WSR 01-03-035

PERMANENT RULES

OFFICE OF THE

INSURANCE COMMISSIONER

[ Insurance Commissioner Matter No. R 2000-03 -- Filed January 9, 2001, 11:25 a.m. ]

Date of Adoption: January 9, 2001.

Purpose: E2SSB 6067 provisions relating to maternity, prescription drugs, and restrictions on carrier limitations for maternity coverage coupled with federal and state laws that mandate maternity and contraceptive coverage and that prohibit sex discrimination necessitate rules setting common benefit standards for maternity and prescription drug coverage. The rules are intended to prohibit unreasonable restrictions on health plan coverage as carriers design and offer coverage in compliance with E2SSB 6067, chapter 79, Laws of 2000.

Statutory Authority for Adoption: E2SSB 6067 and RCW 48.43.041, 48.44.020, and 48.46.060.

Adopted under notice filed as WSR 00-23-127 on November 22, 2000.

Changes Other than Editing from Proposed to Adopted Version: WAC 284-43-821 and 284-43-823, health plans that provide maternity services must cover the full range of related services including pregnancy prevention, termination, and sterilization. Plans cannot contain limitations or restrictions that are not applied to other health services. For example, carriers could not avoid the nine month preexisting condition exclusion by imposing a twelve month "benefit" waiting period. Health plans that cover prescription drugs must also cover prescription contraceptives. The general prohibition on discrimination is removed. Carriers may require cost sharing on prescription contraceptives to the same extent applied to other covered prescriptions. WAC 284-43-824, the rule applies to plans offered, issued, or renewed on or after July 1, 2001.

Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 2, Amended 0, Repealed 0.

Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

Number of Sections Adopted on the Agency's Own Initiative: New 2, Amended 0, Repealed 0.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 0, Repealed 0.

Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 0, Repealed 0. Effective Date of Rule: Thirty-one days after filing.

January 9, 2001

Deborah Senn

Insurance Commissioner

OTS-4516.4


NEW SECTION

WAC 284-43-821   Maternity and pregnancy-related exclusions, limitations and conditions in individual plans.   (1) Health carriers offering or issuing an individual health plan providing coverage for maternity services shall not exclude medically necessary consultations, examinations, radiology, laboratory, anesthesia, hospitalization and medical care for pregnancy-related services including pregnancy diagnosis; pregnancy prevention; sterilization; therapeutic and voluntary termination of pregnancy; miscarriage; prenatal, delivery and postpartum care; complications of pregnancy; breast feeding; and prenatal testing when medically necessary for the detection of congenital and heritable disorders.

(2) A carrier may not impose benefit waiting periods, limitations, or restrictions on maternity services that are not required for other covered services. A carrier may require cost sharing, such as copayments or deductibles, to the extent that such requirements are imposed for other covered services.

(3) No health carrier offering or issuing prescription drug benefits in the individual market may exclude FDA-approved prescription contraceptive drugs and devices. Health carriers are not prohibited from excluding nonprescription drugs and devices, or using closed formularies, provided, however, such formularies shall include oral, implant and injectable contraceptive drugs, intrauterine devices and prescription barrier methods.

(4) A carrier may require cost sharing, such as copayments or deductibles, to the extent that such requirements are imposed for other covered prescriptions.

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NEW SECTION
WAC 284-43-823   Maternity and pregnancy-related exclusions, limitations and conditions in group plans.   (1) Health carriers offering or issuing a group health plan providing coverage for maternity services shall not exclude medically necessary consultations, examinations, radiology, laboratory, anesthesia, hospitalization and medical care for pregnancy-related services including pregnancy diagnosis; pregnancy prevention; sterilization; therapeutic and voluntary termination of pregnancy; miscarriage; prenatal, delivery and postpartum care; complications of pregnancy; breast feeding; and prenatal testing when medically necessary for the detection of congenital and heritable disorders.

(2) A carrier may not impose benefit waiting periods, limitations, or restrictions on maternity services that are not required for other covered services. A carrier may require cost sharing, such as copayments or deductibles, to the extent that such requirements are imposed for other covered services.

(3) No health carrier offering or issuing prescription drug benefits in the group market may exclude FDA-approved prescription contraceptive drugs and devices. Health carriers are not prohibited from excluding nonprescription drugs and devices, or using closed formularies, provided, however, such formularies shall include oral, implant and injectable contraceptive drugs, intrauterine devices and prescription barrier methods.

(4) A carrier may require cost sharing, such as copayments or deductibles, to the extent that such requirements are imposed for other covered prescriptions.

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NEW SECTION
WAC 284-43-824   Effective date.   WAC 284-43-821 and 283-43-823 are effective for plans offered, issued, or renewed on or after July 1, 2001.

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Washington State Code Reviser's Office