WSR 13-19-088
PROPOSED RULES
OFFICE OF
INSURANCE COMMISSIONER
[Insurance Commissioner Matter No. R 2013-16—Filed September 18, 2013, 7:58 a.m.]
Original Notice.
Preproposal statement of inquiry was filed as WSR 13-15-165.
Title of Rule and Other Identifying Information: Long-term care prompt payment requirements.
Hearing Location(s): Office of the Insurance Commissioner, Training Room (T-120), 5000 Capitol Way South, Tumwater, WA, on October 23, 2013, at 11:00 a.m.
Date of Intended Adoption: October 28, 2013.
Submit Written Comments to: Kacy Scott, P.O. Box 40258, Olympia, WA 98504-0258, e-mail rulescoordinator@oic.wa.gov, fax (360) 586-3109, by October 22, 2013.
Assistance for Persons with Disabilities: Contact Lori [Lorie] Villaflores by October 22, 2013, TTY (360) 586-0241 or (360) 725-7087.
Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: These proposed rules implement prompt payment requirements for long-term care insurance as required by RCW 48.83.170 (SB 5216) enacted during the 2013 legislative session. The legislation also amended RCW 48.83.090 requiring issuers to make long-term care denials within thirty days instead of sixty days.
Reasons Supporting Proposal: RCW 48.83.170, enacted during the 2013 legislative session, requires the commissioner to adopt by rule prompt payment requirements for long-term care insurance. As required by the legislation, the commissioner considered prompt payment requirements developed by the National Association of Insurance Commissioners (NAIC) in developing these proposed rules.
Statutory Authority for Adoption: RCW 48.02.060 and 48.83.170(3).
Statute Being Implemented: RCW 48.83.090 and 48.83.170.
Rule is not necessitated by federal law, federal or state court decision.
Name of Proponent: Mike Kreidler, insurance commissioner, governmental.
Name of Agency Personnel Responsible for Drafting: Kacy Scott, P.O. Box 40254, Olympia, WA 98504-0254, (360) 725-7041; Implementation: John Hamje, P.O. Box 40255, Olympia, WA 98504-0255, (360) 725-7262; and Enforcement: AnnaLisa Gellermann, P.O. Box 40255, Olympia, WA 98504-0255, (360) 725-7050.
No small business economic impact statement has been prepared under chapter 19.85 RCW. This proposed rule does not require a small business economic impact statement under the provisions of RCW 19.85.025(3).
The proposed rule is adopting prompt payment requirements using the exact language found in long-term care insurance model regulation put forth by the NAIC; this model language is specifically referenced in section 2 of SB 5216.
The only change in NAIC model language is the deletion of adjective "business" to describe the number of days for response; this change was required by SB 5126, section 1.
SB 5216 became effective July 28, 2013.
A cost-benefit analysis is not required under RCW 34.05.328. This proposed rule does not require a cost-benefit analysis under the provisions of RCW 34.05.328 (5)(b)(iii).
The rule is adopting prompt payment requirements using the exact language found in long-term care insurance model regulation put forth by NAIC; this model language is specifically referenced in section 2 of SB 5216.
The only change in this NAIC model language is the deletion of adjective "business" to describe the number of days for response; this change was required by SB 5126, section 1.
SB 5216 became effective July 28, 2013.
September 18, 2013
Mike Kreidler
Insurance Commissioner
NEW SECTION
WAC 284-83-325 Prompt payment of clean claims.
(1) The purpose of this section is to effectuate RCW 48.83.090 and 48.83.170 by establishing prompt payment requirements for long-term care insurance.
(2) For purposes of this section, the following definitions apply:
(a) "Claim" means a request for payment of benefits under an in-force policy, regardless of whether the benefit claimed is covered under the policy or any terms or conditions of the policy have been met.
(b) "Clean claim" means a claim that has no defect or impropriety, including any lack of required substantiating documentation, such as satisfactory evidence of expenses incurred, or particular circumstance requiring special treatment that prevents timely payment from being made on the claim.
(3) Within thirty days after receipt of a claim for benefits under a long-term care insurance policy or certificate, an insurer must pay such a claim if it is a clean claim, or send a written notice acknowledging the date of receipt of the claim and one of the following:
(a) The insurer is declining to pay all or part of the claim and the specific reason(s) for the denial; or
(b) That additional information is necessary to determine if all or any part of the claim is payable and the specific additional information that is necessary.
(4) Within thirty days after receipt of all the requested additional information, an insurer must pay a claim for benefits under a long-term care insurance policy or certificate if it is a clean claim, or send a written notice that the insurer is declining to pay all or part of the claim, and the specific reason or reasons for denial.
(5) If an insurer fails to comply with subsection (3) or (4) of this section, such insurer must pay interest at the rate of one percent per month on the amount of the claim that should have been paid but that remains unpaid for forty-five days after the receipt of the claim with respect to subsection (3) of this section or all requested additional information with respect to subsection (4) of this section. The interest payable pursuant to this subsection must be included in any late reimbursement without requiring the person who filed the original claim to make any additional claim for such interest.
(6) The provisions of this section do not apply where the insurer has a reasonable basis supported by specific information that such claim was fraudulently submitted.