Washington Code 43.71.110 – Premium assistance and cost-sharing reduction program
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(1) Subject to the availability of amounts appropriated for this specific purpose, a premium assistance and cost-sharing reduction program is hereby established to be administered by the exchange.
Terms Used In Washington Code 43.71.110
- Appeal: A request made after a trial, asking another court (usually the court of appeals) to decide whether the trial was conducted properly. To make such a request is "to appeal" or "to take an appeal." One who appeals is called the appellant.
- Appropriation: The provision of funds, through an annual appropriations act or a permanent law, for federal agencies to make payments out of the Treasury for specified purposes. The formal federal spending process consists of two sequential steps: authorization
- Authority: means the Washington state health care authority, established under chapter 41. See Washington Code 43.71.010
- Exchange: means the Washington health benefit exchange established in RCW 43. See Washington Code 43.71.010
- Fraud: Intentional deception resulting in injury to another.
- person: may be construed to include the United States, this state, or any state or territory, or any public or private corporation or limited liability company, as well as an individual. See Washington Code 1.16.080
(2) Premium assistance and cost-sharing reduction amounts must be established by the exchange within parameters established in the omnibus appropriations act.
(3) The exchange must establish, consistent with the omnibus appropriations act:
(a) Procedural requirements for eligibility and continued participation in any premium assistance program or cost-sharing program established under this section, including participant documentation requirements that are necessary to administer the program; and
(b) Procedural requirements for facilitating payments to carriers.
(4) Subject to the availability of amounts appropriated for this specific purpose, an individual is eligible for premium assistance and cost-sharing reductions under this section if the individual:
(a)(i) Is a resident of the state;
(ii) Has income that is up to an income threshold determined through appropriation or by the exchange if no income threshold is determined through appropriation;
(iii) Is enrolled in a silver or gold standard plan offered in the enrollee’s county of residence;
(iv) Applies for and accepts all federal advance premium tax credits for which they may be eligible before receiving any state premium assistance;
(v) Applies for and accepts all federal cost-sharing reductions for which they may be eligible before receiving any state cost-sharing reductions;
(vi) Is ineligible for minimum essential coverage through medicare, a federal or state medical assistance program administered by the authority under chapter 74.09 RCW, or for premium assistance under RCW 43.71A.020; and
(vii) Meets any other eligibility criteria established by the exchange; or
(b) Meets alternate eligibility criteria as established in the omnibus appropriations act.
(5)(a) The exchange may disqualify an individual from receiving premium assistance or cost-sharing reductions under this section if the individual:
(i) No longer meets the eligibility criteria in subsection (4) of this section;
(ii) Fails, without good cause, to comply with any procedural or documentation requirements established by the exchange in accordance with subsection (3) of this section;
(iii) Fails, without good cause, to notify the exchange of a change of address in a timely manner;
(iv) Voluntarily withdraws from the program; or
(v) Performs an act, practice, or omission that constitutes fraud, and, as a result, an issuer rescinds the individual’s policy for the qualified health plan.
(b) The exchange must develop a process for an individual to appeal a premium assistance or cost-sharing assistance eligibility determination from the exchange.
(6) Prior to establishing or altering premium assistance or cost-sharing reduction amounts, eligibility criteria, or procedural requirements under this section, the exchange must:
(a) Publish notice of the proposal on the exchange’s website and provide electronic notice of the proposal to any person who has requested such notice. The notice must include an explanation of the proposal, the date, time, and location of the public hearing required in (b) of this subsection, and instructions and reasonable timelines to submit written comments on the proposal;
(b) Conduct at least one public hearing no sooner than 20 days after publishing the notice required in (a) of this subsection; and
(c) Publish notice of the finalized premium assistance or cost-sharing reduction amounts, eligibility criteria, or procedural requirements on the exchange’s website and provide the notice electronically to any person who has requested it. The notice must include a detailed description of the finalized premium assistance or cost-sharing reduction amounts, eligibility criteria, or procedural requirements and a description and explanation of how they vary from the initial proposal.
(7) The definitions in this subsection apply throughout this section unless the context clearly requires otherwise.
(a) “Advance premium tax credit” means the premium assistance amount determined in accordance with the federal patient protection and affordable care act, P.L. 111-148, as amended by the federal health care and education reconciliation act of 2010, P.L. 111-152, or federal regulations or guidance issued under the affordable care act.
(b) “Income” means the modified adjusted gross income attributed to an individual for purposes of determining his or her eligibility for advance premium tax credits.
(c) “Standard plan” means a standardized health plan under RCW 43.71.095.
[ 2021 c 246 § 1.]