BP BHEAD INT H

AN ACT Relating to disclosure by health carriers; adding a new section to chapter 48.43 RCW; and creating a new section.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF WASHINGTON:

NEW SECTION. Sec. 1. A new section is added to chapter 48.43 RCW to read as follows:

(1) Each health carrier that offers a health plan as defined in RCW 48.43.--- (section 4, chapter 265, Laws of 1995) to the public shall provide disclosure forms in a manner prescribed by the insurance commissioner. The disclosure forms shall include the following:

(a) A separate roster of plan primary care providers who are regulated by chapter 18.130 RCW, including the provider's degree and certification, practice specialty, the year first licensed to practice, and, if different, the year initially licensed to practice in Washington state;

(b) In concise and specific terms:

(i) The premium cost of the health plan coverage;

(ii) Copayment, coinsurance, or deductible requirements; and

(iii) The health plan benefits to which an enrollee is entitled. The disclosure shall state where and in what manner an enrollee may obtain services, including the procedures for selecting or changing primary care providers and the locations of hospitals and outpatient treatment centers that are under contract with the health carrier;

(c) Any limitations of the services, kinds of service, benefits, and exclusions that apply to the plan. A description of limitations shall include:

(i) Procedures for emergency room, nighttime, or weekend visits and referrals to specialist providers;

(ii) Whether services received outside the plan are covered and in what manner they are covered;

(iii) Procedures an enrollee must follow, if any, to obtain prior authorization for services;

(iv) The circumstances under which prior authorization is required for emergency medical care and a statement as to whether and where the plan provides twenty-four-hour emergency services;

(v) The circumstances under which the plan may retroactively deny coverage for emergency medical treatment and nonemergency medical treatment that had prior authorization under the plan's written policies;

(vi) A statement whether plan providers must comply with any specified numbers, targeted averages, or maximum durations of patient visits. If any of these are required of plan providers, the disclosure shall state the specific requirements;

(vii) The procedures to be followed by an enrollee for consulting a provider other than the primary care provider, and whether the enrollee's provider, the plan's medical director, or a committee must first authorize the referral;

(viii) The necessity of repeating prior authorization if the specialist care is continuing; and

(ix) Whether a point of service option is available, and if so, how it is structured;

(d) Grievance procedures for claim or treatment denials, dissatisfaction with care, and access to care issues;

(e) A response to whether a plan provider is restricted to prescribing drugs from a plan list or plan formulary and the extent to which an enrollee will be reimbursed for costs of a drug that is not on a plan list or plan formulary;

(f) A response to whether plan provider compensation programs include any incentives or penalties that are intended to encourage plan providers to withhold services or minimize or avoid referrals to specialists. If these types of incentives or penalties are included, the health carrier shall provide a concise description of them. The health carrier may also include, in a separate section, a concise explanation or justification for the use of these incentives or penalties; and

(g) A statement that the disclosure form is a summary only and that the plan evidence of coverage should be consulted to determine governing contractual provisions.

(2) A health carrier shall not disseminate a completed disclosure form until the form is submitted to the insurance commissioner. For purposes of this section, a health carrier is not required to submit to the insurance commissioner its separate roster of plan providers or any roster updates.

(3) Upon request, a health carrier shall provide the information required under subsection (1) of this section to all employers who are considering participating in a health plan that is offered by the health carrier or to an employer that is considering renewal of a plan that is provided by the health carrier.

(4) An employer shall provide to its eligible employees the disclosures required under subsection (1) of this section no later than the initiation of any open enrollment period or at least ten days before any employee enrollment deadline that is not associated with an open enrollment period.

(5) An employer shall not execute a contract with a health carrier until the employer receives the information required under subsection (1) of this section.

NEW SECTION. Sec. 2. Nothing in this act provides any private right or cause of action to, or on behalf of, any enrollee, prospective enrollee, employer, or other person, whether a resident or nonresident of this state. This act provides solely an administrative remedy to the insurance commissioner for any violation of Title 48 RCW or any related rule.