Centennial Accord Plan - Health Care Authority Programs and Services

Agency Information

Tools & Software

Statutory Authority: Chapter 41.05 Revised Code of Washington (RCW) | Title 182 Washington Administrative Code (WAC)

The HCA administers three health care programs: Basic Health (BH), Community Health Services (CHS), and Public Employees Benefits (PEBB) program. Through these programs, HCA is able to provide access to high-quality health care for more than 500,000 Washington residents. The HCA also oversees the Uniform Medical Plan (UMP), a state-administered, self-insured preferred provider plan that is available to those covered under PEBB. Additionally, the HCA is responsible for development of the Prescription Drug Program (PDP) as mandated by RCW 70.14.

Funding for HCA programs is authorized by the legislature to provide health service delivery to those eligible for participation in the PEBB and BH, as well as to Community Health Services grant awardees. State funding for BH and CHS is from the Health Services Account (HSA). State funding for PEBB is made to HCA from a variety of state agency fund sources.

HCA Organizational Structure

Executive Services
Communications
Health Care Policy
Office of the Medical Director
Performance and Strategic Initiatives Programs
Basic Health (BH)
Community Health Services (CHS)
Prescription Drug Program (PDP)
Public Employees Benefits Board (PEBB)
Uniform Medical Plan (UMP)
Financial Services
Human Resources
Information Services
Internal Audit
Legal Services

HCA Mission and Vision

The HCA’s mission is to make affordable, quality health care more accessible.

The HCA’s vision is to deliver the best value in health care.

Make cost effective, high quality benefits accessible for all our enrollees
Provide excellent service to all customers
Reduce the rate of growth in health care costs
Improve, simplify, and streamline operational efficiencies across all divisions
Promote a performance based culture of mutual respect, open communication, accountability, and employee development

Basic Health (BH)

Statutory Authority: RCW 70.47 | Chapter 182-25 WAC

Basic Health is a state-sponsored program that provides health care coverage to low-income Washington residents whose incomes fall below 200% of the federal income guidelines (FIG). Monthly premiums are based on family size, income, age, and the health plan selected. Coverage is available to eligible Washington residents through five contracted health plans.

For those who qualify for BH, state funds are used to help pay a portion of the monthly premium. Members may pay as little as $17 per month for each enrolled adult. To qualify, applicants must meet BH’s income guidelines, live in Washington State, not be eligible for Medicare, and not be in the country on a temporary student visa, and not institutionalized at the time of enrollment.
Basic Health is currently at its capacity of 100,000. However, the program is accepting applications. There may be a delay in getting BH coverage while waiting for an open space.

Copayments or coinsurance are required for most services, with the exception of preventive care, skilled nursing, hospice, home health, and maternity care. There is an annual deductible of $150 per person and an out-of-pocket maximum of $1,500 per person, per year applied to coinsurance after payment of the deductible (copays still apply).

Basic Health Financial Sponsor Program

Statutory Authority: RCW 70.47.010(5)(b) and 70.47.060(2)(c) | Chapter 182-25-070 WAC

The Financial Sponsor Program allows employers and other financial sponsors to assist in purchasing health care by paying all or a portion of the premiums on behalf of their eligible enrollees.

Services Available to Tribes: Tribes, like other financial sponsors, may pay all or a portion of the premiums for their enrollees and assist them with the BH application process. Tribes and members participate in BH through a contractual agreement with the HCA. Currently, BH has sponsorship agreements with the Jamestown S'Klallam Tribe, the Lower Elwha Klallam Tribe, the Lummi Tribe, the Port Gamble S'Klallam Tribe, the Quileute Tribe, the Quinault Nation, the Shoalwater Bay Tribe, and Squaxin Island Tribe to provide BH coverage to eligible tribal members through the BH Financial Sponsor program.

Funding Currently Available to Tribes: Funding is not allocated specifically to tribes.

Consultation Processes and Procedures: Varying degrees of consultation and coordination may be initiated by contacting the operational staff, the Tribal Liaison, or through communication with the BH Assistant Administrator, the Deputy Administrator and/or the HCA Administrator. Operations staff must inform the Tribal Liaison of all tribal communications as per agency protocol.

The quarterly tribal sponsor meetings, Basic Health Advisory Board, and the American Indian Health Commission for Washington State will be used as venues for ongoing communication and coordination. Consultation will be held in accordance with the HCA Consultation Policy.

Dispute Resolution Process: There is a BH specific process to allow individual enrollees to appeal BH decisions. Tribal representatives may assist tribal enrollees in this process.

Community Health Services (CHS)

Statutory Authority: RCW 41.05.220 | Chapter 182-20 WAC

The CHS program promotes access to quality and affordable health care for the uninsured, underinsured. In state fiscal year 2005, CHS funded 33 community health clinic contractors to provide access to medical and dental primary care for people at/or below 200% of FIG. This access provided for more than 227,000 medical and 56,000 dental patients without insurance to be served.

CHS strategies to provide health care access:

Collaboration with other agencies in community health needs assessment identifying and employing effective, innovative projects and interventions.
Be active participants and maintaining open lines of communication with agencies and tribes.
Develop quality improvement initiatives to monitor and measure the quality of services provided by contracted safety net clinics.

CHS coordinates and manages relationships between HCA and tribes by:

Working with the Governor's Office of Indian Affairs, tribal entities, and tribal organizations to minimize health care barriers and enhance quality of health care.
Collaborating with tribes and tribal entities to identify opportunities for partnerships.

Services Available to Tribes: CHS funds two urban Indian clinics and two tribal operated clinics, including: Port Gamble S'Klallam Tribe, Seattle Indian Health Board, Shoalwater Bay Tribe and the Spokane N.A.T.I.V.E. Project.

Funding Currently Available to Tribes: Tribal organizations may compete for state grant funding.

Consultation Processes and Procedures: Varying degrees of consultation and coordination may be initiated by contacting the operational staff, the Tribal Liaison, or through communication with the CHS Executive Director, the Deputy Administrator and/or the HCA Administrator. Operations staff must inform the Tribal Liaison of all tribal communications as per agency protocol.

The American Indian Health Commission for Washington State will be used as a venue for ongoing communication and coordination. Consultation will be held in accordance with the HCA Consultation Policy.

Dispute Resolution Processes: CHS dispute resolution is defined in the grant award contracts.

Prescription Drug Program (PDP)

Statutory Authority: RCW 70.14 | Chapter 182-50 WAC

The PDP is continuing to develop the state’s evidence-based preferred drug list as mandated by RCW 70.14. In addition, by January 2006, the HCA will establish a “Prescription Drug Purchasing Consortium” as directed by the legislature in SSB 5471. The consortium will be open to Washington residents who have no prescription drug insurance, as well as those who have prescription drug insurance, but whose insurance plans do not cover the particular drugs they need. The consortium also will be open to local government entities, businesses and labor organizations. There is no income or other eligibility requirement. Participants will be charged an enrollment fee for participation.

Although the final structure of the consortium has not been established, the PDP is developing the program with the following principles in mind:

Affordability: maintaining low membership fees to gain access to discounts ranging from 15 to 20 percent on prescription drugs.
Accessibility: creating easy to use enrollment procedures to give access to prescription drug discounts from local retail pharmacies, or through mail order delivery.
Flexibility: continuing to develop additional options to be offered to consortium participants.

The PDP will continue to be responsible for developing the preferred drug list and for negotiating prescription drug price discounts for state agencies. The PDP will endeavor to negotiate similar discounts for Washington State residents and make them available through the Prescription Drug Purchasing Consortium.

This program is in the early stages of development.

Services Available to Tribes: Not specific to tribes, but they may be eligible to participate.

Funding Currently Available to Tribes: Funding not specific to tribes.

Consultation Processes and Procedures: Consultation and coordination may be initiated by contacting the Tribal Liaison or through communication with the PDP Manager, the Deputy Administrator and/or the HCA Administrator. Operations staff must inform the Tribal Liaison of all tribal communications as per agency protocol.

Dispute Resolution Processes: Not applicable.

Public Employees Benefits Board (PEBB)

Statutory Authority: RCW 41.05 | Chapters 182-08 and 182-12 WAC

The state of Washington provides health benefits and related insurance coverage to all eligible state and higher-education employees as a benefit of employment. In addition, K-12 school districts and local government entities (such as ports, cities, and water districts) also may choose to join PEBB plans.

The Public Employees Benefits Board, created within HCA, establishes eligibility requirements and approves plan benefits of all participating health care organizations. The PEBB program administers medical, dental, life and long-term disability insurance coverage for eligible employees. Most coverage is available on a self-paid or partial self-paid basis to eligible retirees, former employees and employees who are temporarily not in pay status.

Services Available to Tribes: Tribes currently do not receive services under PEBB.

Funding Currently Available to Tribes: Tribes currently are not eligible for PEBB.

Consultation Processes and Procedures: Consultation and coordination may be initiated by contacting the Tribal Liaison or through communication with the PEBB Assistant Administrator, the Deputy Administrator and/or the HCA Administrator. Operations staff must inform the Tribal Liaison of all tribal communications as per agency protocol.

Dispute Resolution Processes: Tribes currently are not eligible for PEBB.

Uniform Medical Plan (UMP)

Statutory Authority: RCW 41.05.140

The UMP is a self-insured, preferred provider health insurance plan available to public employees, both active and retired, and their dependents. It is administered by the HCA, and is offered only to those covered through PEBB. Coverage is available worldwide.

UMP doesn't have a contractual relationship with tribes. However, when individual tribal members are enrolled in UMP, services at tribal health clinics are billed to UMP and paid at the same rate as network providers. Although UMP does not have contracts with tribal clinics, it covers the services as if there were.

Prescriptions purchased at tribal health clinics may be processed through Express Scripts, UMP's pharmacy benefit management administrator, by submitting a paper claim if the pharmacy is not on line with ESI.

Services Available to Tribes: Tribes currently do not receive services under PEBB.

Funding Currently Available to Tribes: Tribes currently are not eligible for PEBB.

Consultation Processes and Procedures: Consultation and coordination can be initiated by contacting the Tribal Liaison or through communication with the UMP Assistant Administrator and/or the HCA Administrator. Operations staff must inform the Tribal Liaison of all tribal communications as per agency protocol.

Dispute Resolution Processes: Although UMP does not have a contractual relationship with Tribes, if tribal clinics experience problems with billing or claims they are encouraged to contact the HCA Tribal Liaison or the UMP Assistant Administrator. Individual tribal members should follow appeals processes outlined in their UMP Certificate of Coverage.

Health Care Policy (HCP)

Statutory Authority: RCW 41.05

Health Care Policy formulates agency health care policy, provides data-driven research on emerging health care policy issues, and develops evidence based strategies through collaboration with other state and private health care purchasers, health care providers and carriers. HCP coordinates HCA’s legislative activity and legislative bill review process. HCP also manages various agency and inter-agency policy projects and studies, including legislative studies.

HCP coordinates health care purchasing and health plan contract management for PEBB and BH. This includes providing program support in developing, negotiating and enforcing health care contracts and monitoring contract performance through the development of contractor performance expectations. HCP also coordinates initiatives with other state agencies and interested purchasers to maximize state purchasing leverage, including the development of data-driven purchasing methodologies, strategies and tools to achieve cost containment, access and quality.

HCP implements stakeholder plans in support of HCA programs and is a health policy liaison with key external stakeholders, including the health plans, consumers, providers, legislators, legislative staff, and the Governor’s office. HCP provides health policy consultation and technical assistance to HCA programs and stakeholders, including analysis and review of proposed legislation.

Initiative Seeking Tribal Participation

SSB 5064, the health information technology and electronic medical records (EMR) bill, was passed last session. It requires the HCA, along with a Health Information Infrastructure Advisory Board (HIIAB) to develop a strategy for the adoption and promotion of Health IT and EMRs in Washington State that complies with other requirements for interoperability, privacy, security, etc.

The Board is comprised of twelve members that have been appointed and mostly designated by legislation. An interim report is due to the Legislature in December, 20005 and a final report with strategy recommendation(s) by December 2006. HCA is providing for wider participation through a Health Information Stakeholder Advisory Committee (HIISAC) that can provide continuous feedback and in-put into this activity.

HCP is seeking to appoint tribal representative to Health Information Stakeholder Advisory Committee (HIISAC) to actively participate in providing feedback and input to the HCA and the Board in development of the overall strategy required in the legislation.

Consultation Processes and Procedures: Consultation and coordination can be initiated by contacting the Tribal Liaison or through communication with the Director of Health Care Policy, the Deputy Administrator and/or the HCA Administrator. Staff must inform the Tribal Liaison of all tribal communications as per agency protocol.

Office of the Medical Director

Statutory Authority: RCW 41.05.015

The Office of the Medical Director plays a major role in pursuing HCA’s vision while HCA achieves its mission to make affordable, quality health care more accessible to eligible public employees (PEBB), covered BH members and individuals accessing community health clinics supported by grants from the CHS.

The Office of the Medical Director is responsible for:

Oversight and establishment of health care related policy;
Development of quality standards and determining appropriateness of health care services rendered to enrollees;
Leadership and management of the monitoring and compliance program developed to ensure contractor’s fulfillment with HCA’s quality standards;
Assuring clinical appropriateness of HCA decisions on benefits, appeals and health policy;
Oversight of PEB contracted plans, UMP, and serves as the designated Medical Director for the BH;
Advises HCA Administrator on benefits package design;
Acts as spokesperson for the agency with provider organizations;
Manages annual site monitoring of contracted plans related to effective utilization management and quality care provisions;
Makes recommendations regarding future contractual requirements and compliance based on monitoring reviews and (national and state) quality initiatives; and
Leads projects in conjunction with legislative initiatives on topics such as wellness, chronic disease, long term care, certificate of need, health technology assessment and electronic medical records.

Consultation Processes and Procedures: Consultation and coordination can be initiated by contacting the Tribal Liaison or through communication with the Medical Director, Deputy Administrator and/or the HCA Administrator. Staff must inform the Tribal Liaison of all tribal communications as per agency protocol.