WSR 09-23-072




[ Insurance Commissioner Matter No R 2008-16 -- Filed November 16, 2009, 9:03 a.m. ]

     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, 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

November 16, 2009

Mike Kreidler

Insurance Commissioner


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.]

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