WSR 10-20-006

EMERGENCY RULES

OFFICE OF

INSURANCE COMMISSIONER

[ Insurance Commissioners Docket No. R 2010-13 -- Filed September 22, 2010, 3:32 p.m. , effective September 22, 2010, 3:32 p.m. ]


     Effective Date of Rule: Immediately.

     Purpose: Explain the requirements that carriers must follow for persons under age nineteen who apply for coverage under an individual health benefit plan on or after September 23, 2010.

     Statutory Authority for Adoption: RCW 48.02.060, 48.18.120(2), 48.20.450, 48.44.050, 48.46.200.

     Other Authority: RCW 48.18.120(2), 48.20.450, 48.43.012, 48.43.015, 48.43.018, P.L. 111-148, sec. 2704.

     Under RCW 34.05.350 the agency for good cause finds that state or federal law or federal rule or a federal deadline for state receipt of federal funds requires immediate adoption of a rule.

     Reasons for this Finding: The Patient Protection and Affordable Care Act (P.L. 111-148) establishes specific requirements that health carriers must follow when they receive an application for individual coverage from a person under age nineteen, and making the enrollment process available to persons in that age group. These requirements go into effect for policy years beginning on or after September 23, 2010. The commissioner received a petition from a health plan asking for rule making to address the guaranteed issue, special and open enrollment period requirements in that rule so that all carriers understood the way they are expected to implement the federal requirements in Washington state. These rules help prevent disruption in the individual health insurance marketplace by promoting a uniform approach to new regulatory requirements.

     Number of Sections Adopted in Order to Comply with Federal Statute: New 2, Amended 0, Repealed 0; Federal Rules or Standards: New 2, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted at Request of a Nongovernmental Entity: New 2, Amended 0, Repealed 0.

     Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0;      Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 2, Amended 0, Repealed 0.

     Date Adopted: September 22, 2010.

Mike Watson

Chief Deputy

Insurance Commissioner

SUBCHAPTER J


HEALTH PLAN ENROLLMENT AND COVERAGE REQUIREMENTS

NEW SECTION
WAC 284-43-1001   Purpose and scope.   Health carriers may require any person applying for an individual health benefit plan to complete the standard health questionnaire designated under chapter 48.41.RCW, and may reject an individual for an individual health benefit plan based upon preexisting conditions under certain circumstances described in RCW 48.43.012, 48.43.015 and 48.43.018. Section 2704 of the Patient Protection and Affordable Care Act, P.L. 111-148 and the interim final regulations interpreting it, 45 C.F.R. Sec. 145.103 and 147.108, restrict a carrier's application of preexisting condition exclusions to the coverage of and enrollment of persons under age nineteen. These rules explain the requirements that are in effect in Washington as a result of these federal changes applicable to policy years beginning on or after September 23, 2010.

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     Reviser's note: The typographical error in the above section occurred in the copy filed by the agency and appears in the Register pursuant to the requirements of RCW 34.08.040.
NEW SECTION
WAC 284-43-1005   Definitions.   As used in this section, unless the context requires otherwise:

     "Applicant" means a person who applies for enrollment in an individual health plan as the subscriber or an enrollee, or the dependent or spouse of a subscriber or enrollee.

     "Carrier" has the same meaning as its definition in RCW 48.43.005(16) and includes "issuers" as that term is used in the Patient Protection and Affordable Care Act, P.L. 111-148.

     "Open enrollment" means a period of time as defined in these rules, held at the same time each year, during which applicants may enroll in the carrier's individual health benefit plan without being subject to health screening or otherwise required to provide evidence of insurability as a condition for enrollment.

     "Special enrollment" means a defined period of time of not less than thirty-one days, triggered by a specific qualifying event experienced by the applicant, during which applicants may enroll in the carrier's individual health benefit plan without being subject to health screening or otherwise required to provide evidence of insurability as a condition for enrollment.

     "Standard health questionnaire" means the standard health questionnaire designated under chapter 48.41 RCW.

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NEW SECTION
WAC 284-43-1010   Preexisting conditions.   For any individual health benefit plan, a carrier must waive any exclusion of benefits, including a denial of coverage, and may not otherwise limit coverage based upon a preexisting condition waiting period if the applicant or enrollee is a person under age 19. This requirement:

     (1) Does not apply to an individual grandfathered plan under P.L. 111-148, the Patient Protection and Affordable Care Act;

     (2) Includes those persons under age nineteen with a preexisting condition who seek coverage as the primary insured or as a dependent or as a spouse under individual health benefit plans that permit the enrollment of dependents, and enrolled persons under age nineteen who seek benefits for which they are otherwise eligible.

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NEW SECTION
WAC 284-43-1015   Enrollment of persons under age nineteen.   (1) If a carrier offers an individual health benefit plan, for policy years beginning on January 1, 2011, for any individual health benefit plan, a carrier must offer an open enrollment period for persons under age nineteen that begins November 1, 2010, and extends through December 1, 2010. Both during the initial open enrollment period of November 1, 2010 through December 15, 2010, any special enrollment period or any other enrollment period, a carrier must not require a person under age nineteen applying for an individual health benefit plan to complete the standard health questionnaire designated under chapter 48.41 RCW or provide other evidence of insurability.

     (2) A carrier may offer enrollment in an individual health benefit plan outside the open or special enrollment period, but must not require any evidence of insurability or completion of the standard health questionnaire.

     (3) For individual health plan policy years beginning on or after September 23, 2010, a carrier must offer a special open enrollment period to a person under age 19 who experiences a qualifying event. The special enrollment period must continue for at least thirty-one days from the date of a qualifying event. The prohibitions against requiring evidence of insurability or completion of the standard questionnaire apply. A qualifying event means the occurrence of one of the following:

     (a) The person under age nineteen or the person under whose policy they were enrolled loses employer sponsored insurance;

     (b) The person under age nineteen loses eligibility under medicaid or other public program providing health benefits;

     (c) The person under age nineteen or the person under whose policy they were enrolled loses coverage as the result of dissolution of marriage;

     (d) The person under age nineteen or the person under whose policy they were enrolled changes residence, and the health plan under which they were covered does not provide coverage in that service area;

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     Reviser's note: The typographical error in the above section occurred in the copy filed by the agency and appears in the Register pursuant to the requirements of RCW 34.08.040.

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