WSR 08-11-110

EXPEDITED RULES

OFFICE OF

INSURANCE COMMISSIONER

[ Insurance Commissioner Matter No. R 2008-17 -- Filed May 20, 2008, 2:43 p.m. ]

Title of Rule and Other Identifying Information: The office of insurance commissioner (OIC) is proposing to repeal WAC 284-43-210 which requires carriers to submit access plans. In addition, WAC 284-43-220 would be amended to eliminate references to WAC 284-43-210.

NOTICE

THIS RULE IS BEING PROPOSED UNDER AN EXPEDITED RULE-MAKING PROCESS THAT WILL ELIMINATE THE NEED FOR THE AGENCY TO HOLD PUBLIC HEARINGS, PREPARE A SMALL BUSINESS ECONOMIC IMPACT STATEMENT, OR PROVIDE RESPONSES TO THE CRITERIA FOR A SIGNIFICANT LEGISLATIVE RULE. IF YOU OBJECT TO THIS USE OF THE EXPEDITED RULE-MAKING PROCESS, YOU MUST EXPRESS YOUR OBJECTIONS IN WRITING AND THEY MUST BE SENT TO Kacy Scott, Insurance Commissioner, P.O. Box 40258, Olympia, WA 98504-0258, e-mail Kacys@oic.wa.gov , AND RECEIVED BY July 22, 2008.


Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: WAC 284-43-210, adopted in 1998, describes a series of documents and/or answers to specific questions about how a health plan operates called an "access plan" that carriers must file with the OIC and make available to any interested party on request. This rule is proposed for repeal because that statutory basis for the rule, RCW 48.43.095 (1)(c), was repealed in 2000. Many of the requirements of WAC 284-43-210 overlap with WAC 284-43-820. In addition, WAC 284-43-220 would be amended to eliminate references to WAC 284-43-210.

Reasons Supporting Proposal: The statutory basis for the rule, RCW 48.43.095 (1)(c), was repealed in 2000.

Statutory Authority for Adoption: RCW 48.02.060.

Rule is not necessitated by federal law, federal or state court decision.

Name of Proponent: [OIC], governmental.

Name of Agency Personnel Responsible for Drafting: Donna Dorris, P.O. Box 40258, Olympia, WA 98504-0258, (360) 725-7040; Implementation: Beth Berendt, P.O. Box 40255, Olympia, WA 98504-0255, (360)725-7117; and Enforcement: Carol Sureau, P.O. Box 40255, Olympia, WA 98504-0255, (360) 725-7050.

May 20, 2008

Mike Kreidler

Insurance Commissioner

OTS-1378.1


AMENDATORY SECTION(Amending Matter No. R 2003-01, filed 4/23/03, effective 5/24/03)

WAC 284-43-220   Network reports -- Format.   Each health carrier must file with the commissioner ((an access plan,)) a Provider Network Form A, Network Enrollment Form B and Geographic Network Report.

(1) ((Access plan. A health carrier must describe each of its networks in an access plan as prescribed by WAC 284-43-210.

(2))) Provider Network Form A. A carrier must file an electronic report of all participating providers by network. This report must contain all data items shown in Provider Network Form A prescribed by and available from the commissioner. Updated reports must be filed each month. Filing of this data satisfies the reporting requirements of RCW 48.44.080 and the requirements of RCW 48.46.030 relating to filing of notices that describes changes in the provider network.

(((3))) (2) Network Enrollment Form B. By March 31, 2004, and every year thereafter, a carrier must prepare an electronic report showing the total number of covered persons who were entitled to health care services during each month of the year, excluding nonresidents. A separate report must be filed for each network by line of business. The report must contain all data items shown in and conform to the format of Network Enrollment Form B prescribed by and available from the commissioner.

(((4))) (3) Geographic Network Report. By March 31st of every year, a carrier also must file an electronic or hard copy paper report meeting the standards below. The carrier must update the reports whenever a material change in the carrier's provider network occurs that significantly affects the ability of covered persons to access covered services. Each carrier must file for each network, using a network accessibility analysis system, such as GeoNetworks or any other similar system:

(a) A map showing the location of covered persons and primary care providers with a differentiation between single and multiple provider locations;

(b) An access table illustrating the relationship between primary care providers and covered persons as of December of each year by county, including at a minimum:

(i) Total number of covered persons;

(ii) Total number of primary care providers (or, if the plan is a Preferred Provider Organization style of managed care, the total number of contracted providers);

(iii) Number of covered persons meeting the carrier's self defined access standard;

(iv) Percentage of covered persons meeting the carrier's self defined access standard; and

(v) Average distance to at least one primary care provider for its covered persons; and

(c) An alphabetical list by county and city showing:

(i) Total number of covered persons;

(ii) Total number of primary care providers (or, if the plan is a Preferred Provider Organization style of managed care, the total number of contracted providers);

(iii) Total number of obstetric and women's health care providers;

(iv) Total number of specialists;

(v) Total number of nonphysician providers by license type;

(vi) Total number of hospitals; and

(vii) Total number of pharmacies.

(((5))) (4) A carrier may vary the method of reporting required under subsection (((4))) (3) of this section upon written request and subsequent written approval by the commissioner. In the request, the carrier must show that the carrier does not use or does not have easy access to electronic or data systems permitting the method of reporting required without incurring substantial costs.

(((6))) (5) For purposes of this section:

(a) "Line of business" means either individual, small group or large group coverage;

(b) "Network" means the group of participating providers and facilities providing health care services to a particular line of business.

[Statutory Authority: RCW 48.02.060, 48.18.120, 48.20.450, 48.20.460, 48.43.515, 48.44.050, 48.46.030, 48.46.200, 48.42.100, 48.43.515, 48.46.030. 03-09-142 (Matter No. R 2003-01), 284-43-220, filed 4/23/03, effective 5/24/03. Statutory Authority: RCW 48.02.060, 48.18.120, 48.20.450, 48.20.460, 48.30.010, 48.44.050, 48.46.030, 48.46.200. 00-04-034 (Matter No. R 99-2), 284 -43-220, filed 1/24/00, effective 1/1/01. Statutory Authority: RCW 48.02.060, 48.20.450, 48.20.460, 48.30.010, 48.44.020, 48.44.050, 48.44.080, 48.46.030, 48.46.060(2), 48.46.200 and 48.46.243. 98-04-005 (Matter No. R 97-3), 284-43-220, filed 1/22/98, effective 2/22/98.]


REPEALER

     The following section of the Washington Administrative Code is repealed:
WAC 284-43-210 Access plan.

Washington State Code Reviser's Office