(5) A comprehensive health insurance plan must be cost effective as defined in WAC 182-558-0020.
(6) If a client's comprehensive health insurance premium is more than the average cost per user, the client must provide the agency proof from the client's provider(s):
(a) Of an existing medical condition that requires or will be requiring extensive medical care; and
(b) That the cost of the medicaid expenditures would be greater if the agency does not pay premium assistance.
(7) 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 medicaid;
(b) The agency receives and accepts the completed Application for HCA Premium Payment Program (HCA 13-705) form; and
(c) A client's apple health managed care enrollment, if applicable, ends.
(8) A client enrolled in the PPP is exempt from mandatory managed care under chapter 182-538 and 182-538A WAC.
(9) 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 must be submitted to the agency no later than the end of the third month following the last month of coverage.
(11) 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 must be submitted to the agency no later than the end of the sixth month following the date of service.
(13) The agency may review a client's eligibility for the PPP at any time including, but not limited to, when the client's:
(a) Health insurance plan has an annual open enrollment;
(b) Medicaid eligibility changes or ends;
(c) Medical assistance unit changes;
(d) Premium changes; or
(e) Private health insurance coverage changes or ends.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 19-11-129, § 182-558-0030, filed 5/22/19, effective 6/22/19; WSR 17-03-014, § 182-558-0030, filed 1/5/17, effective 3/1/17.]
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