PERMANENT RULES
INSURANCE COMMISSIONER
Effective Date of Rule: Thirty-one days after filing.
Purpose: These new rules establish and implement the data submission requirements for carriers that provide health benefit plans for school district employees.
Statutory Authority for Adoption: RCW 48.02.060 and 48.02.210(3).
Adopted under notice filed as WSR 12-23-069 on November 20, 2012.
Changes Other than Editing from Proposed to Adopted Version: WAC 284-198-001, clarify rules apply to carriers and not school districts; WAC 284-198-005(8), clarify definition of "enrollee" includes dependents; WAC 284-198-020(2), clarify premium and paid claims accounted for - not reported - on monthly basis, delete reporting of administrative expenses and IBNR reserves on PMPM basis; WAC 284-198-020(3), survey instructions may permit aggregation of data for benefit packages with small enrollment; WAC 284-198-025(1), data submission deadline no earlier than April 1st, and at least sixty days after data submission instructions posted on OIC web site; WAC 284-198-025(3), deleted restrictions regarding how data must be submitted; WAC 284-198-045 (2)-(22), technical edits, clarify data elements to be reported for health benefit plans; WAC 284-198-045 (2)-(23), require reporting of additional category of administrative expenses for payments to associations, trusts, and other third parties; and WAC 284-198-045 (2)-(24)-(25), report payments received for separate disease management, wellness, and other similar programs offered with a health benefit plan, describe the offered programs.
A final cost-benefit analysis is available by contacting Kacy Scott, P.O. Box 40258, Olympia, WA 98504-0258, phone (360) 725-7041, fax (360) 586-3109, e-mail kacys@oic.wa.gov.
Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 11, Amended 0, Repealed 0.
Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.
Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.
Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 0, Repealed 0.
Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 11, Amended 0, Repealed 0.
Date Adopted: February 7, 2013.
Mike Kreidler
Insurance Commissioner
OTS-5169.2
K-12 EMPLOYEE HEALTH INSURANCE DATA REPORTING RULES
(2) This chapter explains the K-12 public school district employee health benefit plan data submission requirements established pursuant to RCW 28A.400.275 and 48.02.210, for the entities listed in subsection (1) of this section.
(3) The provisions of this chapter do not apply to school districts or other entities not subject to regulation under Title 48 RCW. School district reporting requirements under RCW 28A.400.275 will be provided through separate instructions.
[]
(1) "Association health plan" means a health benefit plan or policy issued through an association either pursuant to a master contract or through group contracts that predicate eligibility for enrollment in whole or in part on membership in an association.
(2) "Benefit package" has the same meaning as "health plan" or "health benefit plan."
(3) "Carrier" means, solely for the purpose of this chapter, health care service contractors, health maintenance organizations, and disability insurers that offer health benefit plans to K-12 public school district employees.
(4) "Commissioner" means the Washington state insurance commissioner.
(5) "Data call" means the commissioner's instructions to carriers for submission of information pursuant to RCW 28A.400.275 and 48.02.210.
(6) "Actual earned premium" means premium as defined in RCW 48.43.005, plus any rate credits or recoupment less any refunds, for the applicable period, whether received before, during or after the applicable period.
(7) "Enrollee" means a person entitled to coverage for benefits under a health benefit plan, including an enrollee, subscriber, dependent, policyholder, or a beneficiary of a group plan.
(8) "General administrative expenses" means actual paid expenses for administration, as reported to the commissioner and the National Association of Insurance Commissioners.
(9) "Health plan" or "health benefit plan" means any policy, contract or agreement offered to provide, arrange, reimburse or pay for medical services, as described in RCW 48.43.005(26).
(10) "Health plan premium" means the amount agreed upon as the health plan unit rate charged by the carrier for each plan participant for coverage under a comprehensive medical plan for a defined period of time, regardless of the entity responsible for paying the premium or its equivalent.
(11) "Health plan rate" means the unit rate used to calculate the premium charged, received or deposited as consideration for a health benefit plan or the continuance of a health benefit plan.
(12) "Submission" means the transfer to and actual receipt by the commissioner of data, documents and information, provided by the carrier consistent with the format, method and timing specified by the commissioner.
(13) "Total claim expenses" means the dollar amount of claims recorded as paid during the reporting period.
[]
[]
(2) The survey instrument will collect health plan earned premium and paid claims expenses accounted for on a monthly basis, for the calendar year, and may also collect those data on a plan year basis. The survey instrument will collect data regarding health plan administrative expenses on an annual basis.
(3) The survey instructions may permit the aggregation of data reported for benefit packages that have a small number of enrollees.
[]
(1) Data, supporting documents and any other information necessary to respond to the commissioner's data call must be submitted to the commissioner by the carrier at the address specified in the instructions not later than the deadline established in the data call. The submission deadline shall be no earlier than April 1st of the year following the reporting period and at least sixty days after data submission instructions are posted.
(2) Carriers must use the survey template form posted on the commissioner's web site when responding to the data call, and follow the instructions, requirements and guidelines for the record layout format also posted on the web site. Carriers may submit additional documents or other explanatory information with the completed survey template. These additional documents must be submitted to the commissioner in compliance with any other record layout format requirements included in the instructions.
(3) If a carrier retains the services of a third party to respond to the data call that entity must respond to the data call within the time frames required of the carrier, and follow the commissioner's instructions for submission. If the commissioner requires resubmission of the data, in whole or in part, the third party must respond within the time frame that the commissioner requires.
(4) The commissioner may contract with an entity to collect the data that must be reported pursuant to this chapter. In such a case carriers must submit the required data to that entity for use by the commissioner in carrying out the requirements of RCW 28A.400.275 and 48.02.210.
[]
[]
[]
[]
| Field | Description | Type (numeric or text) |
| (1) | Carrier name | text |
| (2) | Does carrier offer high deductible health plan options to school districts? | text |
| (3) | Health benefit plan (HBP) name or plan identifier and policy number | text |
| (4) | HBP - Summary of benefit package - Covered benefits, deductibles, coinsurance, copayments | text |
| (5) | HBP premium rate schedule for all tiers | text |
| (6) | HBP begin and end dates for plan year | text |
| (7) | HBP monthly enrollment, including employee and dependent enrollment counts | numeric |
| (8) | HBP aggregate monthly total paid claims | numeric |
| For data fields (#9-#14) report total paid claims and utilization/1000 | ||
| (9) | HBP monthly paid inpatient facility claims | numeric |
| (10) | HBP monthly paid outpatient facility claims | numeric |
| (11) | HBP monthly paid professional services claims | numeric |
| (12) | HBP monthly paid pharmacy claims | numeric |
| (13) | HBP monthly paid capitation payments for medical care | numeric |
| (14) | Other HBP monthly paid medical claims | numeric |
| (15) | A list of deidentified enrollees that had greater than $100,000 paid claims in 2012; including for each: The total amount of paid claims, the enrollment status; and the survey instrument diagnosis code categories | text |
| (16) | HBP actual earned monthly premium | numeric |
| (17) | HBP total premium or rate stabilization reserves for end of plan year | numeric |
| (18) | HBP total incurred but not reported (IBNR) reserves for end of plan year | numeric |
| (19) | HBP total annual general administrative expenses | numeric |
| (20) | HBP total annual administrative expenses for premium taxes, WSHIP assessments, and other government taxes or assessments | numeric |
| (21) | HBP total annual administrative expenses for commissions and consulting, including all direct or indirect producer compensation | numeric |
| (22) | HBP total annual administrative expenses for PPO network access | numeric |
| (23) | HBP total annual administrative expenses for health benefit related direct or indirect payments to associations, trusts, and other third parties, including benefit administration and marketing related compensation | numeric |
| (24) | HBP total annual administrative expenses for all expenses not listed in data fields (20) - (23) | numeric |
| (25) | Total annual payments received for separate disease management, wellness, and similar programs with HBP offered | numeric |
| (26) | HBP description of disease management, wellness, and similar programs | text |
| (27) | Carrier progress toward health care cost savings and reduced administrative costs | text |
| (28) | Description of HBP use of innovative features to reduce premium growth and use of unnecessary health services | text |
| (29) | Data necessary for school districts to more effectively and competitively manage and procure health insurance plans for employees | text |
[]
[]
(2) Carriers that provide coverage to school district employees through association health plans must require the association to provide to a school district any health plan data in the possession of the association that is needed by the school district in order to respond to the district's data reporting requirements under RCW 28A.400.275 and 48.02.210.
[]