Title of Rule: WAC 284-43-220 Network reports.

     Purpose: The proposed rule is intended to reduce the burden of network reporting and increase the consistency of data. The proposal clarifies the information to be reported, limits the reporting to necessary information, extends the deadline for reporting, and changes the manner in which they must be filed.

     Other Identifying Information: Insurance Commissioner Matter No. R 2003-01.

     Statutory Authority for Adoption: 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.

     Statute Being Implemented: RCW 48.42.100, 48.43.515, 48.46.030.

     Summary: The proposed rule renames the network reports that carriers must file. It eliminates the paper filing option for the Form A and B reports. It also modifies the reporting timeline for the Form B report from January 1 to March 31 of each year, and requires the reporting of enrollees by network, rather than by product. The tables containing example Form A and Form B reports are eliminated.

     Reasons Supporting Proposal: The extension of the filing date for the Form B report, transition from paper to electronic filing, and modification of the manner in which enrollee information is reported should increase the speed and efficiency of filing, while lowering carrier costs for compilation and transmittal and OIC costs for storage.

     Name of Agency Personnel Responsible for Drafting: Ruth Ammons, P.O. Box 40255, Olympia, WA 98504-0255, (360) 725-7036; Implementation: Donna Dorris, P.O. Box 40255, Olympia, WA 98504-0255, (360) 725-7119; and Enforcement: Carol Sureau, P.O. Box 40255, Olympia, WA 98504-0255, (360) 725-7050.

     Name of Proponent: Mike Kreidler, Insurance Commissioner, governmental.

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

     Explanation of Rule, its Purpose, and Anticipated Effects: The proposed rule renames network reports and modifies the reporting timeline for the Form B report. It is intended to clarify the information to be reported under Form B and eliminate the filing of unnecessary information to assure efficiency and consistency in data reported by health carriers.

     Currently, the health carriers do not file their provider and enrollee network report data with the OIC in a consistent manner. The proposed rule clarifies the reporting requirements and eliminates unnecessary data. Carriers are currently required to file separate reports for each network by product; the proposed rule eliminates that requirement for reporting by product line. This will reduce the number of required reports and the administrative burden on the carriers. The information will also be easier to use by the OIC staff.

     The existing timeline for Form B reporting is January 1 of each year. Carriers have had some difficulties with the timeline since not all of their data is readily available at year-end. Carriers have often requested an extension in the reporting timeline to assure accuracy of data they report. The extended timeline for reporting will provide carriers with additional time to capture and report accurate data.

     Currently, the Form A and B reports may be transmitted in electronic or hard copy format. The option for filing in hard copy is eliminated by the proposed rule, which should increase the speed and efficiency of filing and lower filing costs for carriers and storage and handling costs for the OIC.

     The rule changes should make filing less burdensome and less costly for all carriers while providing the OIC with all necessary information.

     Proposal Changes the Following Existing Rules: The following WAC sections are proposed to be amended as follows:

     WAC 284-43-220, the introductory paragraph is amended to eliminate confusing examples and clarify the specific network forms that carriers must file. Included are references to the four specific forms to be filed.

     Subsections (1) and (2) are amended and renumbered as subsections (1), (2), (3) and (4). Included are changes that clarify that carriers must file four network reports, including an annual access plan as prescribed by WAC 284-43-210, and a "Geographic Network Report." The reports previously referred to as "Form A" and "Form B" are renamed "Provider Network Form A" and "Network Enrollment Form B." The changes require these forms to be filed electronically and delete examples of the forms previously provided in the tables. Beginning in 2004, the annual filing date for the "Network Enrollment Form B" is changed to March 31. The changes also require carriers to file a separate Form B report for each network by line of business.

     Subsection (3) is renumbered as subsection (5).

     Subsection (6) is created. Included are definitions for the terms "network" and "line of business."

January 22, 2003

Mike Kreidler

Insurance Commissioner

OTS-6089.3

AMENDATORY SECTION(Amending Matter No. R 99-2, filed 1/24/00, effective 1/1/01)

WAC 284-43-220   Network reports -- Format.   ((Beginning January 1, 1999, and by January 31st of every subsequent year,)) Each health carrier ((shall provide a description of each of its networks to the commissioner. In describing its network, each carrier shall include an explanation of its established access standards, noting the criteria used to measure the standards. For example, a carrier should indicate whether travel distances or driving times are used to determine accessibility. In addition, each carrier shall indicate which providers are classified as primary care providers, obstetric and women's health care providers)) must file with the commissioner an access plan, Provider Network Form A, Network Enrollment Form B and Geographic Network Report.

     (1) ((Beginning January 1, 1999, each health carrier shall provide the insurance commissioner with:

     (a) An annual)) 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 ((or hard copy paper)) report of all participating providers by network ((and monthly updates)). This report ((shall)) must contain all ((the)) data items shown in ((the table. (Form A.))) 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.

     (((b) An annual electronic or hard copy paper report indicating)) (3) 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((, by line of business, by product (with identifying form number filed with this office, if appropriate), by county, and by sex. The report shall conform to the table. (Form B.)

     (2) In addition to the provider and covered persons reports, each carrier shall file annual reports meeting the standards below and shall)). 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) 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 ((a)) the carrier's provider network occurs that significantly affects the ability of covered persons to access covered services. Each carrier ((shall)) must file for each network (((with identifying form number(s) filed with this office, if appropriate))), 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) ((County.

     (ii))) Total number of covered persons((.));

     (((iii))) (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);

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

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

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

     (c) ((A list indicating alphabetically by county and by city:

     (i) County;

     (ii) City;

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

     (i) Total number of covered persons;

     (((iv))) (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);

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

     (((vi))) (iv) Total number of specialists;

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

     (((viii))) (vi) Total number of hospitals; and

     (((ix))) (vii) Total number of pharmacies.

     (((3))) (5) A carrier may vary the method of reporting required under subsection (((2))) (4) of this section upon written request and subsequent written approval by the commissioner ((after a showing by)). 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) 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.

(((WAC 284-43-220, Form A) Place illustration here.))

(((WAC 284-43-220, Form B, page 1) Place illustration here.))

(((WAC 284-43-220, Form B, page 2) Place illustration here.))

[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.]

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