SHB 1846 -
By Representative Schmick
WITHDRAWN 03/11/2013
Strike everything after the enacting clause and insert the following:
"Sec. 1 RCW 48.43.715 and 2012 c 87 s 13 are each amended to read
as follows:
(1) Consistent with federal law, the commissioner, in consultation
with the board and the health care authority, shall, by rule, select
the largest small group plan in the state by enrollment as the
benchmark plan for the individual and small group market for purposes
of establishing the essential health benefits in Washington state under
P.L. 111-148 of 2010, as amended.
(2) If the essential health benefits benchmark plan for the
individual and small group market does not include all of the ten
benefit categories specified by section 1302 of P.L. 111-148, as
amended, the commissioner, in consultation with the board and the
health care authority, shall, by rule, supplement the benchmark plan
benefits as needed to meet the minimum requirements of section 1302.
(3) A health plan required to offer the essential health benefits,
other than a health plan offered through the federal basic health
program or medicaid, under P.L. 111-148 of 2010, as amended, may not be
offered in the state unless the commissioner finds that it is
substantially equal to the benchmark plan. When making this
determination, the commissioner ((must)):
(a) Must ensure that the plan covers the ten essential health
benefits categories specified in section 1302 of P.L. 111-148 of 2010,
as amended; and
(b) May consider whether the health plan has a benefit design that
would create a risk of biased selection based on health status and
whether the health plan contains meaningful scope and level of benefits
in each of the ten essential health benefit categories specified by
section 1302 of P.L. 111-148 of 2010, as amended.
(4) A stand-alone dental plan may be offered off the exchange in
the individual and small group market if the commissioner finds that it
meets the requirements of this subsection. For purposes of this
subsection, "stand-alone dental plan" means a health plan that only
covers the essential health benefits category of pediatric oral
services to persons under the age of nineteen. A stand-alone dental
plan is a health plan as defined in RCW 48.43.005, and is not a dental
only plan for the purposes of RCW 48.43.005(26)(k).
(a) The commissioner shall establish by rule the review and
approval requirements and procedures for plan coverage and rating for
stand-alone dental plans. The rules must:
(i) Include a requirement that issuers submit data that is
necessary for the commissioner to evaluate purchasing patterns and
coverage duration for pediatric dental services purchased off the
exchange; and
(ii) Be consistent with federal law.
(b) If a plan is certified by the exchange as a stand-alone dental
plan, it is deemed approved for offer in the nongrandfathered
individual and small group market off the exchange.
(c) The commissioner shall permit issuers to also include the
essential health benefit category of pediatric oral services in a
nongrandfathered individual and small group health benefit plan that
covers the remaining essential health benefits benchmark package and
that is offered off the exchange.
(5) Beginning December 15, 2012, and every year thereafter, the
commissioner shall submit to the legislature a list of state-mandated
health benefits, the enforcement of which will result in federally
imposed costs to the state related to the plans sold through the
exchange because the benefits are not included in the essential health
benefits designated under federal law. The list must include the
anticipated costs to the state of each state-mandated health benefit on
the list and any statutory changes needed if funds are not appropriated
to defray the state costs for the listed mandate. The commissioner may
enforce a mandate on the list for the entire market only if funds are
appropriated in an omnibus appropriations act specifically to pay the
state portion of the identified costs.
Sec. 2 RCW 48.46.243 and 2008 c 217 s 56 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:
(a) To emergency care from a provider who is not a participating
provider((,));
(b) To out-of-area services;
(c) To the delivery of covered pediatric oral services that are
substantially equal to the essential health benefits benchmark plan;
or((,))
(d) 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 the commissioner fifteen days before it is used.
(b) Any contract form not affirmatively disapproved within fifteen
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 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 insurance producer, trustee, or
assignee thereof, may maintain an action against an enrolled
participant to collect sums owed by the health maintenance
organization."
Correct the title.
EFFECT: Defines "stand-alone dental plan" as a health plan that only covers the essential health benefits category of pediatric oral services to persons under the age of 19. Clarifies that a stand-alone dental plan is not a "dental only" plan (under current law, "dental only" plans are exempt from certain insurance regulations). Requires the Insurance Commissioner's rules on stand-alone dental plans to include procedures for plan coverage and rating and a requirement that issuers submit data necessary for the Insurance Commissioner to evaluate purchasing patterns and coverage duration for pediatric dental services purchased off the exchange. Requires the Insurance Commissioner to deem as approved stand-alone dental plans that have been certified by the exchange. Requires the Insurance Commissioner to allow carriers to include the essential health benefit of pediatric oral services in off-exchange individual and small group plans that cover the remaining essential health benefits benchmark package. Allows a health maintenance organization to provide coverage for pediatric oral services that are substantially equal to the essential health benefits benchmark plan using noncontracted providers.