PROPOSED RULES
INSURANCE COMMISSIONER
Original Notice.
Preproposal statement of inquiry was filed as WSR 08-11-107.
Title of Rule and Other Identifying Information: Carrier health plan disclosure.
Hearing Location(s): Insurance Commissioner's Office (OIC), 5000 Capitol Boulevard, Room TR 120, Tumwater, WA 98504-0255, on December 22, 2009, at 10:00 a.m.
Date of Intended Adoption: December 29, 2009.
Submit Written Comments to: Donna Dorris, P.O. Box 40258, Olympia, WA 98504-0258, e-mail donnad@oic.wa.gov, fax (360) 586-3109, by December 21, 2009.
Assistance for Persons with Disabilities: Contact Lori Villaflores by December 21, 2009, TTY (360) 586-0241 or (360) 725-7087.
Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules:
• Eliminating the requirement that carriers file health plan disclosure information with the OIC.
• Requiring carriers to prominently post and display health plan disclosure information on their web sites, provide disclosure information in other forms of electronic communication and paper copies upon request.
Anticipated Effects, Including Any Changes in Existing Rules:
• Carriers will no longer file health disclosure information with the OIC.
• Prospective enrollees have easier access to the most current health disclosure information when selecting a health benefit plan.
Reasons Supporting Proposal:
• Advances in types of electronic communication allow updated health disclosure information to be available in more accurate and timely forms of communication.
• A larger percentage of the population today utilizes electronic communication as an acceptable, comfortable and everyday way of sending and receiving communications. This rule reflects that reality.
• The rule eliminates a filing requirement that the commissioner determined was unnecessary and potentially created confusion for consumers.
• The rule supports the commissioner's business goals of administrative simplification by streamlining the process of disclosing health plan information to consumers, thereby reducing costs for the industry as well as the OIC.
Statutory Authority for Adoption: RCW 48.02.060, 48.43.510.
Statute Being Implemented: RCW 48.43.510.
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: Donna Dorris, P.O. Box 40258, Olympia, WA 98504-0258, (360) 725-7040; Implementation: Beth Berendt, P.O. Box 40255, Olympia, WA 98504-0255, (360) 725-7117; and Enforcement: Carol Sureau, 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. No domestic small businesses are affected by this proposed rule. Therefore, no small business economic impact statement is required.
A cost-benefit analysis is required under RCW 34.05.328. A preliminary cost-benefit analysis may be obtained by contacting Donna Dorris, P.O. Box 40258, Olympia, WA 98504-0258, phone (360) 725-7040, fax (360) 586-3109, e-mail donnad@oic.wa.gov.
November 16, 2009
Mike Kreidler
Insurance Commissioner
OTS-2746.2
AMENDATORY SECTION(Amending Matter No. R 2000-02, filed
1/9/01, effective 7/1/01)
WAC 284-43-820
Health plan disclosure((s -- Prescription
drugs, preventive care, generally)) requirements.
(((1) A
carrier that offers a health plan may not offer to sell a
health plan to an enrollee or to any group representative,
agent, employer, or enrollee representative without first
offering to provide, and providing upon request, the following
information using a standardized summary format filed with the
commissioner and consistent with WAC 284-43-815 before
purchase or selection:
(a) A listing of covered benefits, including prescription
drug benefits, if any, and how consumers may be involved in
decisions about benefits;
(b) A listing of exclusions, reductions, and limitations
to covered benefits, including definitions of terms such as
formulary, generic versus brand name, medical necessity or
other coverage criteria and policies regarding coverage of
drugs, including how drugs are added or removed from the
formulary;
(c) A statement of the carrier's policies for protecting
the confidentiality of health information;
(d) A statement of the cost of premiums and any enrollee
cost-sharing requirements;
(e) A summary explanation of the carrier's grievance
process;
(f) A statement regarding the availability of a
point-of-service option, if any, and how the option operates;
and
(g) A convenient means of obtaining a complete and
detailed list of covered benefits including a copy of the
current formulary, if any is used, a list of participating
primary care and specialty care providers, including
disclosure of network arrangements that restrict access to
providers within any plan network. The offer to provide the
information referenced in this subsection (1) must be clearly
and prominently displayed on any information provided to any
prospective enrollee or to any prospective group
representative, agent, employer, or enrollee representative.
(2) Upon the request of any person, including a current
enrollee, prospective enrollee, or the insurance commissioner,
a carrier must provide written information regarding any
health care plan it offers, that includes the following
written information:
(a) Any documents, instruments, or other information
referred to in the medical coverage agreement;
(b) A full description of the procedures to be followed
by an enrollee for consulting a provider other than the
primary care provider and whether the enrollee's primary care
provider, the carrier's medical director, or another entity
must authorize the referral;
(c) Procedures, if any, that an enrollee must first
follow for obtaining prior authorization for health care
services;
(d) A written description of any reimbursement or payment
arrangements, including, but not limited to, capitation
provisions, fee-for-service provisions, and health care
delivery efficiency provisions, between a carrier and a
provider or network;
(e) Descriptions and justifications for provider
compensation programs, including any incentives or penalties
that are intended to encourage providers to withhold services
or minimize or avoid referrals to specialists;
(f) An annual accounting of all payments made by the
carrier which have been counted against any payment
limitations, visit limitations, or other overall limitations
on a person's coverage under a plan;
(g) A copy of the carrier's grievance process for claim
or service denial and for dissatisfaction with care; and
(h) Accreditation status with one or more national
managed care accreditation organizations, and whether the
carrier tracks its health care effectiveness performance using
the health employer data information set (HEDIS), whether it
publicly reports its HEDIS data, and how interested persons
can access its HEDIS data.
(3) Each carrier shall provide to all enrollees and
prospective enrollees a list of available disclosure items.
(4) Nothing in this section requires a carrier or a
health care provider to divulge proprietary information to an
enrollee, including the specific contractual terms and
conditions between a carrier and a particular provider.
(5) No carrier may advertise or market any health plan to
the public, including to any employer as a plan that covers
services that help prevent illness or promote the health of
enrollees unless it:
(a) Provides all clinical preventive health services
provided by the basic health plan, authorized by chapter 70.47 RCW;
(b) Monitors and reports annually to enrollees on
standardized measures of health care and satisfaction of all
enrollees in the health plan. Standardized measures for this
purpose, include HEDIS, consumer assessment of health plans
(CAHP) or other national standardized measurement systems
adopted by national managed care accreditation organizations
or state agencies that purchase managed health care services
and approved by the commissioner; and
(c) Makes available upon request to enrollees its
integrated plan to identify and manage the most prevalent
diseases within its enrolled population, including cancer,
heart disease, and stroke. Such plans must include means to
identify enrollees with these diseases, implement evidence
based screening, education, monitoring and treatment
protocols, track patient and provider adherence to these
protocols, measure health outcomes, and regularly report
results to enrollees.
(6) No carrier may preclude or discourage its providers
from informing an enrollee of the care he or she requires,
including various treatment options, and whether in the
providers' view such care is consistent with the plan's health
coverage criteria, or otherwise covered by the enrollee's
medical coverage agreement with the carrier. No carrier may
prohibit, discourage, or penalize a provider otherwise
practicing in compliance with the law from advocating on
behalf of an enrollee with a carrier. Nothing in this section
shall be construed to authorize a provider to bind a carrier
to pay for any service.
(7) No carrier may preclude or discourage enrollees or
those paying for their coverage from discussing the
comparative merits of different carriers with their providers.
This prohibition specifically includes prohibiting or
limiting providers participating in those discussions even if
critical of a carrier.
(8) Each carrier must communicate enrollee information
required in this act by means that ensure that a substantial
portion of the enrollee population can make use of the
information.)) (1) Health plan disclosure information must
comply with and include each requirement listed in RCW 48.43.510.
(2) Health plan disclosures must be current and:
(a) Provided by paper copy upon request;
(b) Provided by electronic communication upon request;
(c) Clearly identified as health plan disclosures; and
(d) Prominently displayed and accessible on the carrier's web site.
(3) Each disclosure must be written in a manner that is easily understood by the average plan participant.
(4) Each carrier must provide to all enrollees and prospective enrollees a list of available disclosure items, including instructions on how to access and request copies of health disclosure information in paper and electronic forms, and web site links to the entire health plan disclosure information.
[Statutory Authority: RCW 48.02.060, 48.18.120, 48.20.450, 48.20.460, 48.30.010, 48.44.050, 48.46.100, 48.46.200, 48.43.505, 48.43.510, 48.43.515, 48.43.520, 48.43.525, 48.43.530, 48.43.535. 01-03-033 (Matter No. R 2000-02), § 284-43-820, filed 1/9/01, effective 7/1/01.]