BILL REQ. #: Z-0404.2
State of Washington | 62nd Legislature | 2011 Regular Session |
Read first time 01/14/11. Referred to Committee on Health & Long-Term Care.
AN ACT Relating to health care insurance; amending RCW 48.20.435, 48.21.270, 48.43.093, 48.43.530, 48.43.535, 48.44.215, 48.44.380, 48.46.325, 48.46.460, 48.20.025, 48.44.017, and 48.46.062; reenacting and amending RCW 48.43.005; and providing an effective date.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF WASHINGTON:
Sec. 1 RCW 48.20.435 and 2007 c 259 s 19 are each amended to read
as follows:
Any disability insurance contract that provides coverage for a
subscriber's dependent must offer the option of covering any
((unmarried)) dependent under the age of ((twenty-five)) twenty-six.
Sec. 2 RCW 48.21.270 and 1984 c 190 s 4 are each amended to read
as follows:
(1) An insurer shall not require proof of insurability as a
condition for issuance of the conversion policy.
(2) A conversion policy may not contain an exclusion for
preexisting conditions ((except)) for any applicant who is under age
nineteen. For policies issued to those age nineteen and older, an
exclusion for a preexisting condition is permitted only to the extent
that a waiting period for a preexisting condition has not been
satisfied under the group policy.
(3) An insurer must offer at least three policy benefit plans that
comply with the following:
(a) A major medical plan with a five thousand dollar deductible
((and a lifetime benefit maximum of two hundred fifty thousand
dollars)) per person;
(b) A comprehensive medical plan with a five hundred dollar
deductible ((and a lifetime benefit maximum of five hundred thousand
dollars)) per person; and
(c) A basic medical plan with a one thousand dollar deductible
((and a lifetime maximum of seventy-five thousand dollars)) per person.
(4) The insurance commissioner may revise the ((deductibles and
lifetime benefit)) deductible amounts in subsection (3) of this section
from time to time to reflect changing health care costs.
(5) The insurance commissioner shall adopt rules to establish
minimum benefit standards for conversion policies.
(6) The commissioner shall adopt rules to establish specific
standards for conversion policy provisions. These rules may include
but are not limited to:
(a) Terms of renewability;
(b) Nonduplication of coverage;
(c) Benefit limitations, exceptions, and reductions; and
(d) Definitions of terms.
Sec. 3 RCW 48.43.005 and 2010 c 292 s 1 are each reenacted and
amended to read as follows:
Unless otherwise specifically provided, the definitions in this
section apply throughout this chapter.
(1) "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, family size, and use of wellness activities.
(2) "Adverse benefit determination" means an adverse benefit
determination as defined in 29 C.F.R. 2560.503-1 (2010), as well as any
rescission of coverage, whether or not, in connection with the
rescission, there is an adverse effect on any particular benefit at
that time.
(3) "Basic health plan" means the plan described under chapter
70.47 RCW, as revised from time to time.
(((3))) (4) "Basic health plan model plan" means a health plan as
required in RCW 70.47.060(2)(e).
(((4))) (5) "Basic health plan services" means that schedule of
covered health services, including the description of how those
benefits are to be administered, that are required to be delivered to
an enrollee under the basic health plan, as revised from time to time.
(((5))) (6) "Catastrophic health plan" means:
(a) In the case of a contract, agreement, or policy covering a
single enrollee, a health benefit plan requiring a calendar year
deductible of, at a minimum, one thousand seven hundred fifty dollars
and an annual out-of-pocket expense required to be paid under the plan
(other than for premiums) for covered benefits of at least three
thousand five hundred dollars, both amounts to be adjusted annually by
the insurance commissioner; and
(b) In the case of a contract, agreement, or policy covering more
than one enrollee, a health benefit plan requiring a calendar year
deductible of, at a minimum, three thousand five hundred dollars and an
annual out-of-pocket expense required to be paid under the plan (other
than for premiums) for covered benefits of at least six thousand
dollars, both amounts to be adjusted annually by the insurance
commissioner; or
(c) Any health benefit plan that provides benefits for hospital
inpatient and outpatient services, professional and prescription drugs
provided in conjunction with such hospital inpatient and outpatient
services, and excludes or substantially limits outpatient physician
services and those services usually provided in an office setting.
In July 2008, and in each July thereafter, the insurance
commissioner shall adjust the minimum deductible and out-of-pocket
expense required for a plan to qualify as a catastrophic plan to
reflect the percentage change in the consumer price index for medical
care for a preceding twelve months, as determined by the United States
department of labor. The adjusted amount shall apply on the following
January 1st.
(((6))) (7) "Certification" means a determination by a review
organization that an admission, extension of stay, or other health care
service or procedure has been reviewed and, based on the information
provided, meets the clinical requirements for medical necessity,
appropriateness, level of care, or effectiveness under the auspices of
the applicable health benefit plan.
(((7))) (8) "Concurrent review" means utilization review conducted
during a patient's hospital stay or course of treatment.
(((8))) (9) "Covered person" or "enrollee" means a person covered
by a health plan including an enrollee, subscriber, policyholder,
beneficiary of a group plan, or individual covered by any other health
plan.
(((9))) (10) "Dependent" means, at a minimum, the enrollee's legal
spouse and unmarried dependent children who qualify for coverage under
the enrollee's health benefit plan.
(((10))) (11) "Emergency medical condition" means the emergent and
acute onset of a symptom or symptoms, including severe pain, that would
lead a prudent layperson acting reasonably to believe that a health
condition exists that requires immediate medical attention, if failure
to provide medical attention would result in serious impairment to
bodily functions or serious dysfunction of a bodily organ or part, or
would place the person's health in serious jeopardy.
(((11))) (12) "Emergency services" means ((otherwise covered health
care services medically necessary to evaluate and treat an emergency
medical condition, provided in a hospital emergency department)) a
medical screening examination, as required under section 1867 of the
social security act (42 U.S.C. 1395dd), that is within the capability
of the emergency department of a hospital, including ancillary services
routinely available to the emergency department to evaluate that
emergency medical condition, and further medical examination and
treatment, to the extent they are within the capabilities of the staff
and facilities available at the hospital, as are required under section
1867 of the social security act (42 U.S.C. 1395dd) to stabilize the
patient. Stabilize, with respect to an emergency medical condition,
has the meaning given in section 1867(e)(3) of the social security act
(42 U.S.C. 1395dd(e)(3)).
(((12))) (13) "Employee" has the same meaning given to the term, as
of January 1, 2008, under section 3(6) of the federal employee
retirement income security act of 1974.
(((13))) (14) "Enrollee point-of-service cost-sharing" means
amounts paid to health carriers directly providing services, health
care providers, or health care facilities by enrollees and may include
copayments, coinsurance, or deductibles.
(((14))) (15) "Final external review decision" means a
determination by an independent review organization at the conclusion
of an external review.
(16) "Final internal adverse benefit determination" means an
adverse benefit determination that has been upheld by a plan or carrier
at the completion of the internal appeals process, or an adverse
benefit determination with respect to which the internal appeals
process has been exhausted under the exhaustion rules described in RCW
48.43.530 and 48.43.535.
(17) "Grievance" means a written complaint submitted by or on
behalf of a covered person regarding: (a) Denial of payment for
medical services or nonprovision of medical services included in the
covered person's health benefit plan, or (b) service delivery issues
other than denial of payment for medical services or nonprovision of
medical services, including dissatisfaction with medical care, waiting
time for medical services, provider or staff attitude or demeanor, or
dissatisfaction with service provided by the health carrier.
(((15))) (18) "Health care facility" or "facility" means hospices
licensed under chapter 70.127 RCW, hospitals licensed under chapter
70.41 RCW, rural health care facilities as defined in RCW 70.175.020,
psychiatric hospitals licensed under chapter 71.12 RCW, nursing homes
licensed under chapter 18.51 RCW, community mental health centers
licensed under chapter 71.05 or 71.24 RCW, kidney disease treatment
centers licensed under chapter 70.41 RCW, ambulatory diagnostic,
treatment, or surgical facilities licensed under chapter 70.41 RCW,
drug and alcohol treatment facilities licensed under chapter 70.96A
RCW, and home health agencies licensed under chapter 70.127 RCW, and
includes such facilities if owned and operated by a political
subdivision or instrumentality of the state and such other facilities
as required by federal law and implementing regulations.
(((16))) (19) "Health care provider" or "provider" means:
(a) A person regulated under Title 18 or chapter 70.127 RCW, to
practice health or health-related services or otherwise practicing
health care services in this state consistent with state law; or
(b) An employee or agent of a person described in (a) of this
subsection, acting in the course and scope of his or her employment.
(((17))) (20) "Health care service" means that service offered or
provided by health care facilities and health care providers relating
to the prevention, cure, or treatment of illness, injury, or disease.
(((18))) (21) "Health carrier" or "carrier" means a disability
insurer regulated under chapter 48.20 or 48.21 RCW, a health care
service contractor as defined in RCW 48.44.010, or a health maintenance
organization as defined in RCW 48.46.020.
(((19))) (22) "Health plan" or "health benefit plan" means any
policy, contract, or agreement offered by a health carrier to provide,
arrange, reimburse, or pay for health care services except the
following:
(a) Long-term care insurance governed by chapter 48.84 or 48.83
RCW;
(b) Medicare supplemental health insurance governed by chapter
48.66 RCW;
(c) Coverage supplemental to the coverage provided under chapter
55, Title 10, United States Code;
(d) Limited health care services offered by limited health care
service contractors in accordance with RCW 48.44.035;
(e) Disability income;
(f) Coverage incidental to a property/casualty liability insurance
policy such as automobile personal injury protection coverage and
homeowner guest medical;
(g) Workers' compensation coverage;
(h) Accident only coverage;
(i) Specified disease or illness-triggered fixed payment insurance,
hospital confinement fixed payment insurance, or other fixed payment
insurance offered as an independent, noncoordinated benefit;
(j) Employer-sponsored self-funded health plans;
(k) Dental only and vision only coverage; and
(l) Plans deemed by the insurance commissioner to have a short-term
limited purpose or duration, or to be a student-only plan that is
guaranteed renewable while the covered person is enrolled as a regular
full-time undergraduate or graduate student at an accredited higher
education institution, after a written request for such classification
by the carrier and subsequent written approval by the insurance
commissioner.
(((20))) (23) "Material modification" means a change in the
actuarial value of the health plan as modified of more than five
percent but less than fifteen percent.
(((21))) (24) "Preexisting condition" means any medical condition,
illness, or injury that existed any time prior to the effective date of
coverage.
(((22))) (25) "Premium" means all sums charged, received, or
deposited by a health carrier as consideration for a health plan or the
continuance of a health plan. Any assessment or any "membership,"
"policy," "contract," "service," or similar fee or charge made by a
health carrier in consideration for a health plan is deemed part of the
premium. "Premium" shall not include amounts paid as enrollee point-of-service cost-sharing.
(((23))) (26) "Review organization" means a disability insurer
regulated under chapter 48.20 or 48.21 RCW, health care service
contractor as defined in RCW 48.44.010, or health maintenance
organization as defined in RCW 48.46.020, and entities affiliated with,
under contract with, or acting on behalf of a health carrier to perform
a utilization review.
(((24))) (27) "Small employer" or "small group" means any person,
firm, corporation, partnership, association, political subdivision,
sole proprietor, or self-employed individual that is actively engaged
in business that employed an average of at least one but no more than
fifty employees, during the previous calendar year and employed at
least one employee on the first day of the plan year, is not formed
primarily for purposes of buying health insurance, and in which a bona
fide employer-employee relationship exists. In determining the number
of employees, companies that are affiliated companies, or that are
eligible to file a combined tax return for purposes of taxation by this
state, shall be considered an employer. Subsequent to the issuance of
a health plan to a small employer and for the purpose of determining
eligibility, the size of a small employer shall be determined annually.
Except as otherwise specifically provided, a small employer shall
continue to be considered a small employer until the plan anniversary
following the date the small employer no longer meets the requirements
of this definition. A self-employed individual or sole proprietor who
is covered as a group of one must also: (a) Have been employed by the
same small employer or small group for at least twelve months prior to
application for small group coverage, and (b) verify that he or she
derived at least seventy-five percent of his or her income from a trade
or business through which the individual or sole proprietor has
attempted to earn taxable income and for which he or she has filed the
appropriate internal revenue service form 1040, schedule C or F, for
the previous taxable year, except a self-employed individual or sole
proprietor in an agricultural trade or business, must have derived at
least fifty-one percent of his or her income from the trade or business
through which the individual or sole proprietor has attempted to earn
taxable income and for which he or she has filed the appropriate
internal revenue service form 1040, for the previous taxable year.
(((25))) (28) "Utilization review" means the prospective,
concurrent, or retrospective assessment of the necessity and
appropriateness of the allocation of health care resources and services
of a provider or facility, given or proposed to be given to an enrollee
or group of enrollees.
(((26))) (29) "Wellness activity" means an explicit program of an
activity consistent with department of health guidelines, such as,
smoking cessation, injury and accident prevention, reduction of alcohol
misuse, appropriate weight reduction, exercise, automobile and
motorcycle safety, blood cholesterol reduction, and nutrition education
for the purpose of improving enrollee health status and reducing health
service costs.
Sec. 4 RCW 48.43.093 and 1997 c 231 s 301 are each amended to
read as follows:
(1) ((When conducting a review of the necessity and appropriateness
of emergency services or making a benefit determination for emergency
services:))
(a) A health carrier ((shall)) must cover emergency services
necessary to screen and stabilize a covered person if a prudent
layperson acting reasonably would have believed that an emergency
medical condition existed. In addition, a health carrier ((shall))
must not require prior authorization of such services provided prior to
the point of stabilization if a prudent layperson acting reasonably
would have believed that an emergency medical condition existed.
((With respect to care obtained from a nonparticipating hospital
emergency department, a health carrier shall cover emergency services
necessary to screen and stabilize a covered person if a prudent
layperson would have reasonably believed that use of a participating
hospital emergency department would result in a delay that would worsen
the emergency, or if a provision of federal, state, or local law
requires the use of a specific provider or facility. In addition, a
health carrier shall not require prior authorization of such services
provided prior to the point of stabilization if a prudent layperson
acting reasonably would have believed that an emergency medical
condition existed and that use of a participating hospital emergency
department would result in a delay that would worsen the emergency.))
(b) If an authorized representative of a health carrier authorizes
coverage of emergency services, the health carrier shall not
subsequently retract its authorization after the emergency services
have been provided, or reduce payment for an item or service furnished
in reliance on approval, unless the approval was based on a material
misrepresentation about the covered person's health condition made by
the provider of emergency services.
(b) Emergency services must be provided without the need for any
prior authorization determination, even if the emergency services are
provided on an out-of-network basis.
(c) Coverage of emergency services ((may be subject to applicable
copayments, coinsurance, and deductibles, and a health carrier may
impose reasonable differential cost-sharing arrangements for emergency
services rendered by nonparticipating providers, if such differential
between cost-sharing amounts applied to emergency services rendered by
participating provider versus nonparticipating provider does not exceed
fifty dollars. Differential cost sharing for emergency services may
not be applied when a covered person presents to a nonparticipating
hospital emergency department rather than a participating hospital
emergency department when the health carrier requires preauthorization
for postevaluation or poststabilization emergency services if:)) must be
provided without regard to any other term or condition of the coverage
other than:
(i) Due to circumstances beyond the covered person's control, the
covered person was unable to go to a participating hospital emergency
department in a timely fashion without serious impairment to the
covered person's health; or
(ii) A prudent layperson possessing an average knowledge of health
and medicine would have reasonably believed that he or she would be
unable to go to a participating hospital emergency department in a
timely fashion without serious impairment to the covered person's
health.
(d) If a health carrier requires preauthorization for
postevaluation or poststabilization services, the health carrier shall
provide access to an authorized representative twenty-four hours a day,
seven days a week, to facilitate review. In order for postevaluation
or poststabilization services to be covered by the health carrier, the
provider or facility must make a documented good faith effort to
contact the covered person's health carrier within thirty minutes of
stabilization, if the covered person needs to be stabilized. The
health carrier's authorized representative is required to respond to a
telephone request for preauthorization from a provider or facility
within thirty minutes. Failure of the health carrier to respond within
thirty minutes constitutes authorization for the provision of
immediately required medically necessary postevaluation and
poststabilization services, unless the health carrier documents that it
made a good faith effort but was unable to reach the provider or
facility within thirty minutes after receiving the request.
(e) A health carrier shall immediately arrange for an alternative
plan of treatment for the covered person if a nonparticipating
emergency provider and health plan cannot reach an agreement on which
services are necessary beyond those immediately necessary to stabilize
the covered person consistent with state and federal laws
(i) The exclusion or coordination of benefits;
(ii) An affiliation or waiting period permitted under part 7 of the
federal employee retirement income security act, part A of Title XXVII
of the public health service act, or chapter 100 of the internal
revenue code; or
(iii) Applicable cost sharing.
(d) Any cost-sharing requirement expressed as a copayment amount or
coinsurance rate imposed with respect to a participant or beneficiary
for out-of-network emergency services cannot exceed the cost-sharing
requirement imposed with respect to a participant or beneficiary if the
services were provided in-network.
(i) A participant or beneficiary may be required to pay, in
addition to the in-network cost sharing, the excess of the amount the
out-of-network provider charges over the amount the carrier negotiated
to pay to its in-network provider for the emergency service provided,
excluding any in-network copayment or coinsurance imposed with respect
to the participant or beneficiary.
(ii)(A) If there is more than one amount negotiated with in-network
providers for the emergency service, the amount described under this
subsection (1)(d) is the median of these amounts, excluding any in-network copayment or coinsurance imposed with respect to the
participant or beneficiary.
(B) In determining the median described in (d)(ii)(A) of this
subsection, the amount negotiated with each in-network provider is
treated as a separate amount, even if the same amount is paid to more
than one provider.
(iii) If there is no per-service amount negotiated with in-network
providers such as under a capitation or other similar payment
arrangement, either the amount for the emergency service is calculated
using the same method the carrier generally uses to determine payments
for out-of-network services, such as the usual, customary, and
reasonable amount, excluding any in-network copayment or coinsurance
imposed with respect to the participant or beneficiary. The amount in
this subsection (1) is determined without reduction for out-of-network
cost sharing that generally applies with respect to out-of-network
services, or the amount for emergency service may be calculated using
the amount that would be paid under medicare, part A or part B of Title
XVIII of the social security act, 42 U.S.C. 1395 et seq., for the
emergency service, excluding any in-network copayment or coinsurance
imposed with respect to the participant or beneficiary.
(iv) Any cost-sharing requirement other than a copayment or
coinsurance requirement, such as a deductible or out-of-pocket maximum,
may be imposed with respect to emergency services provided out of
network if the cost-sharing requirement generally applies to out-of-network benefits. A deductible may be imposed with respect to out-of-network emergency services only as part of a deductible that generally
applies to out-of-network benefits. If an out-of-pocket maximum
generally applies to out-of-network benefits, that out-of-pocket
maximum must apply to out-of-network emergency services.
(2) Nothing in this section is to be construed as prohibiting the
health carrier from requiring notification within the time frame
specified in the contract for inpatient admission or as soon thereafter
as medically possible but no less than twenty-four hours. Nothing in
this section is to be construed as preventing the health carrier from
reserving the right to require transfer of a hospitalized covered
person upon stabilization. Follow-up care that is a direct result of
the emergency must be obtained in accordance with the health plan's
usual terms and conditions of coverage. All other terms and conditions
of coverage may be applied to emergency services.
Sec. 5 RCW 48.43.530 and 2000 c 5 s 10 are each amended to read
as follows:
(1) Each carrier that offers a health plan must have a fully
operational, comprehensive grievance process that complies with the
requirements of this section and any rules adopted by the commissioner
to implement this section. For the purposes of this section, the
commissioner shall consider grievance process standards adopted by
national managed care accreditation organizations and state agencies
that purchase managed health care services, and as approved by the
United States department of health and human services or the United
States department of labor.
(2) Each carrier must process as a complaint an enrollee's
expression of dissatisfaction about customer service or the quality or
availability of a health service. Each carrier must implement
procedures for registering and responding to oral and written
complaints in a timely and thorough manner.
(3) Each carrier must provide written notice to an enrollee or the
enrollee's designated representative, and the enrollee's provider, of
its decision to deny, modify, reduce, or terminate payment, coverage,
authorization, or provision of health care services or benefits,
including the admission to or continued stay in a health care facility.
(4) Each carrier must process as an appeal an enrollee's written or
oral request that the carrier reconsider: (a) Its resolution of a
complaint made by an enrollee; or (b) its decision to deny, modify,
reduce, or terminate payment, coverage, authorization, or provision of
health care services or benefits, including the admission to, or
continued stay in, a health care facility. A carrier must not require
that an enrollee file a complaint prior to seeking appeal of a decision
under (b) of this subsection.
(5) To process an appeal, each carrier must:
(a) Provide written notice to the enrollee when the appeal is
received;
(b) Assist the enrollee with the appeal process;
(c) Make its decision regarding the appeal within thirty days of
the date the appeal is received. An appeal must be expedited if the
enrollee's provider or the carrier's medical director reasonably
determines that following the appeal process response timelines could
seriously jeopardize the enrollee's life, health, or ability to regain
maximum function. The decision regarding an expedited appeal must be
made within seventy-two hours of the date the appeal is received;
(d) Cooperate with a representative authorized in writing by the
enrollee;
(e) Consider information submitted by the enrollee;
(f) Investigate and resolve the appeal; and
(g) Provide written notice of its resolution of the appeal to the
enrollee and, with the permission of the enrollee, to the enrollee's
providers. The written notice must explain the carrier's decision and
the supporting coverage or clinical reasons and the enrollee's right to
request independent review of the carrier's decision under RCW
48.43.535.
(6) Written notice required by subsection (3) of this section must
explain in a culturally and linguistically appropriate manner that
complies with the standards established by the United States department
of health and human services or the United States department of labor:
(a) The carrier's decision and the supporting coverage or clinical
reasons; ((and))
(b) The carrier's appeal process, including information, as
appropriate, about how to exercise the enrollee's rights to obtain a
second opinion, and how to continue receiving services as provided in
this section;
(c) Sufficient information to identify the claim involved,
including the date of service, the health care provider, the claim
amount, if applicable, the diagnosis code and its corresponding
meaning, and the treatment code and its corresponding meaning; and
(d) The reason or reasons for the adverse benefit determination or
final internal adverse benefit determination, including the denial code
and its corresponding meaning, as well as the description of the plan's
or carrier's standard that was used in denying the claim. When the
decision is a final internal adverse benefit determination, the
description must include a discussion of the decision.
(7) When an enrollee requests that the carrier reconsider its
decision to modify, reduce, or terminate an otherwise covered health
service that an enrollee is receiving through the health plan and the
carrier's decision is based upon a finding that the health service, or
level of health service, is no longer medically necessary or
appropriate, the carrier must continue to provide that health service
until the appeal is resolved. If the resolution of the appeal or any
review sought by the enrollee under RCW 48.43.535 affirms the carrier's
decision, the enrollee may be responsible for the cost of this
continued health service.
(8) Each carrier must provide a clear explanation of the grievance
process upon request, upon enrollment to new enrollees, and annually to
enrollees and subcontractors. The information provided must include
information for any applicable office of health insurance consumer
assistance or ombudsman established under section 2793 of the public
health service act to assist individuals with the internal claims and
appeals and external review processes.
(9) Each carrier must ensure that the grievance process is
accessible to enrollees who are limited English speakers, who have
literacy problems, or who have physical or mental disabilities that
impede their ability to file a grievance.
(10) Each carrier must: Track each appeal until final resolution;
maintain, and make accessible to the commissioner for a period of three
years, a log of all appeals; and identify and evaluate trends in
appeals.
Sec. 6 RCW 48.43.535 and 2000 c 5 s 11 are each amended to read
as follows:
(1) There is a need for a process for the fair consideration of
disputes relating to decisions by carriers that offer a health plan to
deny, modify, reduce, or terminate coverage of or payment for health
care services for an enrollee.
(2) An enrollee may seek review by a certified independent review
organization of a carrier's decision to deny, modify, reduce, or
terminate coverage of or payment for a health care service, after
exhausting the carrier's grievance process and receiving a decision
that is unfavorable to the enrollee, or after the carrier has exceeded
the timelines for grievances provided in RCW 48.43.530, without good
cause and without reaching a decision.
(3) The commissioner must establish and use a rotational registry
system for the assignment of a certified independent review
organization to each dispute. The system should be flexible enough to
ensure that an independent review organization has the expertise
necessary to review the particular medical condition or service at
issue in the dispute, and that any approved independent review
organization does not have a conflict of interest that will influence
its independence.
(4) Carriers must provide to the appropriate certified independent
review organization, not later than the third business day after the
date the carrier receives a request for review, a copy of:
(a) Any medical records of the enrollee that are relevant to the
review;
(b) Any documents used by the carrier in making the determination
to be reviewed by the certified independent review organization;
(c) Any documentation and written information submitted to the
carrier in support of the appeal; and
(d) A list of each physician or health care provider who has
provided care to the enrollee and who may have medical records relevant
to the appeal. Health information or other confidential or proprietary
information in the custody of a carrier may be provided to an
independent review organization, subject to rules adopted by the
commissioner.
(5) Claimants must be provided with at least five business days to
submit to the independent review organization in writing additional
information that the independent review organization must consider when
conducting the external review. The independent review organization
must forward any additional information submitted by a claimant to the
plan or carrier within one business day of receipt by the independent
review organization.
(6) The medical reviewers from a certified independent review
organization will make determinations regarding the medical necessity
or appropriateness of, and the application of health plan coverage
provisions to, health care services for an enrollee. The medical
reviewers' determinations must be based upon their expert medical
judgment, after consideration of relevant medical, scientific, and
cost-effectiveness evidence, and medical standards of practice in the
state of Washington. Except as provided in this subsection, the
certified independent review organization must ensure that
determinations are consistent with the scope of covered benefits as
outlined in the medical coverage agreement. Medical reviewers may
override the health plan's medical necessity or appropriateness
standards if the standards are determined upon review to be
unreasonable or inconsistent with sound, evidence-based medical
practice.
(((6))) (7) Once a request for an independent review determination
has been made, the independent review organization must proceed to a
final determination, unless requested otherwise by both the carrier and
the enrollee or the enrollee's representative.
(((7))) (a) The independent review organization must provide
written notice to the claimant and the plan or carrier of its decision
to uphold or reverse the adverse benefit determination or internal
adverse benefit determination within no more than forty-five days after
its receipt of the request for external review.
(b) A claimant or carrier may request an expedited external review
if the adverse benefit determination or internal adverse benefit
determination concerns an admission, availability of care, continued
stay, or health care service for which the claimant received emergency
services but has not been discharged from a facility; or involves a
medical condition for which the standard external review time frame of
forty-five days would seriously jeopardize the life or health of the
claimant or jeopardize the claimant's ability to regain maximum
function. The independent review organization must make its decision
to uphold or reverse the adverse benefit determination or final
internal adverse benefit determination and notify the claimant and the
carrier or plan of the determination as expeditiously as possible but
within not more than seventy-two hours after the receipt of the request
for expedited external review. If the notice is not in writing, the
independent review organization must provide written confirmation of
the decision within forty-eight hours after the date of the notice of
the decision.
(c) For claims involving experimental or investigational
treatments, the internal review organization must ensure that adequate
clinical and scientific experience and protocols are taken into account
as part of the external review process.
(8) Carriers must timely implement the certified independent review
organization's determination, and must pay the certified independent
review organization's charges.
(((8))) (9) When an enrollee requests independent review of a
dispute under this section, and the dispute involves a carrier's
decision to modify, reduce, or terminate an otherwise covered health
service that an enrollee is receiving at the time the request for
review is submitted and the carrier's decision is based upon a finding
that the health service, or level of health service, is no longer
medically necessary or appropriate, the carrier must continue to
provide the health service if requested by the enrollee until a
determination is made under this section. If the determination affirms
the carrier's decision, the enrollee may be responsible for the cost of
the continued health service.
(((9))) (10) Each certified independent review organization must
maintain written records and make them available upon request to the
commissioner.
(11) A certified independent review organization may notify the
office of the insurance commissioner if, based upon its review of
disputes under this section, it finds a pattern of substandard or
egregious conduct by a carrier.
(((10))) (12)(a) The commissioner shall adopt rules to implement
this section after considering relevant standards adopted by national
managed care accreditation organizations and the national association
of insurance commissioners.
(b) This section is not intended to supplant any existing authority
of the office of the insurance commissioner under this title to oversee
and enforce carrier compliance with applicable statutes and rules.
Sec. 7 RCW 48.44.215 and 2007 c 259 s 21 are each amended to read
as follows:
(1) Any individual health care service plan contract that provides
coverage for a subscriber's dependent must offer the option of covering
any ((unmarried)) dependent under the age of ((twenty-five)) twenty-six.
(2) Any group health care service plan contract that provides
coverage for a participating member's dependent must offer each
participating member the option of covering any ((unmarried)) dependent
under the age of ((twenty-five)) twenty-six.
Sec. 8 RCW 48.44.380 and 1984 c 190 s 7 are each amended to read
as follows:
(1) A health care service contractor shall not require proof of
insurability as a condition for issuance of the conversion contract.
(2) A conversion contract may not contain an exclusion for
preexisting conditions ((except)) for any applicant who is under age
nineteen. For policies issued to those age nineteen and older, an
exclusion for a preexisting condition is permitted only to the extent
that a waiting period for a preexisting condition has not been
satisfied under the group contract.
(3) A health care service contractor must offer at least three
contract benefit plans that comply with the following:
(a) A major medical plan with a five thousand dollar deductible
((and a lifetime benefit maximum of two hundred fifty thousand
dollars)) per person;
(b) A comprehensive medical plan with a five hundred dollar
deductible ((and a lifetime benefit maximum of five hundred thousand
dollars)) per person; and
(c) A basic medical plan with a one thousand dollar deductible
((and a lifetime maximum of seventy-five thousand dollars)) per person.
(4) The insurance commissioner may revise the ((deductibles and
lifetime benefit)) deductible amounts in subsection (3) of this section
from time to time to reflect changing health care costs.
(5) The insurance commissioner shall adopt rules to establish
minimum benefit standards for conversion contracts.
(6) The commissioner shall adopt rules to establish specific
standards for conversion contract provisions. These rules may include
but are not limited to:
(a) Terms of renewability;
(b) Nonduplication of coverage;
(c) Benefit limitations, exceptions, and reductions; and
(d) Definitions of terms.
Sec. 9 RCW 48.46.325 and 2007 c 259 s 22 are each amended to read
as follows:
(1) Any individual health maintenance agreement that provides
coverage for a subscriber's dependent must offer the option of covering
any ((unmarried)) dependent under the age of ((twenty-five)) twenty-six.
(2) Any group health maintenance agreement that provides coverage
for a participating member's dependent must offer each participating
member the option of covering any unmarried dependent under the age of
((twenty-five)) twenty-six.
Sec. 10 RCW 48.46.460 and 1984 c 190 s 10 are each amended to
read as follows:
(1) A health maintenance organization must offer a conversion
agreement for comprehensive health care services and shall not require
proof of insurability as a condition for issuance of the conversion
agreement.
(2) A conversion agreement may not contain an exclusion for
preexisting conditions ((except)) for an applicant who is under age
nineteen. For policies issued to those age nineteen and older, an
exclusion for a preexisting condition is permitted only to the extent
that a waiting period for a preexisting condition has not been
satisfied under the group agreement.
(3) A conversion agreement need not provide benefits identical to
those provided under the group agreement. The conversion agreement may
contain provisions requiring the person covered by the conversion
agreement to pay reasonable deductibles and copayments, except for
preventive service benefits as defined in 45 C.F.R. 147.130 (2010),
implementing sections 2701 through 2763, 2791, and 2792 of the public
health service act (42 U.S.C. 300gg through 300gg-63, 300gg-91, and
300gg-92), as amended.
(4) The insurance commissioner shall adopt rules to establish
minimum benefit standards for conversion agreements.
(5) The commissioner shall adopt rules to establish specific
standards for conversion agreement provisions. These rules may include
but are not limited to:
(a) Terms of renewability;
(b) Nonduplication of coverage;
(c) Benefit limitations, exceptions, and reductions; and
(d) Definitions of terms.
Sec. 11 RCW 48.20.025 and 2008 c 303 s 4 are each amended to read
as follows:
(1) The definitions in this subsection apply throughout this
section unless the context clearly requires otherwise.
(a) "Claims" means the cost to the insurer of health care services,
as defined in RCW 48.43.005, provided to a policyholder or paid to or
on behalf of the policyholder in accordance with the terms of a health
benefit plan, as defined in RCW 48.43.005. This includes capitation
payments or other similar payments made to providers for the purpose of
paying for health care services for a policyholder.
(b) "Claims reserves" means: (i) The liability for claims which
have been reported but not paid; (ii) the liability for claims which
have not been reported but which may reasonably be expected; (iii)
active life reserves; and (iv) additional claims reserves whether for
a specific liability purpose or not.
(c) "Declination rate" for an insurer means the percentage of the
total number of applicants for individual health benefit plans received
by that insurer in the aggregate in the applicable year which are not
accepted for enrollment by that insurer based on the results of the
standard health questionnaire administered pursuant to RCW
48.43.018(2)(a).
(d) "Earned premiums" means premiums, as defined in RCW 48.43.005,
plus any rate credits or recoupments less any refunds, for the
applicable period, whether received before, during, or after the
applicable period.
(e) "Incurred claims expense" means claims paid during the
applicable period plus any increase, or less any decrease, in the
claims reserves.
(f) "Loss ratio" means incurred claims expense as a percentage of
earned premiums.
(g) "Reserves" means: (i) Active life reserves; and (ii)
additional reserves whether for a specific liability purpose or not.
(2) An insurer must file supporting documentation of its method of
determining the rates charged for its individual health benefit plans.
At a minimum, the insurer must provide the following supporting
documentation:
(a) A description of the insurer's rate-making methodology;
(b) An actuarially determined estimate of incurred claims which
includes the experience data, assumptions, and justifications of the
insurer's projection;
(c) The percentage of premium attributable in aggregate for
nonclaims expenses used to determine the adjusted community rates
charged; and
(d) A certification by a member of the American academy of
actuaries, or other person approved by the commissioner, that the
adjusted community rate charged can be reasonably expected to result in
a loss ratio that meets or exceeds the loss ratio standard of
seventy-four percent, minus the premium tax rate applicable to the
insurer's individual health benefit plans under RCW 48.14.020.
(((3) By the last day of May each year any insurer issuing or
renewing individual health benefit plans in this state during the
preceding calendar year shall file for review by the commissioner
supporting documentation of its actual loss ratio and its actual
declination rate for its individual health benefit plans offered or
renewed in the state in aggregate for the preceding calendar year. The
filing shall include aggregate earned premiums, aggregate incurred
claims, and a certification by a member of the American academy of
actuaries, or other person approved by the commissioner, that the
actual loss ratio has been calculated in accordance with accepted
actuarial principles.
(a) At the expiration of a thirty-day period beginning with the
date the filing is received by the commissioner, the filing shall be
deemed approved unless prior thereto the commissioner contests the
calculation of the actual loss ratio.
(b) If the commissioner contests the calculation of the actual loss
ratio, the commissioner shall state in writing the grounds for
contesting the calculation to the insurer.
(c) Any dispute regarding the calculation of the actual loss ratio
shall, upon written demand of either the commissioner or the insurer,
be submitted to hearing under chapters 48.04 and 34.05 RCW.
(4) If the actual loss ratio for the preceding calendar year is
less than the loss ratio established in subsection (5) of this section,
a remittance is due and the following shall apply:
(a) The insurer shall calculate a percentage of premium to be
remitted to the Washington state health insurance pool by subtracting
the actual loss ratio for the preceding year from the loss ratio
established in subsection (5) of this section.
(b) The remittance to the Washington state health insurance pool is
the percentage calculated in (a) of this subsection, multiplied by the
premium earned from each enrollee in the previous calendar year.
Interest shall be added to the remittance due at a five percent annual
rate calculated from the end of the calendar year for which the
remittance is due to the date the remittance is made.
(c) All remittances shall be aggregated and such amounts shall be
remitted to the Washington state high risk pool to be used as directed
by the pool board of directors.
(d) Any remittance required to be issued under this section shall
be issued within thirty days after the actual loss ratio is deemed
approved under subsection (3)(a) of this section or the determination
by an administrative law judge under subsection (3)(c) of this section.
(5) The loss ratio applicable to this section shall be the
percentage set forth in the following schedule that correlates to the
insurer's actual declination rate in the preceding year, minus the
premium tax rate applicable to the insurer's individual health benefit
plans under RCW 48.14.020.
Sec. 12 RCW 48.44.017 and 2008 c 303 s 5 are each amended to read
as follows:
(1) The definitions in this subsection apply throughout this
section unless the context clearly requires otherwise.
(a) "Claims" means the cost to the health care service contractor
of health care services, as defined in RCW 48.43.005, provided to a
contract holder or paid to or on behalf of a contract holder in
accordance with the terms of a health benefit plan, as defined in RCW
48.43.005. This includes capitation payments or other similar payments
made to providers for the purpose of paying for health care services
for an enrollee.
(b) "Claims reserves" means: (i) The liability for claims which
have been reported but not paid; (ii) the liability for claims which
have not been reported but which may reasonably be expected; (iii)
active life reserves; and (iv) additional claims reserves whether for
a specific liability purpose or not.
(c) "Declination rate" for a health care service contractor means
the percentage of the total number of applicants for individual health
benefit plans received by that health care service contractor in the
aggregate in the applicable year which are not accepted for enrollment
by that health care service contractor based on the results of the
standard health questionnaire administered pursuant to RCW
48.43.018(2)(a).
(d) "Earned premiums" means premiums, as defined in RCW 48.43.005,
plus any rate credits or recoupments less any refunds, for the
applicable period, whether received before, during, or after the
applicable period.
(e) "Incurred claims expense" means claims paid during the
applicable period plus any increase, or less any decrease, in the
claims reserves.
(f) "Loss ratio" means incurred claims expense as a percentage of
earned premiums.
(g) "Reserves" means: (i) Active life reserves; and (ii)
additional reserves whether for a specific liability purpose or not.
(2) A health care service contractor must file supporting
documentation of its method of determining the rates charged for its
individual contracts. At a minimum, the health care service contractor
must provide the following supporting documentation:
(a) A description of the health care service contractor's rate-making methodology;
(b) An actuarially determined estimate of incurred claims which
includes the experience data, assumptions, and justifications of the
health care service contractor's projection;
(c) The percentage of premium attributable in aggregate for
nonclaims expenses used to determine the adjusted community rates
charged; and
(d) A certification by a member of the American academy of
actuaries, or other person approved by the commissioner, that the
adjusted community rate charged can be reasonably expected to result in
a loss ratio that meets or exceeds the loss ratio standard of
seventy-four percent, minus the premium tax rate applicable to the
carrier's individual health benefit plans under RCW 48.14.0201.
(((3) By the last day of May each year any health care service
contractor issuing or renewing individual health benefit plans in this
state during the preceding calendar year shall file for review by the
commissioner supporting documentation of its actual loss ratio and its
actual declination rate for its individual health benefit plans offered
or renewed in this state in aggregate for the preceding calendar year.
The filing shall include aggregate earned premiums, aggregate incurred
claims, and a certification by a member of the American academy of
actuaries, or other person approved by the commissioner, that the
actual loss ratio has been calculated in accordance with accepted
actuarial principles.
(a) At the expiration of a thirty-day period beginning with the
date the filing is received by the commissioner, the filing shall be
deemed approved unless prior thereto the commissioner contests the
calculation of the actual loss ratio.
(b) If the commissioner contests the calculation of the actual loss
ratio, the commissioner shall state in writing the grounds for
contesting the calculation to the health care service contractor.
(c) Any dispute regarding the calculation of the actual loss ratio
shall upon written demand of either the commissioner or the health care
service contractor be submitted to hearing under chapters 48.04 and
34.05 RCW.
(4) If the actual loss ratio for the preceding calendar year is
less than the loss ratio standard established in subsection (5) of this
section, a remittance is due and the following shall apply:
(a) The health care service contractor shall calculate a percentage
of premium to be remitted to the Washington state health insurance pool
by subtracting the actual loss ratio for the preceding year from the
loss ratio established in subsection (5) of this section.
(b) The remittance to the Washington state health insurance pool is
the percentage calculated in (a) of this subsection, multiplied by the
premium earned from each enrollee in the previous calendar year.
Interest shall be added to the remittance due at a five percent annual
rate calculated from the end of the calendar year for which the
remittance is due to the date the remittance is made.
(c) All remittances shall be aggregated and such amounts shall be
remitted to the Washington state high risk pool to be used as directed
by the pool board of directors.
(d) Any remittance required to be issued under this section shall
be issued within thirty days after the actual loss ratio is deemed
approved under subsection (3)(a) of this section or the determination
by an administrative law judge under subsection (3)(c) of this section.
(5) The loss ratio applicable to this section shall be the
percentage set forth in the following schedule that correlates to the
health care service contractor's actual declination rate in the
preceding year, minus the premium tax rate applicable to the health
care service contractor's individual health benefit plans under RCW
48.14.0201.
Sec. 13 RCW 48.46.062 and 2008 c 303 s 6 are each amended to read
as follows:
(1) The definitions in this subsection apply throughout this
section unless the context clearly requires otherwise.
(a) "Claims" means the cost to the health maintenance organization
of health care services, as defined in RCW 48.43.005, provided to an
enrollee or paid to or on behalf of the enrollee in accordance with the
terms of a health benefit plan, as defined in RCW 48.43.005. This
includes capitation payments or other similar payments made to
providers for the purpose of paying for health care services for an
enrollee.
(b) "Claims reserves" means: (i) The liability for claims which
have been reported but not paid; (ii) the liability for claims which
have not been reported but which may reasonably be expected; (iii)
active life reserves; and (iv) additional claims reserves whether for
a specific liability purpose or not.
(c) "Declination rate" for a health maintenance organization means
the percentage of the total number of applicants for individual health
benefit plans received by that health maintenance organization in the
aggregate in the applicable year which are not accepted for enrollment
by that health maintenance organization based on the results of the
standard health questionnaire administered pursuant to RCW
48.43.018(2)(a).
(d) "Earned premiums" means premiums, as defined in RCW 48.43.005,
plus any rate credits or recoupments less any refunds, for the
applicable period, whether received before, during, or after the
applicable period.
(e) "Incurred claims expense" means claims paid during the
applicable period plus any increase, or less any decrease, in the
claims reserves.
(f) "Loss ratio" means incurred claims expense as a percentage of
earned premiums.
(g) "Reserves" means: (i) Active life reserves; and (ii)
additional reserves whether for a specific liability purpose or not.
(2) A health maintenance organization must file supporting
documentation of its method of determining the rates charged for its
individual agreements. At a minimum, the health maintenance
organization must provide the following supporting documentation:
(a) A description of the health maintenance organization's rate-making methodology;
(b) An actuarially determined estimate of incurred claims which
includes the experience data, assumptions, and justifications of the
health maintenance organization's projection;
(c) The percentage of premium attributable in aggregate for
nonclaims expenses used to determine the adjusted community rates
charged; and
(d) A certification by a member of the American academy of
actuaries, or other person approved by the commissioner, that the
adjusted community rate charged can be reasonably expected to result in
a loss ratio that meets or exceeds the loss ratio standard of
seventy-four percent, minus the premium tax rate applicable to the
carrier's individual health benefit plans under RCW 48.14.0201.
(((3) By the last day of May each year any health maintenance
organization issuing or renewing individual health benefit plans in
this state during the preceding calendar year shall file for review by
the commissioner supporting documentation of its actual loss ratio and
its actual declination rate for its individual health benefit plans
offered or renewed in the state in aggregate for the preceding calendar
year. The filing shall include aggregate earned premiums, aggregate
incurred claims, and a certification by a member of the American
academy of actuaries, or other person approved by the commissioner,
that the actual loss ratio has been calculated in accordance with
accepted actuarial principles.
(a) At the expiration of a thirty-day period beginning with the
date the filing is received by the commissioner, the filing shall be
deemed approved unless prior thereto the commissioner contests the
calculation of the actual loss ratio.
(b) If the commissioner contests the calculation of the actual loss
ratio, the commissioner shall state in writing the grounds for
contesting the calculation to the health maintenance organization.
(c) Any dispute regarding the calculation of the actual loss ratio
shall, upon written demand of either the commissioner or the health
maintenance organization, be submitted to hearing under chapters 48.04
and 34.05 RCW.
(4) If the actual loss ratio for the preceding calendar year is
less than the loss ratio standard established in subsection (5) of this
section, a remittance is due and the following shall apply:
(a) The health maintenance organization shall calculate a
percentage of premium to be remitted to the Washington state health
insurance pool by subtracting the actual loss ratio for the preceding
year from the loss ratio established in subsection (5) of this section.
(b) The remittance to the Washington state health insurance pool is
the percentage calculated in (a) of this subsection, multiplied by the
premium earned from each enrollee in the previous calendar year.
Interest shall be added to the remittance due at a five percent annual
rate calculated from the end of the calendar year for which the
remittance is due to the date the remittance is made.
(c) All remittances shall be aggregated and such amounts shall be
remitted to the Washington state high risk pool to be used as directed
by the pool board of directors.
(d) Any remittance required to be issued under this section shall
be issued within thirty days after the actual loss ratio is deemed
approved under subsection (3)(a) of this section or the determination
by an administrative law judge under subsection (3)(c) of this section.
(5) The loss ratio applicable to this section shall be the
percentage set forth in the following schedule that correlates to the
health maintenance organization's actual declination rate in the
preceding year, minus the premium tax rate applicable to the health
maintenance organization's individual health benefit plans under RCW
48.14.0201.
NEW SECTION. Sec. 14 Sections 11 through 13 of this act take
effect January 1, 2012.