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The definitions in this section apply throughout this chapter and chapter 48.--- RCW (the new chapter created in section 15 of this act) unless the context clearly requires otherwise.
"Authority" means the Washington state health care authority.
"Commissioner" means the insurance commissioner or his or her designee.
"Covered lives" means all persons residing in Washington state who are covered:
Under a fully insured individual or group health plan issued or delivered in Washington state; or
By a medicaid managed care organization.
"Health carrier" or "carrier" has the same meaning as defined in RCW 48.43.005.
"Health plan" has the same meaning as defined in RCW 48.43.005 and does not include medicare advantage plans established under medicare part C or outpatient prescription drug plans established under medicare part D.
"Medicaid managed care organization" means a managed health care system under contract with the state of Washington to provide services to medicaid enrollees under RCW 74.09.522.
By September 1, 2025, the authority shall submit any state plan amendments or waiver requests to the centers for medicare and medicaid services that are necessary to implement the medicaid access program established in section 6 of this act.
The assessment, collection, and disbursement of funds for this program shall be conditional upon:
Final approval by the centers for medicare and medicaid services of any state plan amendments or waiver requests that are necessary in order to implement the applicable sections of this chapter including, if necessary, waiver of the broad-based or uniformity requirements as specified under section 1903(w)(3)(E) of the federal social security act and 42 C.F.R. Sec. 433.68(e);
To the extent necessary, amendment of contracts between the authority and managed care organizations to implement this chapter; and
Certification by the office of financial management that appropriations have been adopted that fully support the rates established in section 3 of this act for the upcoming fiscal year.
All health carriers and medicaid managed care organizations shall pay an annual covered lives assessment beginning January 1st of the plan year following the approval in section 2(2)(a) of this act as follows:
For assessments due the first plan year:
The authority shall assess a per member per month assessment of $18 per covered life for medicaid managed care organizations; and
The commissioner shall assess a per member per month assessment of $0.50 per covered life for health carriers.
On or before May 15th of the first plan year of assessments due and on or before May 15th of each subsequent year, the authority shall determine the covered lives assessment at the rate necessary to fund the professional services rate increases in section 6 of this act.
The ratio of the total assessments collected from managed care organizations and health carriers must be set as 36 to one, respectively. Assessments for each calendar year shall be set utilizing the proportion of fully insured to medicaid managed care covered lives from the previous calendar year.
The assessments as applied in subsection (1) of this section are limited to:
The first 3,000,000 member months of fully insured lives per medicaid managed care organization on a per medicaid managed care organization basis; and
The first 3,000,000 member months of fully insured lives per health carrier. For each health carrier, the assessment shall apply to member months of all group health plan lives first, followed by member months of individual health plans lives.
If an assessment against a health carrier or medicaid managed care organization is prohibited by court order, the assessment for the remaining health carriers and medicaid managed care organizations may be adjusted in a manner consistent with subsection (1) of this section to ensure that the assessment amount calculated in subsection (1)(b) of this section will be collected.
The authority shall annually notify, in writing, each medicaid managed care organization of the estimated total assessment and its payment obligation for the upcoming year. The authority shall determine a payment schedule for receipt of assessments under this section in accordance with the medicaid access program rules as defined by the authority. Payment collections may be made no more frequently than quarterly.
Payments from managed care organizations are due to the authority within 45 days of the payment schedule determined under subsection (4) of this section. The authority shall charge interest as defined by RCW 43.17.240, which begins to accrue on the 46th day, on amounts received after the 45-day period. The authority may allow each managed care organization in arrears to submit a payment plan, subject to approval by the authority and initial payment under an approved payment plan.
The authority may abate or defer, in whole or in part, the assessment of a managed care organization if, in the opinion of the authority, payment of the assessment would endanger the ability of the managed care organization to fulfill its contractual obligations under chapter 74.09 RCW. If an assessment against a managed care organization is abated or deferred in whole or in part, the amount by which such assessment is abated or deferred may be assessed against the other managed care organizations in a manner consistent with the basis for assessments in subsection (1) of this section. The managed care organization receiving such abatement or deferment remains liable to the program for the deficiency plus interest the rate established in RCW 43.17.240. Upon receipt of payment of any abatement or deferment by a managed care organization, the authority shall adjust future assessments made against other managed care organizations under this subsection to reflect receipt of the payment.
The authority shall deposit annual assessments and interest collected under this section with the state treasurer to the credit of the medicaid access program account created in section 5 of this act.
Managed care organizations shall submit any annual statements or other reports deemed necessary by the authority to calculate the assessment under this section in a manner consistent with the schedule and procedures in accordance with the medicaid access program rules as defined by the authority.
All health carriers and medicaid managed care organizations shall pay an annual covered lives assessment under section 3 of this act.
The commissioner shall assess a per member per month assessment for health carriers pursuant to section 3 of this act.
The commissioner shall annually notify, in writing, each health carrier of the estimated total assessment and its payment obligation for the upcoming year. The commissioner shall determine a payment schedule for receipt of assessments under this section in accordance with the medicaid access program rules established by the authority. Payment collections may be made no more frequently than quarterly.
Payments from health carriers are due to the commissioner within 45 days of the payment schedule determined under subsection (3) of this section. The commissioner shall charge interest as defined by RCW 43.17.240, which begins to accrue on the 46th day, on amounts received after the 45-day period. The commissioner may allow each health carrier in arrears to submit a payment plan, subject to approval by the commissioner and initial payment under an approved payment plan.
The commissioner shall deposit annual assessments and interest collected under this section with the state treasurer to the credit of the medicaid access program account created in section 5 of this act.
Health carriers shall submit any annual statements or other reports deemed necessary by the commissioner for the health care authority to calculate the assessment in a manner consistent with the schedule and procedures in accordance with section 3 of this act.
The medicaid access program account is created in the state treasury. All receipts from the assessments, interest, and penalties collected by the authority and commissioner under sections 3 and 4 of this act must be deposited into the account. Moneys in the account may be spent only after appropriation. Expenditures from the account may be used only for the administration and implementation of the medicaid access program as established in section 6 of this act.
Disbursements from the account may be made only:
To make payments to health care providers and managed care organizations;
To medicaid managed care organizations to fund the nonfederal share of increased capitation payments based on their projected assessment obligation established by the medicaid access program and the medicaid managed care rate setting process;
To refund erroneous or excessive payments made by health carriers and medicaid managed care organizations; and
To repay the federal government for any excess payments made to health care providers from the account if the assessments or payment increases set forth by the medicaid access program are deemed out of compliance with federal statutes and regulations in a final determination by a court of competent jurisdiction with all appeals exhausted. In such a case, the authority may require health care providers receiving excess payments to refund the payments in question to the account. The state in turn shall return funds to the federal government in the same proportion as the original financing. If a health care provider is unable to refund payments, the state shall develop either a payment plan, deduct moneys from future medicaid payments, or both.
The purpose of the medicaid access program is to increase, beginning January 1st of the second plan year after the conditions of section 2 of this act are met, subject to available funds and appropriations from the medicaid access program account, professional services rates covered by medicaid including fee-for-service and managed care up to the corresponding medicare rates as of December 31, 2024, for the same service and site of service. Rates for subsequent years shall be annually adjusted based on the inflation factor using the medicare economic index.
The service categories for the professional services rate increases must include anesthesia, diagnostics, intense outpatient, opioid treatment programs, emergency room, inpatient and outpatient surgery, inpatient visits, low-level behavioral health, maternity services, office and home visits, consults, office administered drugs, and other physician services. If sufficient funds are not available to increase medicaid rates to corresponding medicare rates, the authority may increase medicaid rates to a percentage of corresponding medicare rates, applied uniformly across professional service categories included in this subsection.
Nothing in this act shall be construed to alter the requirements: (1) Under 42 C.F.R. Sec. 438.4 that the rates paid by the state to managed care organizations be actuarially sound; and (2) that the state develop the rates in compliance with standards under 42 C.F.R. Sec. 438.5.
The authority may adopt rules and undertake actions necessary to carry out sections 2, 3, and 6 of this act including, but not limited to, rules prescribing the medicaid access program plan of operations, measures to enforce reporting of covered lives, audits of covered lives reporting, and payment of applicable assessments.
The commissioner may adopt rules and undertake actions necessary to carry out section 4 of this act including, but not limited to, rules prescribing the medicaid access program plan of operations, measures to enforce reporting of covered lives, audits of covered lives reporting, and payment of applicable assessments.
The medicaid access program, health carriers and medicaid managed care organizations assessed by the program, the authority, and employees of the authority are not civilly or criminally liable and may not have any penalty or cause of action of any nature arise against them for any action or inaction, including any discretionary decision or failure to make a discretionary decision, when the action or inaction is done in good faith and in the performance of the powers and duties assigned to the program. This section does not prohibit legal actions against the program to enforce the program's statutory or contractual duties or obligations.
The medicaid access program, health carriers and medicaid managed care organizations assessed by the program, the commissioner, the commissioner's representatives, and the commissioner's employees are not civilly or criminally liable and may not have any penalty or cause of action of any nature arise against them for any action or inaction, including any discretionary decision or failure to make a discretionary decision, when the action or inaction is done in good faith and in the performance of the powers and duties assigned to the program. This section does not prohibit legal actions against the program to enforce the program's statutory or contractual duties or obligations.
(1) All earnings of investments of surplus balances in the state treasury shall be deposited to the treasury income account, which account is hereby established in the state treasury.
(1) All earnings of investments of surplus balances in the state treasury shall be deposited to the treasury income account, which account is hereby established in the state treasury.
The provisions of this act are not severable. In the event that any portion of this act shall have been validly implemented and the entire act is later rendered ineffective, prior assessments and payments under the validly implemented portions shall not be affected.
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.
This act expires if by January 1, 2027, the federal centers for medicare and medicaid services does not provide final approval of the state plan amendment or waiver requests under section 2 of this act.
Section 12 of this act expires July 1, 2028.
Section 13 of this act takes effect July 1, 2028.