PROPOSED RULES
FINANCIAL MANAGEMENT
Original Notice.
Preproposal statement of inquiry was filed as WSR 08-21-089.
Title of Rule and Other Identifying Information: Regulating property and liability self-insurance requirements as to local governments and nonprofit corporations.
Hearing Location(s): Washington Cities Insurance Authority, 320 Andover Park East, Tukwila, WA 98138, on July 8, 2009, at 12:00 p.m. and on July 9, 2009, 9:00 a.m.; and at the Grant County Public Works, 124 Enterprise Street S.E., Ephrata, WA 98823, on July 13, 2009, at 12:00 p.m and on July 14, 2009, at 9 a.m.
Date of Intended Adoption: August 5, 2009.
Submit Written Comments to: Roselyn Marcus, Office of Financial Management, P.O. Box 43113, Olympia, WA 98504-3113, e-mail Roselyn.Marcus@ofm.wa.gov, fax (360) 664-2832, by July 7, 2009.
Assistance for Persons with Disabilities: Contact Lillian Austin by July 2, 2009, TTY (360) 902-0679 or (360) 902-0533.
Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: Currently, chapter 82-60 WAC provides standards for both property and liability local government self-insurance programs and health and welfare local government self-insurance programs. As the programs have matured and the insurance environment has changed over years, these two types of programs (property/liability and health/welfare) have become so different as to require separate standards for each type of self-insurance program. As a result, temporary guidelines were put into place with the intent to engage in rule making at a later time using the APA process described in chapter 34.05 RCW.
Local government self-insurance programs have operated under the above-mentioned temporary guidelines for a number of years, which has caused confusion among the programs in determining what standards they are required to meet. Also, because the rules had not been updated and were not specific enough to each type of program given the changes in the insurance, economic and legal environment over time, oral waivers from requirements in both rules and guidelines were provided to some programs, creating further confusion due to lack of written documentation.
The state risk manager is required to adopt rules which create standards for solvency, management, operations and certain contracts. The office of financial management (OFM), working with the property and liability advisory board, has created proposed revisions to chapter 82-60 WAC which (1) remove the health and welfare rules from chapter 82-60 WAC and address them in a separate rule-making process, (2) replace temporary guidelines with updated rules specific to joint property and liability self-insurance programs to be adopted using the APA process described in chapter 34.05 RCW as required by RCW 48.62.061, and (3) remove the provision for waivers from rules and guidelines and allow the state risk manager to consistently regulate all programs.
Reasons Supporting Proposal: The revisions to chapter 82-60 WAC will result in standards adopted in rule which can be easily identified and are specific to individual and joint property and liability programs. Individual and joint health and welfare programs will be able to clearly identify standards that apply to those programs in a newly created separate chapter. By creating rules, rather than guidelines, local governments wishing to form new programs will be able to easily locate the specific regulations which apply to their programs in the rules, as prescribed in RCW 48.62.061. Because these rules will clearly identify standards specific to each type of program, regulation will be consistent and waivers will be unnecessary.
Statutory Authority for Adoption: RCW 48.62.061.
Statute Being Implemented: Chapter 48.62 RCW.
Rule is not necessitated by federal law, federal or state court decision.
Agency Comments or Recommendations, if any, as to Statutory Language, Implementation, Enforcement, and Fiscal Matters: To obtain a copy of the rules showing how they are being amended from their current versions in chapter 82-60 WAC, contact either Shannon Stuber at shannon.stuber@ofm.wa.gov, phone (360) 902-7311, or Roselyn Marcus at roselyn.marcus@ofm.wa.gov, phone (360) 902-0568.
Name of Proponent: Office of financial management, governmental.
Name of Agency Personnel Responsible for Drafting, Implementation and Enforcement: Shannon Stuber, General Administration Building, P.O. Box 41027, Olympia, (360) 902-7311.
No small business economic impact statement has been prepared under chapter 19.85 RCW. The implementation of these rules have no or minimal cost to small business.
A cost-benefit analysis is not required under RCW 34.05.328. OFM is not an agency listed in RCW 34.05.328 (5)(a)(i). Further, OFM does not voluntarily make section 201 applicable to this rule adoption nor to date, has JARRC made section 201 applicable to this rule adoption.
May 28, 2009
Roselyn Marcus
Director of Legal Affairs
Rules Coordinator
OTS-2419.3
AMENDATORY SECTION(Amending WSR 05-04-072, filed 2/1/05,
effective 3/4/05)
WAC 82-60-010
Preamble and authority.
These rules
governing local government and nonprofit self-insurance
transactions are adopted by the state risk manager to
implement chapter 48.62 RCW relating to the management and
operations of both individual and joint local government
((health and welfare benefit and)) property and liability
self-insurance programs and nonprofit property and liability
self-insurance programs.
[Statutory Authority: RCW 48.62.061. 05-04-072, amended and recodified as § 82-60-010, filed 2/1/05, effective 3/4/05. Statutory Authority: Chapter 48.62 RCW. 93-16-079, § 236-22-010, filed 8/3/93, effective 9/3/93; 92-12-092, § 236-22-010, filed 6/3/92, effective 7/1/92.]
(2) "Assessment" means the moneys paid by the members to a joint self-insurance program.
(3) (("Beneficiary" means any individual entitled to
payment of all or part of a covered claim under a local
government health and welfare self-insurance program.
(4))) "Broker of record" means the insurance producer licensed in the state of Washington who, through a contractual agreement with the joint self-insurance program, procures insurance on behalf of the joint self-insurance program.
(4) "Case reserves" means the total of all claims and claims adjustment expenses for covered events which have occurred and have been reported to the joint and individual self-insurance programs as of the date of the financial statement. Case reserves include an estimate for each reported claim based on the undiscounted jury verdict value of said claim.
(5) "Claim adjustment expense" means expenses, other than claim payments, incurred in the course of investigating and settling claims.
(((5))) (6) "Claim" means a demand for payment for
damages or policy benefit because of the occurrence of an
event ((such as:
(a) For health and welfare benefits, a covered service or services being delivered; or
(b) For property and liability, the destruction or damage of property or related deaths or injuries.
Unless specifically referenced, the term "claim" is used for both health and welfare and property and liability programs.
(6))) that includes, but is not limited to, the destruction or damage of property or reputation, bodily injury or death and alleged civil rights violations.
(7) "Claims auditor" means a person who has the following qualifications:
(a) A minimum of five years in claims management and investigative experience;
(b) A minimum of three years of experience in auditing the same manner of claims filed against the program being audited;
(c) Proof of professional liability insurance; and
(d) Provides a statement that the auditor is independent from the program being audited, its vendors, insurers, brokers, and third-party administrators.
(8) "Competitive process" means a ((documented formal
process providing a fair and open opportunity to qualified
parties and culminating in a selection based on criteria which
may include such factors as the party's fees or costs,
ability, capacity, experience, reputation, responsiveness to
time limitations, responsiveness to solicitation requirements,
quality of previous performance, and compliance with statutes
and rules relating to contracts or services.
(7) "Contribution" means the amount paid or payable by the employee into a health and welfare self-insurance program.
(8))) formal sealed, electronic, or web-based bid procedure used for all nonclaims related purchases for goods and services over fifty thousand dollars. For purchases between five thousand dollars and fifty thousand dollars, competitive process means quotations obtained from at least three vendors by telephone or written quotations, or both, and supported by evidence of competition. Purchases up to five thousand dollars are exempt from competitive bids providing procurement is based on obtaining maximum quality at minimum cost.
(9) "Competitive solicitation" means a documented formal process requiring sealed bids, providing an equal and open opportunity to qualified parties and culminating in a selection based on criteria which may include such factors as the consultant's fees or costs, ability, capacity, experience, reputation, responsiveness to time limitations, responsiveness to solicitation requirements, quality of previous performance, and compliance with statutes and rules relating to contracts or services.
(10) "Consultant" means an independent individual or firm contracting with a joint self-insurance program to perform actuarial, claims auditing or third-party administration services, represent the program as broker of record, or render an opinion or recommendation according to the consultant's methods, all without being subject to the control of the program, except as to satisfaction of the contracted deliverables.
(11) "Foundation agreement" means the interlocal agreement binding local government members or the contract binding nonprofit members to a joint self-insurance program.
(12) "Governing body" means the multimember board, commission, committee, council, or other policy or rule-making body of a public agency, or any committee thereof when the committee acts on behalf of the governing body, conducts hearings, or takes testimony or public comment.
(13) "Incurred but not reported, or IBNR" means claims
and claim adjustment expenses for covered events which have
occurred but have not yet been reported to the self-insurance
program as of the date of the financial statement. IBNR
claims include (a) known loss events that are expected to be
presented later as claims, (b) unknown loss events that are
expected to become claims, and (c) ((expected)) future
development on claims already reported.
(((9))) (14) "Individual self-insurance program" means a
formal program established and maintained by a local
government entity to provide advance funding to self-insure
((health and welfare benefits or)) for property and liability
risks on its own behalf as opposed to risk assumption, which
means a decision to absorb the entity's financial exposure to
a risk of loss without the creation of a formal program of
advance funding of anticipated losses.
(((10))) (15) "Interlocal agreement" means an agreement
established under the Interlocal Cooperation Act defined in
chapter 39.34 RCW.
(16) "Joint self-insurance program" means any two or more
local government entities, two or more nonprofit corporations
or a combination of local government entities and nonprofit
corporations which have entered into a cooperative risk
sharing foundation agreement ((pursuant to the provisions of
the Interlocal Cooperation Act (chapter 39.34 RCW) and/or))
subject to regulation under chapter 48.62 RCW.
(((11) "Liability for unpaid claims" means the amount
needed to provide for the estimated ultimate cost of settling
claims which have occurred on or before a particular date. The estimated liability includes the amount of money that will
be needed for future payments on both claims which have been
reported and IBNR claims.
(12) "Liability for unpaid claim adjustment expenses" means the amount needed to provide for the estimated ultimate costs required to investigate and settle claims for covered events that have occurred on or before a particular date, whether or not reported to the government entity or nonprofit corporation at that date.
(13))) (17) "Jury verdict value" means the claim value established on an individual case basis by the entity's analysis of the jury verdict results within a jurisdiction in addition to other factors including, but not limited to, severity of injury or damage, length of recovery, credibility of parties and witnesses, ability of attorney, sympathy factors, degree of negligence of the parties and contribution or recovery from other sources.
(18) "Member" means a local government entity or nonprofit corporation that:
(a) Is a signatory to a joint insurance program's foundation agreement;
(b) Agrees to future assessments or reassessments as part of the program's joint self-insurance program; and
(c) Is a past or present participant in ((a joint
self-insurance)) the excess or self-insured retention portion
of the pool's insurance program subject to regulation under
chapter 48.62 RCW.
(((14))) (19) "Nonprofit corporation," as defined in RCW 24.03.005(3), means a corporation of which no part of the
income ((of which)) is distributable to its members, directors
or officers.
(((15))) (20) "Primary assets" means cash and investments
(less any nonclaims liabilities).
(21) "Reassessment" means additional moneys paid by the members to a joint self-insurance program.
(22) "Risk sharing" means a decision by the members of a joint self-insurance program to jointly absorb certain or specified financial exposures to risks of loss through the creation of a formal program of advance funding of actuarially determined anticipated losses; and/or joint purchase of insurance or reinsurance as a member of a joint self-insurance program formed under chapter 48.62 RCW.
(23) "Secondary assets" means insurance receivables, real estate or other assets (less any nonclaims liabilities) the value of which can be independently verified by the state risk manager.
(24) "Self-insurance program" means any individual or
joint ((local government entity or nonprofit corporation))
self-insurance program required by chapter 48.62 RCW to comply
with this chapter.
(((16))) (25) "Services" means administrative,
electronic, management, loss prevention, training or other
support services which do not include the participation in or
purchase of the pools excess or self-insured insurance
programs.
(26) "Stop-loss insurance" means ((insurance against the
risk of economic loss assumed under a self-insurance program.
(17))) a promise by an insurance company that it will cover losses of the entity it insures over and above an agreed-upon aggregated amount.
(27) "Third-party administrator" means((:
(a) An)) a independent association, agency, entity or
enterprise which, through a contractual agreement ((is
responsible for the overall operational and financial
management of the self-insurance program; or
(b) An independent association, agency, entity or enterprise which, through a contractual agreement, provides a professional service for the analysis, design, implementation, or termination of a self-insurance program; or
(c) An independent association, agency, entity or enterprise which, through a contractual agreement, administers the claim payment process on behalf of a self-insurance program. Such claim administration process includes, but is not limited to, receiving requests for claim payments, investigation, verification and adjustment of the claim. Claim payment disbursement is also considered an administrative process)), provides one or more of the following ongoing services: Pool management or administration services, claims administration services, risk management services, or services for the design, implementation, or termination of an individual or joint self-insurance program.
(28) "Unallocated loss adjustment expense (ULAE)" means costs that cannot be associated with specific claims but are related to the claims adjustment process, such as administrative and internal expenses related to settlement of claims at the termination of the program.
(29) "Unpaid claims" means the obligations for future payment resulting from claims due to past events. This liability includes loss and adjustments expenses, incurred but not reported claims (IBNR), case reserves, and unallocated loss adjustment expenses (ULAE).
[Statutory Authority: RCW 48.62.061. 05-04-072, amended and recodified as § 82-60-020, filed 2/1/05, effective 3/4/05. Statutory Authority: Chapter 48.62 RCW. 93-16-079, § 236-22-020, filed 8/3/93, effective 9/3/93.]
(1) The individual self-insurance program must notify the state risk manager of its existence or termination.
(2) The program may contract for claims handling and investigation services, or the program may choose to provide these services internally. In either case, the person responsible for the program shall establish sufficient contract monitoring and internal control procedures to provide adequate oversight over the claims handling and investigation process.
(3) The program shall establish standards requiring each claim be reserved for settlement, legal and loss adjustment expense. Settlement (indemnity) reserves shall be established by a reserving process which may include estimates of jury verdict value.
(4) The program shall establish claims reserving processes that include a periodic review of case reserves.
(5) The individual self-insurance program may obtain the services of an independent claims auditor to evaluate the claims handling procedures of its contractor or internal staff.
(6) The program may use the services of an actuary to determine the funding levels necessary to fund reserves restricted for payment of claims and related claims expenses.
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(1) Each member shall pay assessments and reassessments when required by the governing body of the program.
(2) Each member shall obtain approval to join the program from the governing body of the respective member. The approval shall be by resolution or ordinance of the governing body as appropriate for the entity type.
(3) Each member shall become a signatory to the foundation agreement and subsequent amendments to the foundation agreement of the joint self-insurance program.
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(2) A program intending to provide services to nonmembers shall submit a written plan to the state risk manager for approval prior to providing services. The plan shall include, at a minimum, the services to be provided, the time frame for providing such services, the expected revenues and expenditures resulting from providing said services, and a written legal determination of all potential federal and state tax liabilities created by providing services to nonmembers. The arrangement to provide such services shall be approved in writing by the state risk manager within sixty days of the joint self-insurance program's final plan submission.
(3) Every joint self-insurance program providing services as of the effective date of these regulations must submit a written plan meeting the requirements stated herein.
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(2) Amendments to the foundation agreement shall be adopted by ordinance or resolution of the governing board or council of each member. The signed amendment and copy of the ordinance or resolution, as appropriate, shall be retained by the joint self-insurance program. The foundation agreement and subsequent amendments shall be published on the electronic web site of the joint self-insurance program.
(3) Changes to any terms of the foundation agreement shall require amendment using the approval and adoption process described above.
(4) The addition of new members to a joint self-insurance program and/or the subscription of the foundation agreement by said new members shall not be considered as amendments to the foundation agreement.
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(2) The interlocal agreement of a joint self-insurance program shall be adopted by resolution or ordinance by each participating member's governing body)) an acknowledgement that the entity shall be subject to assessments and reassessments as required by the joint self-insurance program. Copies of each resolution or ordinance shall be retained by the joint self-insurance program and available for inspection by the state risk manager. The foundation agreement, along with a list of members participating in the program, shall be published on the public web site of each joint self-insurance program. The foundation agreement and subsequent amendments shall be filed in accordance with requirements of chapter 39.34 RCW.
[Statutory Authority: RCW 48.62.061. 05-04-072, amended and recodified as § 82-60-030, filed 2/1/05, effective 3/4/05. Statutory Authority: Chapter 48.62 RCW. 93-16-079, § 236-22-030, filed 8/3/93, effective 9/3/93.]
(2) The governing body of the joint self-insurance program shall establish and maintain primary assets in an amount at least equal to the unpaid claims estimate at the expected level as determined by the program's actuary as of fiscal year end. All joint self-insurance programs that do not meet the requirement to maintain sufficient primary assets shall notify the state risk manager in writing of the condition. The state risk manager shall take corrective action, which may include the service of a cease and desist order upon the program, to require that the program increase primary assets in an amount equal to the unpaid claims estimate at the expected level as determined by the program's actuary as of fiscal year end.
(3) The governing body of the joint self-insurance program shall establish and maintain total primary and secondary assets in an amount equal to or greater than the unpaid claim estimate at the seventy percent confidence level as determined by the program's actuary as of fiscal year end. All joint self-insurance programs that do not meet the reserve requirements to maintain sufficient primary and secondary assets shall notify the state risk manager in writing of the condition. The state risk manager shall require that the program submit a written corrective action plan to the state risk manager within sixty days of notification. Such plan shall include a proposal for improving the financial condition of the self-insurance program and a time frame for completion. The state risk manager shall approve or deny the proposed plan in writing within thirty days of receipt of the final plan submission. Failure by the joint self-insurance program to respond or submit a plan to improve the financial condition of the program shall cause the state risk manager to take corrective action, which may include the service of a cease and desist order upon the program.
(4) The state risk manager shall evaluate the operational safety and soundness of the program by monitoring changes in liquidity, claims reserves and liabilities, member equity, self-insured retention, and other financial trends over time. Programs experiencing adverse trends may cause the state risk manager to increase frequency of on-site program review and monitoring, including increased communication with the governing body and requirements for corrective plans.
(5) When the state risk manager determines it necessary to analyze the program's soundness and financial safety, the state risk manager may obtain an independent actuarial evaluation to determine the adequacy of reserves. Costs of these services shall be the responsibility of the joint self-insurance program.
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(2) This provision shall not be construed to prohibit individual choice of coverage by members from several offered by the joint self-insurance program. The assessment formula, including the insured and self-insured components, shall be consistently applied to reflect the selection from among these choices.
(3) The assessment formula shall be available for review by the state risk manager.
[Statutory Authority: RCW 48.62.061. 05-04-072, recodified as § 82-60-033, filed 2/1/05, effective 3/4/05. Statutory Authority: Chapter 48.62 RCW. 93-16-079, § 236-22-033, filed 8/3/93, effective 9/3/93.]
(a) Applicable restrictions, limitations, and exclusions;
(b) The procedure for filing a claim for benefits;
(c) The procedure for requesting an adjudication of disputes or appeals arising from beneficiaries regarding the payment or denial of any claim for benefits; and
(d) A schedule of any direct monetary contributions toward the program financing required by the employee.
Such benefits or procedures shall not be amended without written notice to the covered employees and retirees at least thirty days in advance of the effective date of the change unless exigent circumstances can be demonstrated.
(2))) All joint self-insurance programs shall furnish to each member of the program written statements which describe:
(((a) All)) (1) Insurance coverages or benefits currently
provided by the program, including any applicable
restrictions, limitations, and exclusions;
(((b))) (2) The method by which ((members pay
assessments)) members' (re)assessments are determined;
(((c))) (3) The procedure for filing a claim against the
joint self-insurance program; ((and
(d))) (4) The procedure for a member to request an
adjudication of disputes or appeals arising from coverage,
claim payment or denial, membership, and other issues((.
Such statements shall not be amended without written notice to the members at least thirty days in advance of the effective date of the change)); and
(5) General characteristics of the insurance coverage portion of the program.
[Statutory Authority: RCW 48.62.061. 05-04-072, amended and recodified as § 82-60-034, filed 2/1/05, effective 3/4/05. Statutory Authority: Chapter 48.62 RCW. 93-16-079, § 236-22-034, filed 8/3/93, effective 9/3/93.]
(2) Member terminations. All joint self-insurance programs shall maintain a written plan that provides for the termination of membership of a member.
[Statutory Authority: RCW 48.62.061. 05-04-072, amended and recodified as § 82-60-036, filed 2/1/05, effective 3/4/05. Statutory Authority: Chapter 48.62 RCW. 93-16-079, § 236-22-036, filed 8/3/93, effective 9/3/93.]
(a) A procedure for accounting for moneys received, payments made and liabilities of the joint program which complies with generally accepted accounting principles;
(b) An investment policy which conforms to RCW 48.62.111 governing the investments of the program; and
(c) The preparation and submission of accurate and timely
annual financial ((statements)) reports of the program as
prescribed by the state auditor's office.
(d) The submission of audited financial statements to the state risk manager within one year of the program's fiscal year end which meet the requirements of the state risk manager as described in 82.60.060(3).
(2) No financial plan of a joint self-insurance program
shall permit ((interfund)) loans to any member from primary
assets held ((against liabilities for unpaid claims and claim
adjustment expenses except for those amounts which are clearly
inactive or in excess of liabilities for unpaid claims and
claim adjustment expenses.
(3) No financial plan of a joint self-insurance program shall permit loans from assets held against liabilities for unpaid claims and claim adjustment expenses to any member)) for payment of unpaid claims at the expected level as determined by an actuary as of fiscal year end.
[Statutory Authority: RCW 48.62.061. 05-04-072, amended and recodified as § 82-60-037, filed 2/1/05, effective 3/4/05. Statutory Authority: Chapter 48.62 RCW. 93-16-079, § 236-22-037, filed 8/3/93, effective 9/3/93.]
(((a))) (1) Provide a method of third-party administrator
selection using a formal competitive solicitation process;
(((b))) (2) Require a complete written description of the
services to be provided, remuneration levels, ((and)) contract
period and expiration date providing for a contract term no
greater than five years. The contract may include an
additional one year extension to be exercised at the
discretion of the joint self-insurance program;
(((c))) (3) Provide for the confidentiality ((and
ownership)) of the program's information, data and other
intellectual property developed or shared during the course of
the contract;
(((d))) (4) Provide for the program's ownership of the
information, data, and other intellectual property developed
or shared during the course of the contract;
(5) Provide for the expressed authorization of the joint
self-insurance program, consultants to the program, the state
auditor, the state risk manager, or their designees, to enter
the third-party administrator's premises to inspect and audit
the records and performance of the third-party administrator
which pertains to the program; ((and
(e))) (6) Require the compliance with all applicable
local, state and federal laws((.
(2) None of the above shall otherwise relieve the entity from other contracting requirements imposed on those entities));
(7) Establish a monitoring and acceptance procedure to determine compliance with third-party administrator contract requirements; and
(8) Establish indemnification provisions and set forth insurance requirements between the parties.
[Statutory Authority: RCW 48.62.061. 05-04-072, amended and recodified as § 82-60-038, filed 2/1/05, effective 3/4/05. Statutory Authority: Chapter 48.62 RCW. 93-16-079, § 236-22-038, filed 8/3/93, effective 9/3/93.]
(1) Amount of capitalization each nonprofit corporation will pay to become a member of the joint self-insurance program and criteria used to determine the capitalization amount;
(2) Self-insured retention level for nonprofit corporation members;
(3) ((Flexibility in premium assessment rates with
emphasis on rates for nonprofit corporations that recognize
the potential and actual loss experience of the nonprofit
corporation;)) Legal determination of federal and state tax
liabilities resulting from the inclusion of nonprofit members;
(4) Procedures for reviewing the financial soundness of each nonprofit corporation being considered for membership in the self-insurance program; and
(5) Representation of nonprofit corporations on the governing board of directors but local government entities must retain control as required by RCW 48.62.121 (2)(a).
[Statutory Authority: RCW 48.62.061. 05-04-072, § 82-60-039, filed 2/1/05, effective 3/4/05.]
[Statutory Authority: RCW 48.62.061. 05-04-072, recodified as § 82-60-040, filed 2/1/05, effective 3/4/05. Statutory Authority: Chapter 48.62 RCW. 93-16-079, § 236-22-040, filed 8/3/93, effective 9/3/93.]
(a) Claims filing procedures((, internal financial
control mechanisms, and claim and claim adjustment expense
reports.
(b) All individual and joint health and welfare self-insurance programs and all joint property and liability self-insurance programs shall have a written claim appeal procedure that contains, as a minimum, a time limit for filing an appeal, a time limit for response, and a provision for a second level of review.
(2)(a) All self-insurance programs may contract for claims administration services with a qualified third-party administrator, provided all the requirements under subsection (1) of this section are included in the contract.
(b) Individual and joint property and liability self-insurance programs may perform claims administration services on their own behalf. Individual and joint health and welfare self-insurance programs may perform claims administration services on their own behalf, provided the state risk manager is supplied with documentation and a detailed written explanation in support of the self-insurance program's proposed claims administration activities. The documentation and proposal shall include, as a minimum, the following:
(i) The nature, type and anticipated volume of claims to be administered.
(ii) The number of employment positions established or to be established which are required to perform the self-insurance program's claim administration functions, including an organizational chart showing reporting responsibilities.
(iii) Qualifications of personnel having claim reserving and settlement authority.
(iv) A projection of expected claim administration expenses.
(3) All self-insurance programs shall have conducted by an independent qualified professional not currently performing claims administration services to the program, a review of claim reserving, adjusting and payment procedures no less than every three years. Such review shall be in writing and retained for a period not less than three years.)) and forms.
(b) Standards requiring each claim be reserved for settlement, legal and loss adjustment expense. Indemnity (settlement) reserves shall be established by a reserving process which estimates the jury verdict value.
(c) Standards requiring case reserves be reviewed every ninety days or when reasonably practicable and such review is documented in the claims diary.
(d) Standards requiring appropriate adjuster work loads.
(e) Standards requiring claims payment procedures include sufficient internal controls to ensure adequate review and approval by claims management staff.
(f) Standards requiring file documentation be complete and up-to-date.
(g) Standards requiring timely and appropriate claim resolution practices.
(h) Standards requiring opportunities for recoveries be reviewed and documented for each claim.
(i) Standards requiring compliance with Internal Revenue Service (IRS) rules for 1099MISC regulations.
(j) Standards requiring claims files be audited on the following categories: Staffing, caseloads, supervision, diary, coverage, reserves, promptness of contacts, field investigations, file documentation, settlements, litigation management and subrogation.
(2) All joint self-insurance programs may perform claims administration services on their own behalf or may contract for claims administration services with a qualified third-party administrator, provided all of the specific requirements under subsection (1) of this section are included in the contract.
(3) All joint self-insurance programs shall have a written member coverage appeal procedure that contains, as a minimum, procedures for a member filing an appeal with the joint self-insurance program, including the time limit for filing, a time limit for response, and a provision for an additional level of review.
(4) All joint self-insurance programs shall maintain a
((dedicated claim account from which only)) financial system
that identifies claim and claim adjustment expenses ((can be
paid)).
(5) All joint self-insurance programs shall provide for the purchase of goods and services to replace or repair property in a manner which will, in the judgment of the governing body of the joint self-insurance program, avoid further damage, injury, or loss of use to a member or third-party claimant.
(6) All joint self-insurance programs shall maintain
((written)) claim ((and claim adjustment)) expense reports for
all claims made against the joint self-insurance program
and((, separate written reports for each individual)) its
members.
(7) All joint self-insurance programs shall obtain an independent review of claim reserving, adjusting and payment procedures every three years at a minimum. Said audit shall be conducted by an independent qualified claims auditor not affiliated with the program, its insurers, its broker of record, or its third-party administrator. Such review shall be in writing and identify strengths, areas of improvement, findings, conclusions and recommendations. Such review shall be provided to the governing body and retained for a period not less than six years. The scope of the claims audit shall include claims administration procedures listed in subsection (1) of this section.
(8) The state risk manager may require more frequent claims audits for programs that, in the state risk manager's opinion, are not operationally or financially sound. Failure to obtain the requested independent claims audit when required may result in the procurement of such audit by the state risk manager on behalf of the program. Costs of these services shall be the responsibility of the joint self-insurance program.
[Statutory Authority: RCW 48.62.061. 05-04-072, amended and recodified as § 82-60-050, filed 2/1/05, effective 3/4/05. Statutory Authority: Chapter 48.62 RCW. 93-16-079, § 236-22-050, filed 8/3/93, effective 9/3/93.]
(2) The annual report to the state risk manager shall require the following information to be submitted in electronic form:
(a) Unaudited annual financial statements, including attestation, as provided to the state auditors office;
(b) Actuarial reserve review report on which the net claims liabilities at fiscal year end reported in the unaudited financial statements are based;
(c) Copies of all insurance coverage documents;
(d) List of contracted consultants;
(e) Details of changes in articles of incorporation, bylaws or foundation agreement;
(f) Details of services provided by contract to nonmembers;
(g) List of members added or terminated.
Such reports shall be submitted to the state risk manager no later than one hundred fifty days following the completion of the joint program's fiscal year.
(((2) All joint self-insurance programs authorized to
transact business in the state of Washington shall submit
quarterly financial reports to the state risk manager. Such
reports shall be submitted to the state risk manager no later
than sixty days following the completion of each of the
program's four quarters within its fiscal year.)) (3) Audited
financial statements shall be provided to the state risk
manager within one year of the program's fiscal year end and
comply with requirements for submission of audited financial
statements established by the state risk manager.
(4) All joint self-insurance programs shall submit quarterly financial reports if, in the estimation of the state risk manager, the financial condition of a program warrants additional quarterly reporting requirements.
(5) Failure to provide required financial reports may result in corrective action by the state risk manager. Such actions may include:
(a) Increase in frequency of examinations, the cost of which shall be the responsibility of the program;
(b) On-site monitoring by the state risk manager;
(c) Service of a cease and desist order upon the program.
[Statutory Authority: RCW 48.62.061. 05-04-072, amended and recodified as § 82-60-060, filed 2/1/05, effective 3/4/05. Statutory Authority: Chapter 48.62 RCW. 93-16-079, § 236-22-060, filed 8/3/93, effective 9/3/93.]
(a) Any change in the terms of the foundation agreement;
(b) Elimination or reduction of stop loss insurance;
(c) Acceptance of any loans or lines of credit;
(d) Provision of services to nonmembers;
(e) Addition of members of other entity types than those included in original application approved by state risk manager.
(2) The following program changes require written notification to the state risk manager prior to implementing the following changes:
(a) Increases in retention level;
(b) Decrease or elimination of insurance limits;
(c) Initial contract with a third-party administrator, or change in third-party administrator;
(d) Any change to bylaws.
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(2) All joint self-insurance programs shall meet the following standards regarding restrictions on the financial interests of the program administrators:
(((1))) (a) No member of the board of directors; trustee;
administrator, including a third-party administrator; or any
other person having responsibility for the management or
administration of a joint self-insurance program or the
investment or other handling of the program's money shall:
(((a))) (i) Receive directly or indirectly or be
pecuniarily interested in any fee, commission, compensation,
or emolument arising out of any transaction to which the
program is or is expected to be a party except for salary or
other similar compensation regularly fixed and allowed for
because of services regularly rendered to the program.
(((b))) (ii) Receive compensation as a consultant to the
program while also acting as a member of the board of
directors, trustee, third-party administrator, or as an
employee.
(((c))) (iii) Have any direct or indirect pecuniary
interest in any loan or investment of the program.
(((2))) (b) No consultant((, third-party administrator))
or legal counsel to the joint self-insurance program shall
directly or indirectly receive or be pecuniarily interested in
any commission or other compensation arising out of any
contract or transaction between the joint self-insurance
program and any insurer((, health care service contractor, or
health care supply provider. This provision shall not
preclude licensed insurance brokers or agents from receiving
compensation for insurance transactions performed within the
scope of their licenses, provided such compensation is
disclosed to the self-insurance program's governing body.
(3))) or consultant.
(c) Brokers of record for the joint self-insurance programs may receive compensation for insurance transactions performed within the scope of their licenses. The terms of compensation shall be provided for by contract between the broker of record and the governing body, and the amount or percentage of the compensation must be disclosed in writing. Contracts between brokers of record and the governing body shall include a provision that contingent commissions or other form of compensation not specified in the contract shall not be paid to the broker of record as a result of any joint self-insurance program insurance transactions. The joint self-insurance program shall establish a contract provision which requires the broker provide to the program a written annual report on a form provided by the state risk manager which discloses the actual financial compensation received. The report shall include verification that no undisclosed commission was received as a result of any such insurance transaction made on behalf of the program.
(d) No third-party administrator shall serve as an officer or on the board of directors of a self-insurance program.
[Statutory Authority: RCW 48.62.061. 05-04-072, amended and recodified as § 82-60-080, filed 2/1/05, effective 3/4/05. Statutory Authority: Chapter 48.62 RCW. 93-16-079, § 236-22-080, filed 8/3/93, effective 9/3/93.]
(2) The state risk manager, with concurrence from the two advisory boards, shall determine the assessment rate on a fiscal year basis and the review and investigation fees on a fiscal year basis.
(3))) Services covered by the state risk manager fees will include program reviews, monitoring and continuing oversight.
(2) The ((review and investigation)) state risk manager
fees shall be paid by ((the)) each joint self-insurance
program to the state of Washington, office of financial
management within ((thirty)) sixty days of the date of
invoice. Any joint self-insurance program failing to remit
its fee when due is subject to denial of permission to operate
or to a cease and desist order until the fee is paid.
(((4))) (3) A joint self-insurance program that has
voluntarily or involuntarily terminated shall continue to pay
an administrative ((cost assessment and review and
investigation fees)) fee until such time as all liabilities
for unpaid claims and claim adjustment expenses and all
administrative responsibilities of the joint self-insurance
program have been satisfied.
(((5))) (4) The state risk manager shall assess each
prospective joint self-insurance program((, and each
prospective individual health and welfare benefit
self-insurance program,)) an initial investigation fee at a
rate determined annually by the state risk manager, with the
concurrence of the advisory boards. ((Such fee shall be
sufficient to cover the costs for the initial review and
approval of that self-insurance program.))
[Statutory Authority: RCW 48.62.061. 05-04-072, amended and recodified as § 82-60-100, filed 2/1/05, effective 3/4/05. Statutory Authority: Chapter 48.62 RCW. 93-16-079, § 236-22-100, filed 8/3/93, effective 9/3/93; 92-12-092, § 236-22-100, filed 6/3/92, effective 7/1/92.]
(2) The state risk manager shall review any fee appealed by a joint self-insurance program, together with the reasons for the appeal. Within fourteen days of receipt of notification from the self-insurance program, the state risk manager shall respond in writing to the self-insurance program, either reaffirming the fee or modifying it, and stating the reasons for the decision.
[Statutory Authority: RCW 48.62.061. 05-04-072, amended and recodified as § 82-60-200, filed 2/1/05, effective 3/4/05. Statutory Authority: Chapter 48.62 RCW. 93-16-079, § 236-22-200, filed 8/3/93, effective 9/3/93.]
[Statutory Authority: RCW 48.62.061. 05-04-072, amended and recodified as § 82-60-210, filed 2/1/05, effective 3/4/05. Statutory Authority: Chapter 48.62 RCW. 93-16-079, § 236-22-210, filed 8/3/93, effective 9/3/93.]
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The following sections of the Washington Administrative Code are repealed:
WAC 82-60-031 | Program financing. |
WAC 82-60-032 | Nondiscrimination in contributions. |
WAC 82-60-035 | Wellness programs. |
WAC 82-60-070 | State risk manager may waive requirements. |