WAC 388-505-0211   Premium requirements for premium-based children's healthcare programs.  (1) For the purposes of this chapter, "premium" means an amount paid for medical coverage.

     (2) Payment of a premium is required as a condition of eligibility for premium-based children's healthcare coverage, as described in WAC 388-505-0210(4), unless the child is:

     (a) Pregnant; or

     (b) An American Indian or Alaska native.

     (3) The premium requirement begins the first of the month following the determination of eligibility. There is no premium requirement for medical coverage received in a month or months before the determination of eligibility.

     (4) The premium amount for the assistance unit is based on the net available income as described in WAC 388-450-0005. If the household includes more than one assistance unit, the premium amount billed for the assistance units may be different amounts.

     (5) The premium amount for each eligible child is fifteen dollars per month per child, up to a maximum of forty-five dollars per month, per household.

     (6) All children in an assistance unit are ineligible for medical coverage when the head of household fails to pay required premium payments for three consecutive months.

     (7) When the department terminates the medical coverage of a child due to nonpayment of premiums, the child has a three-month period of ineligibility beginning the first of the following month. The three-month period of ineligibility is rescinded only when the:

     (a) Past due premiums are paid in full prior to the begin date of the period of ineligibility; or

     (b) The child becomes eligible for a nonpremium-based medical program. The department will not rescind the three-month period of ineligibility for reasons other than the criteria described in this subsection.

     (8) The department writes off past-due premiums after twelve months.

     (9) When the designated three-month period of ineligibility is over, all past due premiums that are an obligation of the head of household must be paid or written off before a child can become eligible for premium-based children's healthcare.

     (10) A family cannot designate partial payment of the billed premium amount as payment for a specific child in the assistance unit. The full premium amount is the obligation of the head of household of the assistance unit. A family can decide to request medical coverage only for certain children in the assistance unit, if they want to reduce premium obligation.

     (11) A change that affects the premium amount is effective the month after the change is reported and processed.

     (12) A sponsor or other third party may pay the premium on behalf of the child or children in the assistance unit. The premium payment requirement remains the obligation of head of household of the assistance unit. The failure of a sponsor or other third party to pay the premium does not eliminate the:

     (a) Establishment of the period of ineligibility described in subsection (7) of this section; or

     (b) Obligation of the head of household to pay past-due premiums.



[Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.530, 74.09.700, and 2007 c 5. 08-05-018, § 388-505-0211, filed 2/12/08, effective 3/14/08. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.522, 74.09.450, and 2004 c 276. 04-16-064, § 388-505-0211, filed 7/30/04, effective 8/30/04. Statutory Authority: RCW 74.08.090, 74.09.055, 2004 c 276. 04-08-125, § 388-505-0211, filed 4/7/04, effective 5/8/04.]