Washington State House of Representatives Office of Program Research	BILL ANALYSIS
Health Care Committee

HB 1728

Brief Description:  Regulating the activities of insurance third‑party administrators.

Sponsors:  Representatives Campbell, Schual‑Berke, Skinner and Cody.

Brief Summary of Bill

$Regulates third party administrators for health carriers under Title 48 RCW.

Hearing Date:  2/15/01

Staff:  Dave Knutson (786‑7146).

Background: 

The insurance industry is regulated by the Insurance Commissioner under the statutory authority granted in Title 48 RCW.  The commissioner oversees the corporate activities of health carriers and regulates the provisions of health insurance services to consumers.

A ?third party administrator@ manages a health insurance program or health plan for an organization, and functions as an intermediary between a health carrier and an insured person.  Third party administrators typically process claims and may also collect premiums and solicit enrollees.  Some administrators are given broad authority to manage an insurance plan, including rejecting claims. 

There are currently no state statutes or regulations specific to the regulation of third party administrators for health carriers.

Summary of Bill: 

A new chapter is added to the insurance code, Title 48 RCW, setting forth a statutory scheme for the regulation by the commissioner of "third party administrator=s@ (TPA).  A TPA is defined as "a person who directly or indirectly underwrites, collects charges or premiums, or adjusts or settles claims, in connection with health insurance coverage offered by an health carrier. . . .@   The chapter addresses licensing requirements, the regulatory powers of the commissioner, and the legal obligations among the insurer, the insured, and the TPA. 

A detailed written agreement is required between a TPA and a health carrier that addresses the duties assumed by the TPA on behalf of the carrier.  The agreement must address all TPA functions required under the chapter.

The TPA is required to keep extensive records regarding all transactions.  The commissioner has a right of access to these records, but such access does not otherwise affect the confidentiality of the records.  The commissioner is barred from any disclosure of the records, except to the extent necessary in the exercise of his regulatory authority.

The business relationship between the TPA and the health carrier is subject to considerable regulation, with the carrier being primarily responsible for the proper management of the program.

The TPA has a duty of disclosure to both the health carrier and an enrollee. An enrollee must be informed of the nature of the contractual relationship among the parties and any fees charged by the TPA must be itemized separate from any premium.

The licensing requirements for TPAs are subject to extensive regulation by the commissioner, who is granted broad latitude with respect to the issuance, suspension and revocation of licenses.

The commissioner may deny a license if he determines that an applicant is incompetent, untrustworthy, financially irresponsible, has a poor personal or business reputation, has been subject to denial or revocation of a license in another jurisdiction, or would be subject to license suspension or revocation as provided elsewhere in the chapter.

It is mandatory that the commissioner deny, suspend or revoke a license if a TPA is found to be in unsound financial condition, or the business is potentially injurious to health carriers or the public, or the TPA has failed to pay any judgment within 60 days of entry.  Such action is discretionary for certain violations of law or regulations, failure to cooperate with the regulatory process, criminal behavior, insolvency, or potentially harmful business practices.  A fine may be imposed in lieu of other discretionary action by the commissioner.

A TPA is required to file an annual report with the commissioner identifying the health carriers represented by the TPA and such other information as may be required by the commissioner.  The commissioner, in turn, is required to complete a review of each TPA doing business in this state.  The commissioner must certify that the TPA is either solvent and in compliance with existing law, or note any deficiencies in the operations of the TPA.

Appropriation:  None.

Fiscal Note:  Requested on February 13, 2001.

Effective Date:  Ninety days after adjournment of session in which bill is passed.