Health coverage access

AN ACT Relating to assuring equity in health coverage; amending 1
RCW 43.71.020, 43.71.110, and 43.71.120; adding a new section to 2
chapter 74.09 RCW; adding a new section to chapter 43.71 RCW; and 3
creating a new section. 4
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF WASHINGTON:5
NEW SECTION. Sec. 1. (1) The legislature finds the following:6
(a) Washington is home to more than 1,000,000 immigrants who 7
strengthen the state's economy, attend school, work, and pay taxes, 8
but are structurally excluded from the social safety net;9
(b) Individuals with health insurance coverage have better health 10
outcomes than those who lack coverage. Uninsured individuals are more 11
likely to be in poor health and more likely to delay or forego needed 12
health care services, which ultimately drives up the cost of care;13
(c) Federal law unjustly excludes certain categories of 14
immigrants from receiving affordable health coverage. As a result, 15
immigrants are disproportionately uninsured and at risk for poor 16
health outcomes. In 2021, undocumented immigrants had an uninsured 17
rate six times that of United States citizens; 18
(d) Washington has a long history of working toward equity in 19
immigrant health coverage. The state's basic health program covered 20
low-income residents without regard to immigration status until it 21
H-0485.1
HOUSE BILL 1482
State of Washington 69th Legislature 2025 Regular Session
By Representatives Thai, Macri, Doglio, Davis, Reed, Ramel, Parshley,
Santos, Salahuddin, Ormsby, Scott, Pollet, Hill, and Simmons
Read first time 01/21/25. Referred to Committee on Health Care &
Wellness.
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was dismantled in anticipation of affordable care act reforms which 1
have proven to be insufficient in addressing the disparity in 2
coverage. By contrast, the state's "cover all kids" law was retained 3
and continues to be successful in reducing immigration-related 4
inequity among Washington's children. In recent years, the Washington 5
state legislature has worked to fill this gap by funding apple health 6
expansion for fiscal year 2025 and by providing state subsidies that 7
have been accessible to immigrant community members through the 8
purchase of health insurance through Washington's Cascade care 9
savings program; and 10
(e) There are remaining opportunities for the state to seek 11
federal flexibility to cover immigrants otherwise excluded from 12
federal health programs, including funding apple health expansion to 13
cover all income-eligible persons and subsidize qualified health and 14
dental plans to bring their costs into parity with the affordable 15
care act subsidized plans. 16
(2) The legislature intends to: 17
(a) Improve the health of all people in the state by extending 18
health coverage options at parity to all Washington residents, 19
regardless of immigration status, by: 20
(i) Codifying a state medicaid equivalent program which is 21
accessible at no cost to people who meet income eligibility standards 22
for federal medicaid or federal insurance affordability programs, 23
except for their immigration status; and 24
(ii) Extending financial assistance for qualified health plans 25
and qualified dental plans for enrollees who are ineligible for 26
federal advance premium tax credits due to federal immigration status 27
restrictions. 28
(b) Work towards equity in providing culturally diverse and 29
linguistically appropriate care through these programs.30
NEW SECTION. Sec. 2. A new section is added to chapter 74.09 31
RCW to read as follows: 32
(1) The apple health expansion program is established. Under the 33
program, the authority shall provide health coverage to individuals 34
who: 35
(a) Are at least 19 years old; 36
(b) Have a countable income that is at or below 138 percent of 37
the federal poverty level, adjusted for family size and determined 38
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annually by the federal department of health and human services using 1
the modified adjusted gross income methodology; and2
(c) Are ineligible for federal assistance affordability programs, 3
including medical assistance, as defined in the social security Title 4
XIX state plan, and federal advance premium tax credits, due to 5
immigration status restrictions. 6
(2) The amount, scope, and duration of health care services 7
provided to individuals under this section must be no less than, and 8
the cost of coverage for those health care services must be no more 9
than, that provided to individuals eligible for categorically needy 10
medical assistance, with the exception of long-term services and 11
supports. 12
(3) The authority shall use the same eligibility, enrollment, and 13
appeals procedures as those used for categorically needy medical 14
assistance, except where flexibility is necessary to maintain privacy 15
or minimize burden to applicants or enrollees. 16
(4) The authority shall manage its application and renewal 17
procedures to maximize enrollment of eligible individuals, including 18
assuring a seamless transition for individuals losing eligibility for 19
other coverage, including child, pregnancy and postpartum, or 20
emergency coverage. 21
(5)(a) The authority shall establish the community accountability 22
committee for apple health expansion. The community accountability 23
committee shall adopt a charter establishing its scope of work, 24
structure, limitations, and responsibilities. The authority shall 25
provide administrative and research support to the committee.26
(b) The committee shall consist of at least five and no more than 27
nine geographically diverse members. The majority of the members must 28
be either representatives of community-based organizations working 29
directly with enrollees of the apple health expansion program or 30
enrollees of the apple health expansion program themselves. The 31
remaining committee members may be either service providers from the 32
apple health expansion program or representatives of organizations 33
working with or supporting the program. Members may not have a 34
conflict of interest with managed care organizations or their 35
affiliated entities. A chair shall be selected from the members of 36
the committee by a majority vote of the committee. After the initial 37
members are appointed, vacancies must be filled with the mutual 38
agreement of the committee members and the agency. The committee is a 39
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class one group under RCW 43.03.220 and eligible committee members 1
shall receive stipends in accordance with that section.2
(c) The committee shall monitor the performance of managed care 3
organizations and provide recommendations to the authority to 4
maximize accountability to enrollees and the community-based 5
organizations that support the enrollees. The authority shall 6
incorporate the recommendations of the committee into contracting 7
activities, state plan amendments, and enforcement activities. The 8
committee shall focus on the effectiveness of services, quality of 9
outcomes, and contractual compliance of the managed care 10
organizations providing services under the program. The committee 11
must have ready access to data to gauge managed care organization 12
system performance, including enrollee demographic information, 13
language access service utilization data, grievance and complaint 14
data, and information regarding contract noncompliance.15
(d) The committee shall submit a report to the appropriate 16
committees of the legislature and the office of financial management 17
with recommendations from the committee regarding opportunities to 18
maximize accountability to the community in contracting and 19
contractual compliance by July 1, 2026, and every two years 20
following. 21
(6) The authority shall submit a report to the appropriate 22
committees of the legislature and the office of financial management 23
on the status and cost of the phased-in services described in this 24
section by July 1, 2026. The authority may contract with consultants 25
and partner with other agencies, as needed, to develop these reports.26
(7) The authority shall adopt rules to implement this section.27
NEW SECTION. Sec. 3. A new section is added to chapter 43.71 28
RCW to read as follows: 29
The exchange, in collaboration with the authority, shall 30
establish and maintain a culturally and geographically diverse and 31
linguistically appropriate immigrant health coverage outreach and 32
education campaign, including direct support to community-based 33
partners. For the purposes of the campaign, direct support is 34
established by providing funding directly to community-based 35
organizations, rather than third-party contractors and consultants, 36
that: (1) Serve impacted communities by providing services directly 37
to immigrant and refugee communities; and (2) are able to demonstrate 38
a direct link to individual impacted community members. The campaign 39
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shall continue until there is parity between insurance coverage rates 1
for immigrants and citizens. 2
Sec. 4. RCW 43.71.020 and 2018 c 44 s 2 are each amended to read 3
as follows: 4
(1) The Washington health benefit exchange is established and 5
constitutes a self-sustaining public-private partnership separate and 6
distinct from the state, exercising functions delineated in chapter 7
317, Laws of 2011. By January 1, 2014, the exchange shall operate 8
consistent with applicable federal law subject to statutory 9
authorization. The exchange shall have a governing board consisting 10
of persons with expertise in the Washington health care system and 11
private and public health care coverage. The membership of the board 12
shall be appointed as follows: 13
(a) Each of the two largest caucuses in both the house of 14
representatives and the senate shall submit to the governor a list of 15
five nominees who are not legislators or employees of the state or 16
its political subdivisions, with no caucus submitting the same 17
nominee. 18
(i) The nominations from the largest caucus in the house of 19
representatives must include at least one employee benefit 20
specialist; 21
(ii) The nominations from the second largest caucus in the house 22
of representatives must include at least one health economist or 23
actuary; 24
(iii) The nominations from the largest caucus in the senate must 25
include at least one representative of health consumer advocates;26
(iv) The nominations from the second largest caucus in the senate 27
must include at least one representative of small business;28
(v) The remaining nominees must have demonstrated and 29
acknowledged expertise in at least one of the following areas: 30
Individual health care coverage, small employer health care coverage, 31
health benefit plan administration, health care finance and 32
economics, actuarial science, or administering a public or private 33
health care delivery system. 34
(b) The governor shall appoint two members from each list 35
submitted by the caucuses under (a) of this subsection. The 36
appointments made under this subsection (1)(b) must include at least 37
one employee benefits specialist, one health economist or actuary, 38
one representative of small business, and one representative of 39
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health consumer advocates. The remaining four members must have a 1
demonstrated and acknowledged expertise in at least one of the 2
following areas: Individual health care coverage, small employer 3
health care coverage, health benefit plan administration, health care 4
finance and economics, actuarial science, or administering a public 5
or private health care delivery system. 6
(c) The governor shall appoint a ninth member to serve as chair. 7
The chair may not be an employee of the state or its political 8
subdivisions. The chair shall serve as a nonvoting member except in 9
the case of a tie. 10
(d) The following members shall serve as nonvoting, ex officio 11
members of the board: 12
(i) The insurance commissioner or his or her designee; and13
(ii) The administrator of the health care authority, or his or 14
her designee. 15
(2) Initial members of the board shall serve staggered terms not 16
to exceed four years. Members appointed thereafter shall serve two-17
year terms. 18
(3) A member of the board whose term has expired or who otherwise 19
leaves the board shall be replaced by gubernatorial appointment. Upon 20
the expiration of a member's term, the member shall continue to serve 21
until a successor has been appointed and has assumed office. When the 22
person leaving was nominated by one of the caucuses of the house of 23
representatives or the senate, his or her replacement shall be 24
appointed from a list of five nominees submitted by that caucus 25
within thirty days after the person leaves. If the member to be 26
replaced is the chair, the governor shall appoint a new chair within 27
thirty days after the vacancy occurs. A person appointed to replace a 28
member who leaves the board prior to the expiration of his or her 29
term shall serve only the duration of the unexpired term. Members of 30
the board may be reappointed to multiple terms. 31
(4) No board member may be appointed if his or her participation 32
in the decisions of the board could benefit his or her own financial 33
interests or the financial interests of an entity he or she 34
represents. A board member who develops such a conflict of interest 35
shall resign or be removed from the board. 36
(5) Members of the board must be reimbursed for their travel 37
expenses while on official business in accordance with RCW 43.03.050 38
and 43.03.060. The board shall prescribe rules for the conduct of its 39
business. Meetings of the board are at the call of the chair.40
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(6) The exchange and the board are subject only to the provisions 1
of chapter 42.30 RCW, the open public meetings act, and chapter 42.56 2
RCW, the public records act, and not to any other law or regulation 3
generally applicable to state agencies , except the exchange shall 4
maintain immigration and citizenship status information restrictions 5
as if it were a state agency subject to RCW 43.17.425. Consistent 6
with the open public meetings act, the board may hold executive 7
sessions to consider proprietary or confidential ((nonpublished)) 8
unpublished information. 9
(7)(a) The board shall establish an advisory committee to allow 10
for the views of the health care industry and other stakeholders to 11
be heard in the operation of the health benefit exchange.12
(b) The board may establish technical advisory committees or seek 13
the advice of technical experts when necessary to execute the powers 14
and duties included in chapter 317, Laws of 2011. 15
(8) Members of the board are not civilly or criminally liable and 16
may not have any penalty or cause of action of any nature arise 17
against them for any action taken or not taken, including any 18
discretionary decision or failure to make a discretionary decision, 19
when the action or inaction is done in good faith and in the 20
performance of the powers and duties under chapter 317, Laws of 2011. 21
Nothing in this section prohibits legal actions against the board to 22
enforce the board's statutory or contractual duties or obligations.23
(9) In recognition of the government-to-government relationship 24
between the state of Washington and the federally recognized tribes 25
in the state of Washington, the board shall consult with the American 26
Indian health commission. 27
Sec. 5. RCW 43.71.110 and 2021 c 246 s 1 are each amended to 28
read as follows: 29
(1) Subject to the availability of amounts appropriated for this 30
specific purpose, a premium assistance and cost-sharing reduction 31
program is hereby established to be administered by the exchange.32
(2) Premium assistance and cost-sharing reduction amounts must be 33
established by the exchange within parameters established in the 34
omnibus appropriations act. In determining such amounts, the exchange 35
shall prioritize reaching parity in financial assistance for 36
enrollees, regardless of immigration status, by January 1, 2028, such 37
that the total amount of premium assistance and cost-sharing 38
reductions available to individuals eligible for federal advance 39
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premium tax credits is equivalent to those who are ineligible due to 1
federal immigration status restrictions. The exchange shall submit a 2
report to the relevant committees of the legislature and the office 3
of financial management on the status and cost of such parity by 4
November 1, 2025. 5
(3) The exchange must establish, consistent with the omnibus 6
appropriations act: 7
(a) Procedural requirements for eligibility and continued 8
participation in any premium assistance program or cost-sharing 9
program established under this section, including participant 10
documentation requirements that are necessary to administer the 11
program; and 12
(b) Procedural requirements for facilitating payments to 13
carriers. 14
(4) Subject to the availability of amounts appropriated for this 15
specific purpose, an individual is eligible for premium assistance 16
and cost-sharing reductions under this section if the individual:17
(a)(i) Is a resident of the state; 18
(ii) Has income that is up to an income threshold determined 19
through appropriation or by the exchange if no income threshold is 20
determined through appropriation; 21
(iii) Is enrolled in a silver or gold standard plan offered in 22
the enrollee's county of residence; 23
(iv) Applies for and accepts all federal advance premium tax 24
credits for which they may be eligible before receiving any state 25
premium assistance; 26
(v) Applies for and accepts all federal cost-sharing reductions 27
for which they may be eligible before receiving any state cost-28
sharing reductions; 29
(vi) Is ineligible for minimum essential coverage through 30
medicare, a federal or state medical assistance program administered 31
by the authority under chapter 74.09 RCW, or for premium assistance 32
under RCW 43.71A.020; and 33
(vii) Meets any other eligibility criteria established by the 34
exchange; or 35
(b) Meets alternate eligibility criteria as established in the 36
omnibus appropriations act. 37
(5)(a) The exchange may disqualify an individual from receiving 38
premium assistance or cost-sharing reductions under this section if 39
the individual: 40
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(i) No longer meets the eligibility criteria in subsection (4) of 1
this section; 2
(ii) Fails, without good cause, to comply with any procedural or 3
documentation requirements established by the exchange in accordance 4
with subsection (3) of this section; 5
(iii) Fails, without good cause, to notify the exchange of a 6
change of address in a timely manner; 7
(iv) Voluntarily withdraws from the program; or8
(v) Performs an act, practice, or omission that constitutes 9
fraud, and, as a result, an issuer rescinds the individual's policy 10
for the qualified health plan. 11
(b) The exchange must develop a process for an individual to 12
appeal a premium assistance or cost-sharing assistance eligibility 13
determination from the exchange. 14
(6) Prior to establishing or altering premium assistance or cost-15
sharing reduction amounts, eligibility criteria, or procedural 16
requirements under this section, the exchange must:17
(a) Publish notice of the proposal on the exchange's website and 18
provide electronic notice of the proposal to any person who has 19
requested such notice. The notice must include an explanation of the 20
proposal, the date, time, and location of the public hearing required 21
in (b) of this subsection, and instructions and reasonable timelines 22
to submit written comments on the proposal; 23
(b) Conduct at least one public hearing no sooner than 20 days 24
after publishing the notice required in (a) of this subsection; and25
(c) Publish notice of the finalized premium assistance or cost-26
sharing reduction amounts, eligibility criteria, or procedural 27
requirements on the exchange's website and provide the notice 28
electronically to any person who has requested it. The notice must 29
include a detailed description of the finalized premium assistance or 30
cost-sharing reduction amounts, eligibility criteria, or procedural 31
requirements and a description and explanation of how they vary from 32
the initial proposal. 33
(7) The definitions in this subsection apply throughout this 34
section unless the context clearly requires otherwise.35
(a) "Advance premium tax credit" means the premium assistance 36
amount determined in accordance with the federal patient protection 37
and affordable care act, P.L. 111-148, as amended by the federal 38
health care and education reconciliation act of 2010, P.L. 111-152, 39
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or federal regulations or guidance issued under the affordable care 1
act. 2
(b) "Income" means the modified adjusted gross income attributed 3
to an individual for purposes of determining his or her eligibility 4
for advance premium tax credits. 5
(c) "Standard plan" means a standardized health plan under RCW 6
43.71.095. 7
Sec. 6. RCW 43.71.120 and 2021 c 246 s 2 are each amended to 8
read as follows: 9
(1) The exchange, in close consultation with the authority and 10
the office of the insurance commissioner, must explore all 11
opportunities to apply to the secretary of health and human services 12
under 42 U.S.C. Sec. 18052 for a waiver or other available federal 13
flexibilities to: 14
(a) Receive federal funds for the implementation of the premium 15
assistance or cost-sharing reduction programs established under RCW 16
43.71.110; 17
(b) Increase access to qualified health plans; ((and))18
(c) Implement or expand other exchange programs that increase 19
affordability of or access to health insurance coverage in Washington 20
state; and21
(d) Improve affordability and benefits for lawfully present 22
immigrants with a countable income that is at or below 138 percent of 23
the federal poverty level, up to and including transitioning such 24
individuals to the state program established in section 2 of this act 25
through a waiver, with accompanying federal pass-through funds, if 26
available. 27
(2) If, through the process described in subsection (1) of this 28
section(([,])), an opportunity to submit a waiver is identified, the 29
exchange, in collaboration with the office of the insurance 30
commissioner and the health care authority, may develop an 31
application under this section to be submitted by the health care 32
authority. If an application is submitted, the health care authority 33
must notify the chairs and ranking minority members of the 34
appropriate policy and fiscal committees of the legislature.35
(3) Any application submitted under this section must meet all 36
federal public notice and comment requirements under 42 U.S.C. Sec. 37
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18052(a)(4)(B), including public hearings to ensure a meaningful 1
level of public input. 2
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