Centennial Accord Plan - Health Care Authority Programs and Services

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Health Care Authority (HCA)

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

The HCA, a cabinet level agency, oversees

Basic Health (BH)
Community Health Services (CHS)
Health Insurance Partnership (HIP) (New Program Established in 2008)
Health Technology Assessment (HTA)
Prescription Drug Program (PDP)
Public Employees Benefits Board (PEBB) programs
Public Employees Health Plans (PEHP)
Washington Wellness (WW)

The HCA administers health care benefits for more than 500,000 Washington residents through the BH program for low-income residents and the PEBB program for state government workers and retirees. With the passage of Senate Bill 5640 in the 2007 legislative session, employees of tribal governments may apply to participate in PEBB insurance coverage effective January 1, 2009. The HCA also helps expand access to health care through grant programs administered by CHS and other agency programs that encourage the use of evidence-based practices, promote health information technology, and help consumers make informed health care decisions.

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

HCA Mission and Vision

Vision: Shaping the Future of Health Care.
Mission: HCA is a leader in health care policy, purchases quality health care and other benefits, and provides excellent services for its programs.

HCA Strategic Plan 2007-09

Goals 2007-09

Cost: Make PEBB and BH more affordable for participants and the state.
Quality: Improve the quality of care delivered through the PEBB and BH programs.
Leadership: Lead in the statewide expansion of access to quality, affordable care.
Performance: Build a high performance HCA organization.

HCA Administrator

Steve Hill was appointed in April 2005 by Governor Christine Gregoire to serve as the Administrator of the Washington State Health Care Authority; he is a member of the Governor's Health Policy team. The Governor’s Health Policy team is leading the state's effort in effective uses of technology, consumer incentives, wellness promotion, and other avenues to improve access to affordable, quality health care. The HCA Administrator directly oversees HCA’s Financial & Contract Services, Health Care Policy, and Public Affairs. Agency-tribal relations are also under the direct authority of the HCA Administrator, who provides leadership in state-tribal government-to-government relations. The role of the HCA Administrator is to establish, implement and continue to enhance government-to-government policies in recognition of the unique legal status of federally recognized tribes as sovereign nations with specific rights assured through historic treaties that create a unique relationship between tribes and state agencies. The Administrator meets routinely with the agency tribal liaison, who reports directly to the Administrator on tribal issues.

HCA Tribal Liaison

Jan Ward Olmstead has served as HCA’s Tribal Liaison since 2003. The Tribal Liaison’s role, at the direction of the HCA Administrator, is to coordinate and manage relationships between the HCA and tribes by:

Acting as the point of contact for tribes, tribal organizations, and federal, state, and local agencies on tribal issues relative to the HCA.
Collaborating with tribes and tribal entities to identify opportunities for partnerships in program areas.
Working with internal staff, the Governor’s Office of Indian Affairs, tribal entities, and tribal organizations to minimize health care barriers and enhance quality of health care.
Providing regular updates and briefings to the HCA Administrator.

Jan can be reached by phone at 360-923-2803 or by e-mail. Organizationally, the tribal program is in CHS.

HCA Deputy Administrators

Beth Dupre, Deputy Administrator, is responsible for the HCA’s daily operations, including the delivery of services. She ensures that policies are in place, staff is adequately trained, and appropriate procedures are followed. Her role in tribal relations is to ensure staff awareness of the HCA’s Centennial Accord Plan and government-to-government policies and to make improvements in HCA’s organizational infrastructure to enhance consultation and collaboration. Beth has direct authority over the Benefits Administration and Insurance Accounting System (BAIAS) project, BH Procurement, Human Resources & Administration Services, Legal Services, Print & Production Services, BH, CHS, Information Services, Performance & Accountability, and PEBB. Beth was the HCA's Assistant Administrator for BH prior to her appointment as Deputy Administrator in May 2006.

John Williams, Deputy Administrator, was appointed in October 2007 to serve as a Deputy Administrator in the HCA. He is responsible for benefits administration, including policy development, planning, and management of the health benefits programs delivered to customers. John has direct authority over: HTA, PEBB procurement, PEHP, Office of the Medical Director (OMD), PDP, and WW. John’s role in tribal relations is to improve organizational infrastructure to support cultural competencies in health care delivery and evidence based practices.

HCA Organizational Structure

Programs

Basic Health (BH)
Community Health Services (CHS)
Health Insurance Partnership (HIP)
Health Technology Assessment (HTA)
Prescription Drug Program (PDP)
Public Employees Benefits Board (PEBB)
Public Employees Health Plans (PEHP)
Prescription Drug Program (PDP)

Support Divisions

Financial and Contract Services
Health Care Policy
Human and Administrative Resources
Information Services
Legal Services
Office of the Medical Director
Print and Production Services
Public Affairs

Basic Health (BH)

Statutory Authority: RCW 70.47 | Chapter 182-25 WAC

Basic Health is a state-sponsored program which offers health care coverage to income-eligible 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. Currently, coverage is available in all Washington counties.

For those who qualify for BH, state funds are used to help pay a portion of the monthly premium. To qualify, applicants must meet BH income guidelines, live in Washington State, not be eligible for Medicare, not be in the country on a temporary student visa, and not institutionalized at the time of enrollment.

Members may pay low monthly premiums for each enrollee. BH has an annual deductible, out-of-pocket yearly maximum, coinsurance, and copayments.

Basic Health Financial Sponsor Program

Statutory Authority: RCW 70.47.010(b) and .060(2) (d) | 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 tribal sponsorship agreements with the Jamestown S’Klallam, Kalispel, Lower Elwha Klallam, Lummi, Makah, Port Gamble S’Klallam, Quileute, Quinault, Shoalwater Bay, and Squaxin Island Tribes to provide BH coverage to eligible tribal members.

Funding Currently Available to Tribes: Not applicable.

Consultation Processes and Procedures: Varying degrees of consultation and coordination may be initiated by contacting the operations staff, or the Tribal Liaison, or through communication with the BH Assistant Administrator, the Deputy Administrators or the HCA Administrator. Agency protocol requires the operations staff to inform the Tribal Liaison of tribal communication.

Tribal sponsor meetings, the BH 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 specific process to allow individual enrollees to appeal BH decisions. Tribal representatives may assist tribal enrollees in this process.

Community Health Services (CHS) Grant Program

Statutory Authority: RCW 41.05.220 | Chapter 182-20 WAC

CHS offers grants to not-for-profit health organizations and other community based organizations that provide primary health services to people at or below 200 percent of the Federal Income Guideline. Tribal organizations may compete for any CHS state grant.

CHS currently funds the following Tribes or Urban Indian Clinics:

Port Gamble S’Klallam Tribe
Seattle Indian Health Board
Shoalwater Bay Indian Tribe
Stillaguamish Tribe of Indians
The N.A.T.I.V.E. Project
Makah Tribe

Community Health Care Collaborative (CHCC) Grant Program

The 2006 Legislature established this competitive grant program to provide funding to community based organizations that serve low-income individuals who are uninsured or underinsured. The goals of the program are to: 1) increase access to medical treatment, 2) use health care resources efficiently, and 3) improve quality of care. The focus of the program is to foster innovative health care delivery models that can be replicated by other organizations throughout the state. Port Gamble S’Klallam Tribe is a recipient of this grant.

Adult Dental Access (ADA) Grant Program

The 2008 Legislature established this competitive grant program to increase access to dental care for adults. It is a one time grant that increases the number of adult dental services by funding any of the following four areas: 1) purchase of equipment, 2) remodel of existing f acilities, 3) new construction, or 4) recruitment of staff. Shoalwater Bay Tribe and Seattle Indian Health Board are recipients of this grant.

HCA Tribal Relations Program

The HCA tribal program operates organizationally within CHS.

Funding Currently Available to Tribes : Tribes may participate in the competitive grant process.

Consultation Processes and Procedures: Varying degrees of consultation and coordination may be initiated by contacting the operations staff, or the Tribal Liaison, or through communication with the CHS Executive Director, the Deputy Administrators, or the HCA Administrator. Agency protocol requires the operations staff to inform the Tribal Liaison of tribal communication.

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 procedures are defined in the grant award contracts.

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.

In recent legislative sessions, the HCA was directed to implement several new programs or projects related to both the Governor’s five-point plan for improving health care and the Blue Ribbon Commission final report. The initiatives that HCP is responsible for include:

Health information technology and electronic medical records. Originally authorized in 2005, the HCA with a Health Information Infrastructure Advisory Board produced a final report in December, 2006. The HCA was then directed to implement its recommendations for a consumer centric Health Record Bank (HRB) system in 2007 legislation.
Health Insurance Partnership (HIP). Authorized in 2007 legislation, the HIP will provide subsidies for employees of small business to purchase health insurance. It is directed to be operational by early 2009.
Quality Forum. Authorized in 2007 legislation, the Quality Forum (QF) supports the Governor’s data transparency goal to make quality, cost, and performance information in the health care system available to consumers, providers, and policy makers.

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.

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, or the HCA Administrator. Agency protocol requires the operations staff to inform the Tribal Liaison of tribal communications.

Health Technology Assessment (HTA)

Statutory Authority: RCW 70.14.100 | 182-55 WAC

The Health Technology Assessment Program is leading the state’s effort to make health policy and coverage decisions that result in safer health care. The primary goals are to make:

Health care safer by relying on scientific evidence and a committee of practicing clinicians to decide which technologies have proven value.
Coverage decisions of state agencies more consistent.
State purchased health care more cost effective.
Coverage decision processes more open and inclusive by sharing information, holding public meetings, and publishing decision criteria and outcomes.

The program acts as a resource to five participating agencies by sorting through a flood of information about selected medical technologies and producing independent reports that analyze the information and assess the quality of evidence. The program also provides transparency and consistency to industry stakeholders by publishing evaluation criteria, inviting comments, holding open public meetings, and contracting for independent reports. Finally, coverage decisions are made by the Health Technology Clinical Committee (HTCC), an independent committee of health practitioners who review evidence on these medical devices, procedures, and tests to ensure they are safe, work as promoted, and provide value.

All of the independently produced assessment reports are available online for other health care organizations to use as a resource to help them make similar decisions about where to focus limited health care dollars to ensure delivery of safe care that has maximum value and benefit to patients.

Services Available to Tribes: Not applicable.

Funding Currently Available to Tribes: Not applicable.

Dispute Resolution Processes: Not applicable.

Consultation Processes and Procedures: Consultation and coordination may be initiated by contacting the Tribal Liaison or through communication with the HTA Director, the Deputy Administrator, or the HCA Administrator. Agency protocol requires the operations staff to inform the Tribal Liaison of tribal communications.

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 medical 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.
Serves as designated Medical Director for BH and the HCA.
Advises the 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.
Coordinates with other agency medical directors though the Agency Medical Directors Group on health technology assessment, administrative simplification, patient safety, and quality initiatives.

Consultation Processes and Procedures: Consultation and coordination can be initiated by contacting the Tribal Liaison or through communication with the Medical Director, Deputy Administrator or the HCA Administrator. Agency protocol requires the operations staff to inform the Tribal Liaison of tribal communications.

Prescription Drug Program (PDP)

Statutory Authority: RCW 70.14 | 182-50 WAC

The Prescription Drug Program is continuing to develop the state’s evidence-based preferred drug list as mandated by RCW 70.14. In addition, in February 2007, the HCA implemented the Washington Prescription Drug Program (WPDP) which allows state agencies, local governments, private businesses, and individual Washington residents to pool their purchasing power to negotiate lower prescription drug prices. WPDP is a Washington State Health Care Authority program administered by northwest-based ODS Companies through its pharmacy benefit management partner, MedImpact.

The WPDP offers a new prescription drug discount card program that is open to all Washington State residents who do not have prescription drug insurance coverage, or whose insurance does not cover all their prescription drug needs. There are no other eligibility requirements or fees required for membership in the WPDP discount card program.

Although it is not an insurance program, WPDP discount card users can receive discounts prices on drugs very similar to those available to large health insurance companies. All prescriptions legally prescribed by a person authorized to prescribe drugs are eligible for a discount and can be purchased at participating retail pharmacies, or by mail-order.

Discounts vary depending on whether a drug is generic or brand name. On average, members can save up to 60% on generic drugs and 20% on brand name drugs. At the end of March 2008, more than 76,000 Washington residents had enrolled in the WPDP discount program.

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

Funding Currently Available to Tribes: Not Applicable.

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, or the HCA Administrator. Agency protocol requires the operations staff to inform the Tribal Liaison of tribal communications.

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 may choose to participate in PEBB insurance coverage and local government entities (such as ports, cities, and water districts) may apply to participate in PEBB insurance coverage.

With the passage of Senate Bill 5640 in the 2007 legislative session, state law extends PEBB eligibility to tribal employees engaged in “essential government functions” to participate in medical, dental, life, and long-term disability coverage through private health insurance plans as a benefit of employment. Tribes will follow the same conditions and requirements as counties, municipalities, and other political subdivisions, effective January 1, 2009.

PEBB, a division of the HCA, establishes eligibility requirements and approves the 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 on unpaid leave temporarily.

Services Available to Tribes: As of January 1, 2009, employees of tribal governments which successfully apply to PEBB may receive all of the benefits offered to local governments under PEBB.

Funding Currently Available to Tribes: Tribes that participate in PEBB must use tribal resources to purchase PEBB benefits.

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, or the HCA Administrator. Agency protocol requires the operations staff to inform the Tribal Liaison of tribal communications.

Dispute Resolution Processes: The HCA will incorporate consistent language in interlocal agreements with tribes that includes a provision for a jointly appointed dispute board to make determinations regarding disputes. In addition, both parties will have the option of requesting intervention by the Governor. These processes will not modify or reduce the Indian Nation’s rights to judicial proceedings.

Public Employees Health Plans (PEHP)

(Includes Uniform Medical Plan (UMP) and Aetna Public Employees Plan)

Statutory Authority: RCW 41.05.143

The Public Employees Health Plans division of HCA manages the Uniform Medical Plan (UMP) as well as the Aetna Public Employees Plan, a new PEBB plan that started January 1, 2008. Some administrative services and the provider network for the Aetna Public Employees Plan are provided by Aetna, a national carrier. Both UMP and the Aetna plan are self-insured, preferred provider health plans. In 2008, they provide health coverage to over 200,000 public employees, retirees, and dependents. They are available only to those covered through PEBB.

UMP covers services from most providers but usually pays more if the provider is in its network. Coverage is available worldwide. With a few exceptions, the Aetna Public Employees Plan only covers services from Aetna network providers. It is available anywhere in the continental US.

When a UMP or Aetna Public Employees Plan enrollee goes to a tribal health clinic, these plans will pay the clinic’s claims at the same rate as network providers. This happens regardless of whether the tribal health clinic is contracted with the plan or is shown in its provider network directory.

Prescriptions purchased at tribal health clinics may be processed through Washington State Prescription Services, PEHP’s pharmacy benefit manager, by submitting a paper claim if the pharmacy does not bill online.

Services Available to Tribes: Tribes may apply to participate in PEBB benefit programs beginning January 1, 2009. Members choose from among several PEBB health plans with different benefits and premium charges.

Funding Currently Available to Tribes: If tribal members are covered through PEBB and choose either UMP or the Aetna Public Employees Plan for health coverage, services from tribal health clinics will be reimbursed as network benefits.

Consultation Processes and Procedures: Consultation and coordination can be initiated by contacting the Tribal Liaison or through communication with the PEHP Assistant Administrator or the HCA Administrator. Agency protocol requires the operations staff to inform the Tribal Liaison of tribal communications.

Dispute Resolution Processes: If tribal clinics experience problems with billing or claims, they are encouraged to contact the HCA Tribal Liaison or the PEHP Assistant Administrator. Individual tribal members should follow appeals processes outlined in their health plan’s Certificate of Coverage.

Washington Wellness (WW)

Statutory Authority: SB5930, section 40.

Washington Wellness works to make healthy choices easier for state employees, retirees, and their dependents, improve the productivity of state employees, and positively impact the medical cost trend of enrollees in state health plans.

Services Available to Tribes: Not applicable.

Funding Currently Available to Tribes: Not applicable.

Dispute Resolution Processes: Not applicable.