Z-1478.1 _______________________________________________
SENATE BILL 6208
_______________________________________________
State of Washington 53rd Legislature 1994 Regular Session
By Senators Moore, Prince, Prentice, Amondson and McAuliffe; by request of Insurance Commissioner
Read first time 01/17/94. Referred to Committee on Labor & Commerce.
AN ACT Relating to making form and rate filings of health maintenance organizations and health care service contractors subject to prior approval; and amending RCW 48.44.020, 48.44.070, 48.46.060, and 48.46.243.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF WASHINGTON:
Sec. 1. RCW 48.44.020 and 1990 c 120 s 5 are each amended to read as follows:
(1) Any health care service contractor may enter into contracts with or for the benefit of persons or groups of persons which require prepayment for health care services by or for such persons in consideration of such health care service contractor providing one or more health care services to such persons and such activity shall not be subject to the laws relating to insurance if the health care services are rendered by the health care service contractor or by a participating provider.
(2) ((The commissioner may on examination,))
Such contracts and any amendment, rider, or endorsement thereto shall not be
issued, delivered, or used until filed with and approved by the commissioner.
Rates or modification of rates for such health care service contracts shall not
be used until filed with and approved by the commissioner.
(3) A contract form not affirmatively disapproved within sixty days of filing shall be deemed approved, except that the commissioner may extend the approval period an additional fifteen days upon giving notice before the expiration of the initial sixty-day period. The commissioner may approve such a contract form for immediate use at any time. Approval may be subsequently withdrawn for cause.
(4) The commissioner may, subject to the right of the health care service contractor to demand and receive a hearing under chapters 48.04 and 34.05 RCW, disapprove any contract form for any of the following grounds:
(a) If it contains or incorporates by reference any inconsistent, ambiguous or misleading clauses, or exceptions and conditions which unreasonably or deceptively affect the risk purported to be assumed in the general coverage of the contract; or
(b) If it has any title, heading or other indication of its provisions which is misleading; or
(c) If purchase of health care services thereunder is being solicited by deceptive advertising; or
(d) If, the benefits provided therein are unreasonable in relation to the amount charged for the contract;
(e) If it contains unreasonable restrictions on the treatment of patients;
(f) If it violates any provision of ((this
chapter)) applicable state or federal law;
(g) If it fails to conform to minimum
provisions or standards required by ((regulation made by the commissioner
pursuant to)) rule adopted under chapter 34.05 RCW;
(h) If any contract for health care services with any state agency, division, subdivision, board or commission or with any political subdivision, municipal corporation, or quasi-municipal corporation fails to comply with state law.
(((3))) (5)(a) Every contract
between a health care service contractor and a participating provider of health
care services shall be in writing and shall state that in the event the health
care service contractor fails to pay for health care services as provided in
the contract, the enrolled participant shall not be liable to the provider for
sums owed by the health care service contractor. Every such contract shall
provide that this requirement shall survive termination of the contract.
(b) No participating provider, agent, trustee or assignee may maintain any action against an enrolled participant to collect sums owed by the health care service contractor.
Sec. 2. RCW 48.44.070 and 1990 c 120 s 9 are each amended to read as follows:
(1) Forms of contracts between health care service contractors and participating providers shall be filed with and approved by the insurance commissioner prior to use.
(2) Any contract form not affirmatively
disapproved within ((fifteen)) sixty days of filing shall be
deemed approved, except that the commissioner may extend the approval period an
additional fifteen days upon giving notice before the expiration of the initial
((fifteen-day)) sixty-day period. The commissioner may approve
such a contract form for immediate use at any time. Approval may be
subsequently withdrawn for cause.
(3) Subject to the right of the health care service contractor to demand and receive a hearing under chapters 48.04 and 34.05 RCW, the commissioner may disapprove such a contract form if it is in any respect in violation of this chapter or if it fails to conform to minimum provisions or standards required by the commissioner by rule under chapter 34.05 RCW.
Sec. 3. RCW 48.46.060 and 1989 c 10 s 10 are each amended to read as follows:
(1) Any health maintenance organization may enter into agreements with or for the benefit of persons or groups of persons, which require prepayment for health care services by or for such persons in consideration of the health maintenance organization providing health care services to such persons. Such activity is not subject to the laws relating to insurance if the health care services are rendered directly by the health maintenance organization or by any provider which has a contract or other arrangement with the health maintenance organization to render health services to enrolled participants.
(2) Such agreements and any amendment, rider, or endorsement thereto shall not be issued, delivered, or used until filed with and approved by the commissioner. Rates or modification of rates for such health maintenance agreements shall not be used until filed with and approved by the commissioner.
(3) All forms of health maintenance agreements issued by the organization to enrolled participants or other marketing documents purporting to describe the organization's comprehensive health care services shall comply with such minimum standards as the commissioner deems reasonable and necessary in order to carry out the purposes and provisions of this chapter, and which fully inform enrolled participants of the health care services to which they are entitled, including any limitations or exclusions thereof, and such other rights, responsibilities and duties required of the contracting health maintenance organization.
(((3))) (4) An agreement form rate or
rate modification not affirmatively disapproved within sixty days of filing
shall be deemed approved, except that the commissioner may extend the approval
period an additional fifteen days upon giving notice before the expiration of
the initial sixty-day period. The commissioner may approve the agreement form
for immediate use at any time. Approval may be subsequently withdrawn for
cause.
(5) Subject to the right of the health maintenance organization to demand and receive a hearing under chapters 48.04 and 34.05 RCW, the commissioner may disapprove an agreement form for any of the following grounds:
(a) If it contains or incorporates by reference any inconsistent, ambiguous, or misleading clauses, or exceptions or conditions which unreasonably or deceptively affect the risk purported to be assumed in the general coverage of the agreement;
(b) If it has any title, heading, or other indication which is misleading;
(c) If purchase of health care services thereunder is being solicited by deceptive advertising;
(d) If the benefits provided therein are unreasonable in relation to the amount charged for the agreement;
(e) If it contains unreasonable restrictions on the treatment of patients;
(f) If it is in any respect in violation of ((this
chapter)) applicable state or federal law or if it fails to conform
to minimum provisions or standards required by ((the commissioner by rule
under)) rule adopted under chapter 34.05 RCW; or
(g) If any agreement for health care services with any state agency, division, subdivision, board or commission or with any political subdivision, municipal corporation, or quasi-municipal corporation fails to comply with state law.
(((6))) (5) No health maintenance
organization authorized under this chapter shall cancel or fail to renew the
enrollment on any basis of an enrolled participant or refuse to transfer an
enrolled participant from a group to an individual basis for reasons relating
solely to age, sex, race, or health status: PROVIDED HOWEVER, That nothing
contained herein shall prevent cancellation of an agreement with enrolled
participants (a) who violate any published policies of the organization which
have been approved by the commissioner, or (b) who are entitled to become
eligible for medicare benefits and fail to enroll for a medicare supplement
plan offered by the health maintenance organization and approved by the
commissioner, or (c) for failure of such enrolled participant to pay the
approved charge, including cost-sharing, required under such contract, or (d)
for a material breach of the health maintenance agreement.
(((5))) (7) No agreement form or
amendment to an approved agreement form shall be used unless it is first filed
with the commissioner.
Sec. 4. RCW 48.46.243 and 1990 c 119 s 7 are each amended to read as follows:
(1) Subject to subsection (2) of this section, every contract between a health maintenance organization and its participating providers of health care services shall be in writing and shall set forth that in the event the health maintenance organization fails to pay for health care services as set forth in the agreement, the enrolled participant shall not be liable to the provider for any sums owed by the health maintenance organization. Every such contract shall provide that this requirement shall survive termination of the contract.
(2) The provisions of subsection (1) of this section shall not apply to emergency care from a provider who is not a participating provider, to out-of-area services or, in exceptional situations approved in advance by the commissioner, if the health maintenance organization is unable to negotiate reasonable and cost-effective participating provider contracts.
(3)(a) Each participating provider contract
form shall be filed with and approved by the commissioner ((fifteen))
sixty days before it is used.
(b) Any contract form not affirmatively
disapproved within ((fifteen)) sixty days of filing shall be
deemed approved, except that the commissioner may extend the approval period an
additional fifteen days upon giving notice before the expiration of the initial
((fifteen-day)) sixty-day period. The commissioner may approve
such a contract form for immediate use at any time. Approval may be
subsequently withdrawn for cause.
(c) Subject to the right of the health maintenance organization to demand and receive a hearing under chapters 48.04 and 34.05 RCW, the commissioner may disapprove such a contract form if it is in any respect in violation of this chapter or if it fails to conform to minimum provisions or standards required by the commissioner by rule under chapter 34.05 RCW.
(4) No participating provider, or agent, trustee, or assignee thereof, may maintain an action against an enrolled participant to collect sums owed by the health maintenance organization.
--- END ---