Section 182-24-020. Eligibility.

(1) To be eligible for enrollment in BHP, unless otherwise specified elsewhere in this chapter, an individual must be a Washington state resident, age nineteen to sixty-four, who:

(a) Is not eligible for free or purchased medicare;

(b) Is not eligible for or receiving medical assistance from the department of social and health services (DSHS);

(c) Is not enrolled in WHP;

(d) Is not confined or residing in a government-operated institution, unless he or she meets eligibility criteria adopted by the administrator;

(e) Is not a full-time student who has received a temporary visa to study in the United States;

(f) Is a U.S. citizen; or a qualified alien who meets the eligibility requirements in Title 8 United States Code (U.S.C.), Chapter 14, Subchapter I, Section 1613, five-year limited eligibility of qualified aliens for federal means-tested public benefit;

(g) Resides in an area of the state served by a managed health care system participating in the plan;

(h) Chooses to obtain coverage from a particular managed health care system;

(i) Pays or has paid on their behalf their portion of the costs for participation in the plan; and

(j) Whose gross family income at the time of enrollment meets the definition of a subsidized enrollee.

(2) Persons not meeting these criteria, as evidenced by information submitted on the application for enrollment or otherwise obtained by BHP, will not be enrolled. An enrollee who is no longer a Washington resident or who is later determined to have failed to meet BHP's eligibility criteria at the time of enrollment, will be disenrolled.

(3) Eligibility for BHP Plus and maternity benefits through medical assistance is determined by DSHS, based on medicaid eligibility criteria.

(4)(a) An individual otherwise eligible for enrollment in BHP may be denied enrollment if the administrator has determined that acceptance of additional enrollment would exceed limits established by the legislature, would jeopardize the orderly development of BHP, or would result in an overexpenditure of BHP funds. An individual otherwise eligible for enrollment in BHP also may be denied enrollment if no managed health care system(s) is accepting new enrollment in that program or from the geographic area where the applicant lives.

(b) If the administrator closes or limits enrollment, to the extent funding is available, BHP will continue to accept and process applications for enrollment from:

(i) Children eligible for BHP, who were referred to DSHS for BHP Plus coverage, but were found ineligible for BHP Plus for reasons other than noncompliance;

(ii) Employees of a home care agency group enrolled or applying for coverage under WAC 182-22-220;

(iii) Eligible individual home care providers;

(iv) Licensed foster care workers;

(v) Persons who disenrolled from BHP in order to enroll in medicaid, and subsequently became ineligible for medicaid;

(vi) Limited enrollment of new employer groups;

(vii) Members of the Washington National Guard and Reserves who served in Operation Enduring Freedom, Operation Iraqi Freedom, or Operation Noble Eagle, and their spouses and dependents; and

(viii) Subject to availability of funding, additional space for enrollment may be reserved for other applicants as determined by the administrator, in order to ensure continuous coverage and service for current individual and group accounts. (For example: Within established guidelines, processing routine income changes that may affect subsidy eligibility for current enrollees; adding new family members to an existing account; transferring enrollees between group and individual accounts; restoring coverage for enrollees who are otherwise eligible for continued enrollment under WAC 182-24-070 (7)(b) after a limited suspension of coverage due to late payment or other health care coverage; adding newly hired employees to an existing employer group; or adding new or returning members of federally recognized Native American tribes to that tribe's currently approved financial sponsor group.)

(c) If the administrator has closed or limited enrollment, applicants for BHP who are not in any of the categories in (b) of this subsection may reserve space on a waiting list to be processed according to the date the waiting list request or application is received by BHP. When enrollment is reopened by the administrator, applicants whose names appear on the waiting list will be notified by BHP of the opportunity to enroll. BHP may require new application forms and documentation from applicants on the waiting list, or may contact applicants to verify continued interest in applying, before determining their eligibility.

[Statutory Authority: Chapter 70.47 RCW. WSR 11-15-020, § 182-24-020, filed 7/8/11, effective 8/8/11; WSR 10-24-062 (Order 10-03), § 182-24-020, filed 11/30/10, effective 12/31/10.]

Chapter 70.47 RCW. WSR 11-15-020, § 182-24-020, filed 7/8/11, effective 8/8/11; WSR 10-24-062 (Order 10-03), § 182-24-020, filed 11/30/10, effective 12/31/10.

Rules

182-22-220,182-24-070,