WSR 11-07-101

PROPOSED RULES

OFFICE OF

INSURANCE COMMISSIONER

[ Insurance Commissioner Matter No. R 2010-16 -- Filed March 23, 2011, 9:29 a.m. ]

Original Notice.

Preproposal statement of inquiry was filed as WSR 11-01-138.

Title of Rule and Other Identifying Information: Guaranteed issue enrollment of persons under age nineteen.

Hearing Location(s): Office of the Insurance Commissioner, 5000 Capitol Way South, Tumwater, WA, on April 27, 2011, at 10:00 a.m.

Date of Intended Adoption: May 25, 2011.

Submit Written Comments to: Meg Jones, P.O. Box 40258, Olympia, WA 98504-0258, e-mail megj@oic.wa.gov, fax (360) 586-3109, by April 26, 2011.

Assistance for Persons with Disabilities: Contact Lorrie [Lorie] Villaflores by April 24, 2011, TTY (360) 586-0241 or (360) 725-7087.

Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: Under this rule making, the commissioner proposes rules providing guidance to carriers, and those who seek insurance for persons under age nineteen regarding how the new federal law, P.L. 111-148 and the interim final regulations issued June 28, 2010, found at Vol. 75 F.R. 37187-37241, and codified in 45 C.F.R. Parts 144, 146 and 147 will be implemented in Washington's individual health insurance market.

Reasons Supporting Proposal: Open enrollment periods were requested by several health carriers to implement this federal requirement, to mitigate the risk of adverse selection in the individual market. The proposed rules provide for this. In addition, consumer information and protections are included to ensure that there is access and information about the under nineteen enrollment requirements during both open and special enrollment periods.

Statutory Authority for Adoption: RCW 48.02.060, 48.18.120(2), 48.20.450, 48.44.050, 48.46.200.

Statute Being Implemented: RCW 48.18.120(2), 48.20.450, 48.43.012, 48.43.015, 48.43.018; P.L. 111-148, sec. 2704.

Rule is necessary because of federal law, P.L. 111-148 and the interim final regulations issued June 28, 2010, found at Vol. 75 F.R. 37187-37241, and codified in 45 C.F.R. Parts 144, 146 and 147.

Name of Proponent: Office of the insurance commissioner, governmental.

Name of Agency Personnel Responsible for Drafting: Meg Jones, P.O. Box 40528 [40258], Olympia, WA, (360) 725-7170; Implementation: Beth Berendt, P.O. Box 40255, Olympia, WA, (360) 725-7117; and Enforcement: Carol Sureau, P.O. Box 40255, Olympia, WA, (360) 725-7047.

No small business economic impact statement has been prepared under chapter 19.85 RCW. None of the entities affected by the proposed rule qualify as small business entities.

A cost-benefit analysis is required under RCW 34.05.328. A preliminary cost-benefit analysis may be obtained by contacting Meg Jones, P.O. Box 40258, Olympia, WA 98504, phone (360) 725-7170, fax (360) 586-3109, e-mail megj@oic.wa.gov.

March 23, 2011

Mike Kreidler

Insurance Commissioner

OTS-3875.4

SUBCHAPTER J

HEALTH PLAN ENROLLMENT AND COVERAGE REQUIREMENTS
NEW SECTION
WAC 284-43-970   Purpose and scope.   These rules explain the requirements in effect in Washington governing the issue of individual health insurance or health benefit plans to persons under age nineteen, based on section 2704 of the Public Health Service Act, as amended by section 1201 of the Patient Protection and Affordable Care Act, P.L. 111-148 and the interim final regulations interpreting it, 45 CFR 145.103 and 147.108 (2010), which provide that a carrier may not apply preexisting condition exclusions or coverage limitations for persons under age nineteen.

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NEW SECTION
WAC 284-43-975   Definitions.   As used in this section, unless the context requires otherwise:

(1) "Applicant" means a person who applies for enrollment in an individual health plan as a subscriber or an enrollee, or the dependent or spouse of a subscriber or enrollee. For purposes of this subchapter J, a legal guardian is an applicant if they apply for an individual coverage on behalf of a person under age nineteen.

(2) "Carrier" has the same meaning as its definition in RCW 48.43.005(18) and includes "issuers" as that term is used in the Patient Protection and Affordable Care Act, P.L. 111-148.

(3) "Open enrollment" means a period of time as defined in these rules, held at the same time each year, during which applicants may enroll in the carrier's individual health benefit plan without being subject to health screening or otherwise required to provide evidence of insurability as a condition for enrollment.

(4) "Special enrollment" means a defined period of time of not less than thirty-one days, triggered by a specific qualifying event experienced by the applicant, during which applicants may enroll in the carrier's individual health benefit plan without being subject to health screening or otherwise required to provide evidence of insurability as a condition for enrollment.

(5) "Standard health questionnaire" means the standard health questionnaire designated under chapter 48.41 RCW.

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NEW SECTION
WAC 284-43-980   Preexisting conditions.   For any individual health benefit plan, a carrier must waive any exclusion of benefits, including a denial of coverage, and may not otherwise limit coverage based upon a preexisting condition waiting period if the applicant or enrollee is a person under age nineteen. This requirement:

(1) Does not apply to an individual grandfathered plan as defined under P.L. 111-148 (2010), the Patient Protection and Affordable Care Act;

(2) Includes those persons under age nineteen with a preexisting condition who seek coverage as the primary insured or as a dependent or as a spouse under individual health benefit plans that permit the enrollment of dependents, and enrolled persons under age nineteen who seek benefits for which they are otherwise eligible.

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NEW SECTION
WAC 284-43-985   Enrollment of persons under age nineteen.   (1) For any individual health benefit plan offered after January 1, 2011, a carrier must conduct an open enrollment period for persons under age nineteen during two time periods each year. The first open enrollment period must occur from March 15th through April 30th of each year, and the second open enrollment period must occur from September 15th through October 31st.

(2) A carrier must use the same method to establish the effective date of coverage for persons under age nineteen enrolled during the open enrollment periods set forth in this rule that they use for any other individual health benefit plan enrollee.

(3) A carrier must make a special enrollment period of not less than thirty-one days available to any person under age nineteen who experiences a qualifying event. A qualifying event means the occurrence of one of the following:

(a) The discontinuation for any reason of employer sponsored insurance coverage of a person under age nineteen or the person under whose policy they were enrolled;

(b) The loss of eligibility of person under age nineteen for medicaid or a public program providing health benefits;

(c) The loss of coverage for a person under age nineteen as the result of dissolution of marriage;

(d) The person under age nineteen or the person under whose policy they were enrolled changes residence, and the health plan under which they were covered does not provide coverage in that person's new service area;

(e) The person for whom coverage is sought was born, placed for adoption or adopted within sixty days of the application for enrollment. For newborns enrolled under an individual policy, coverage must be effective as of the moment of birth. The requirements of RCW 48.20.430, 48.44.212, and 48.46.250 continue to apply outside an open enrollment period;

(f) Nothing in this rule is intended to alter or affect the application of RCW 48.43.517.

(4) A carrier must use the same method to determine the effective date of coverage for persons under age nineteen enrolled during a special enrollment period set forth in this rule that they use for any other individual health benefit plan enrollee.

(5) During the enrollment periods described in subsections (1) through (4) of this section, or any other enrollment period, a carrier must not require a person under age nineteen applying for an individual health benefit plan to complete the standard health questionnaire designated under chapter 48.41 RCW or otherwise provide evidence of insurability.

(6) A carrier may offer enrollment in an individual health benefit plan outside the open or special enrollment period, but must not require any evidence of insurability or completion of the standard health questionnaire if the applicant is a person under age nineteen.

(7) A carrier must not limit the choice of individual plan for which a person under age nineteen may apply based on the applicant's age.

(8) A carrier must prominently display on its web site information about open enrollment periods and special enrollment periods for persons under age nineteen.

(a) If a carrier elects to limit enrollment for persons under nineteen to the open enrollment periods, the carrier must:

(i) Explain that fact on its web site;

(ii) Promptly make application packets available to interested persons upon request, including outside the open enrollment periods; and

(iii) Provide contact information for the Washington state high risk pool and the federally sponsored preexisting condition insurance pool - Washington.

(b) The web site information about special enrollment periods must include the ability to access or request and receive an application packet for enrollment at any time. The displayed information must also include details written in plain language explaining what constitutes a qualifying event for special enrollment.

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Washington State Code Reviser's Office