2018-S AMH CODY H2881.1

SHB 2018 - H AMD TO H AMD (H-2836.2/97) 311 WITHDRAWN 3-18-97

By Representative Cody

    On page 14, beginning on line 15 of the amendment, after "(1)" strike all material through "activities" on line 18 and insert ""((Adjusted)) Community rate" means the rating method used to establish the premium for health plans adjusted to reflect actuarially demonstrated differences in utilization or cost attributable to geographic region((, age,)) and family size((, and use of wellness activities))"

    Beginning on page 27, after line 18 of the amendment, strike all of sections 206 through 208 and insert the following:

    "Sec. 206.  RCW 48.20.028 and 1995 c 265 s 13 are each amended to read as follows:

    (1)(a) An insurer offering any health benefit plan to any individual shall offer and actively market to all individuals a health benefit plan providing benefits identical to the schedule of covered health services that are required to be delivered to an individual enrolled in the basic health plan.  Nothing in this subsection shall preclude an insurer from offering, or an individual from purchasing, other health benefit plans that may have more or less comprehensive benefits than the basic health plan, provided such plans are in accordance with this chapter.  An insurer offering a health benefit plan that does not include benefits provided in the basic health plan shall clearly disclose these differences to the individual in a brochure approved by the commissioner.

    (b) A health benefit plan shall provide coverage for hospital expenses and services rendered by a physician licensed under chapter 18.57 or 18.71 RCW but is not subject to the requirements of RCW 48.20.390, 48.20.393, 48.20.395, 48.20.397, 48.20.410, 48.20.411, 48.20.412, 48.20.416, and 48.20.420 if the health benefit plan is the mandatory offering under (a) of this subsection that provides benefits identical to the basic health plan, to the extent these requirements differ from the basic health plan.

    (2) Premiums for health benefit plans for individuals shall be calculated using the ((adjusted)) community rating method that spreads financial risk across the carrier's entire individual product population.  All such rates shall conform to the following:

    (a) The insurer shall develop its rates based on ((an adjusted)) a community rate and may only vary the ((adjusted)) community rate for:

    (i) Geographic area; and

    (ii) Family size((;

    (iii) Age; and

    (iv) Wellness activities)).

    (b) ((The adjustment for age in (a)(iii) of this subsection may not use age brackets smaller than five-year increments which shall begin with age twenty and end with age sixty-five.  Individuals under the age of twenty shall be treated as those age twenty.

    (c) The insurer shall be permitted to develop separate rates for individuals age sixty-five or older for coverage for which medicare is the primary payer and coverage for which medicare is not the primary payer.  Both rates shall be subject to the requirements of this subsection.

    (d) The permitted rates for any age group shall be no more than four hundred twenty-five percent of the lowest rate for all age groups on January 1, 1996, four hundred percent on January 1, 1997, and three hundred seventy-five percent on January 1, 2000, and thereafter.

    (e) A discount for wellness activities shall be permitted to reflect actuarially justified differences in utilization or cost attributed to such programs not to exceed twenty percent.

    (f))) The rate charged for a health benefit plan offered under this section may not be adjusted more frequently than annually except that the premium may be changed to reflect:

    (i) Changes to the family composition;

    (ii) Changes to the health benefit plan requested by the individual; or

    (iii) Changes in government requirements affecting the health benefit plan.

    (((g))) (c) For the purposes of this section, a health benefit plan that contains a restricted network provision shall not be considered similar coverage to a health benefit plan that does not contain such a provision, provided that the restrictions of benefits to network providers result in substantial differences in claims costs.  This subsection does not restrict or enhance the portability of benefits as provided in RCW 48.43.015.

    (3) ((Adjusted)) Community rates established under this section shall pool the medical experience of all individuals purchasing coverage, and shall not be required to be pooled with the medical experience of health benefit plans offered to small employers under RCW 48.21.045.

    (4) As used in this section, "health benefit plan," "basic health plan," "((adjusted)) community rate," and "wellness activities" mean the same as defined in RCW 48.43.005.

    Sec. 207. RCW 48.44.022 and 1995 c 265 s 15 are each amended to read as follows:

    (1)(a) A health care service contractor offering any health benefit plan to any individual shall offer and actively market to all individuals a health benefit plan providing benefits identical to the schedule of covered health services that are required to be delivered to an individual enrolled in the basic health plan.  Nothing in this subsection shall preclude a contractor from offering, or an individual from purchasing, other health benefit plans that may have more or less comprehensive benefits than the basic health plan, provided such plans are in accordance with this chapter.  A contractor offering a health benefit plan that does not include benefits provided in the basic health plan shall clearly disclose these differences to the individual in a brochure approved by the commissioner.

    (b) A health benefit plan shall provide coverage for hospital expenses and services rendered by a physician licensed under chapter 18.57 or 18.71 RCW but is not subject to the requirements of RCW 48.44.225, 48.44.240, 48.44.245, 48.44.290, 48.44.300, 48.44.310, 48.44.320, 48.44.325, 48.44.330, 48.44.335, 48.44.340, 48.44.344, 48.44.360, 48.44.400, 48.44.440, 48.44.450, and 48.44.460 if the health benefit plan is the mandatory offering under (a) of this subsection that provides benefits identical to the basic health plan, to the extent these requirements differ from the basic health plan.

    (2) Premium rates for health benefit plans for individuals shall be subject to the following provisions:

    (a) The health care service contractor shall develop its rates based on ((an adjusted)) a community rate and may only vary the ((adjusted)) community rate for:

    (i) Geographic area; and

    (ii) Family size((;

    (iii) Age; and

    (iv) Wellness activities)).

    (b) ((The adjustment for age in (a)(iii) of this subsection may not use age brackets smaller than five-year increments which shall begin with age twenty and end with age sixty-five.  Individuals under the age of twenty shall be treated as those age twenty.

    (c) The health care service contractor shall be permitted to develop separate rates for individuals age sixty-five or older for coverage for which medicare is the primary payer and coverage for which medicare is not the primary payer.  Both rates shall be subject to the requirements of this subsection.

    (d) The permitted rates for any age group shall be no more than four hundred twenty-five percent of the lowest rate for all age groups on January 1, 1996, four hundred percent on January 1, 1997, and three hundred seventy-five percent on January 1, 2000, and thereafter.

    (e) A discount for wellness activities shall be permitted to reflect actuarially justified differences in utilization or cost attributed to such programs not to exceed twenty percent.

    (f))) The rate charged for a health benefit plan offered under this section may not be adjusted more frequently than annually except that the premium may be changed to reflect:

    (i) Changes to the family composition;

    (ii) Changes to the health benefit plan requested by the individual; or

    (iii) Changes in government requirements affecting the health benefit plan.

    (((g))) (c) For the purposes of this section, a health benefit plan that contains a restricted network provision shall not be considered similar coverage to a health benefit plan that does not contain such a provision, provided that the restrictions of benefits to network providers result in substantial differences in claims costs.  This subsection does not restrict or enhance the portability of benefits as provided in RCW 48.43.015.

    (3) ((Adjusted)) Community rates established under this section shall pool the medical experience of all individuals purchasing coverage, and shall not be required to be pooled with the medical experience of health benefit plans offered to small employers under RCW 48.44.023.

    (4) As used in this section and RCW 48.44.023 "health benefit plan," "small employer," "basic health plan," "((adjusted)) community rates," and "wellness activities" mean the same as defined in RCW 48.43.005.

    Sec. 208.  RCW 48.46.064 and 1995 c 265 s 17 are each amended to read as follows:

    (1)(a) A health maintenance organization offering any health benefit plan to any individual shall offer and actively market to all individuals a health benefit plan providing benefits identical to the schedule of covered health services that are required to be delivered to an individual enrolled in the basic health plan.  Nothing in this subsection shall preclude a health maintenance organization from offering, or an individual from purchasing, other health benefit plans that may have more or less comprehensive benefits than the basic health plan, provided such plans are in accordance with this chapter.  A health maintenance organization offering a health benefit plan that does not include benefits provided in the basic health plan shall clearly disclose these differences to the individual in a brochure approved by the commissioner.

    (b) A health benefit plan shall provide coverage for hospital expenses and services rendered by a physician licensed under chapter 18.57 or 18.71 RCW but is not subject to the requirements of RCW 48.46.275, ((48.26.280 [48.46.280])) 48.46.280, 48.46.285, 48.46.290, 48.46.350, 48.46.355, 48.46.375, 48.46.440, 48.46.480, 48.46.510, 48.46.520, and 48.46.530 if the health benefit plan is the mandatory offering under (a) of this subsection that provides benefits identical to the basic health plan, to the extent these requirements differ from the basic health plan.

    (2) Premium rates for health benefit plans for individuals shall be subject to the following provisions:

    (a) The health maintenance organization shall develop its rates based on ((an adjusted)) a community rate and may only vary the ((adjusted)) community rate for:

    (i) Geographic area; and

    (ii) Family size((;

    (iii) Age; and

    (iv) Wellness activities)).

    (b) ((The adjustment for age in (a)(iii) of this subsection may not use age brackets smaller than five-year increments which shall begin with age twenty and end with age sixty-five.  Individuals under the age of twenty shall be treated as those age twenty.

    (c) The health maintenance organization shall be permitted to develop separate rates for individuals age sixty-five or older for coverage for which medicare is the primary payer and coverage for which medicare is not the primary payer.  Both rates shall be subject to the requirements of this subsection.

    (d) The permitted rates for any age group shall be no more than four hundred twenty-five percent of the lowest rate for all age groups on January 1, 1996, four hundred percent on January 1, 1997, and three hundred seventy-five percent on January 1, 2000, and thereafter.

    (e) A discount for wellness activities shall be permitted to reflect actuarially justified differences in utilization or cost attributed to such programs not to exceed twenty percent.

    (f))) The rate charged for a health benefit plan offered under this section may not be adjusted more frequently than annually except that the premium may be changed to reflect:

    (i) Changes to the family composition;

    (ii) Changes to the health benefit plan requested by the individual; or

    (iii) Changes in government requirements affecting the health benefit plan.

    (((g))) (c) For the purposes of this section, a health benefit plan that contains a restricted network provision shall not be considered similar coverage to a health benefit plan that does not contain such a provision, provided that the restrictions of benefits to network providers result in substantial differences in claims costs.  This subsection does not restrict or enhance the portability of benefits as provided in RCW 48.43.015.

    (3) ((Adjusted)) Community rates established under this section shall pool the medical experience of all individuals purchasing coverage, and shall not be required to be pooled with the medical experience of health benefit plans offered to small employers under RCW 48.46.066.

    (4) As used in this section and RCW 48.46.066, "health benefit plan," "basic health plan," "((adjusted)) community rate," "small employer," and "wellness activities" mean the same as defined in RCW 48.43.005."

EFFECT:  Deletes adjusted community rating provisions that include "age" and "wellness," and exempts small businesses from compliance.  Inserts new community rating provisions that permit adjustments only for geographic differences and family size, per the 1993 Health Reform Act.

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