Date of Adoption: January 24, 2000.
Purpose: The primary purpose is to make corrections to chapter 284-43 WAC and address several issues related to interpretations of the existing rules. Some provisions of chapter 284-43 WAC need correction as a consequence of changes in federal and state laws. Finally, new problems have been raised by consumers, by the health care community, and by carriers relating to implementation of the rules contained in chapter 284-43 WAC.
Citation of Existing Rules Affected by this Order: Amending WAC 284-43-120, 284-43-200, 284-43-210, 284-43-220, 284-43-250, 284-43-710, and 284-43-720.
Statutory Authority for Adoption: RCW 48.02.060, 48.18.120, 48.20.450, 48.20.460, 48.30.010, 48.44.050, 48.46.030, 48.46.200.
Adopted under notice filed as WSR 99-24-132 on December 1, 1999.
Changes Other than Editing from Proposed to Adopted Version: WAC 284-43-120, carrier liability provisions for the acts of subcontractors were changed to limit responsibility for acts or omissions that are at the direction of or on behalf of the carrier. WAC 284-43-125, carrier responsibility for compliance with relevant state and federal laws relating to carriers and health plan benefits was changed to remove references to health care delivery laws. WAC 284-43-200 and 284-43-210, in place of the amendment to the chapter's general definition of "managed care" that broadened reporting requirements, new terms are included in specific sections. WAC 284-43-200(6), carriers are given more flexibility to disclose the existence and use of subnetworks in health plans. WAC 284-43-210, carriers are required to disclose their privacy procedures in required access plans. WAC 284-43-220, carriers are permitted to file a single electronic report for each network rather than a report for each plan using the same network. WAC 284-43-250, several changes are made to the women's direct access section to clarify questions and ambiguities raised in comments. However, major substantive provisions and their intended effect remain unchanged. WAC 284-43-720, provisions describing the method for applying a preexisting condition waiting period under group plans is expanded to address additional questions raised in comments. A new section is added delaying the effective dates for sections that impose new reporting or disclosure standards and for the section prohibiting the use of subnetworks for women's directly accessed care.
Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.
Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.
Number of Sections Adopted on the Agency's Own Initiative: New 1, Amended 7, Repealed 0.
Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 1, Amended 7, Repealed 0.
Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 0, Repealed 0. Effective Date of Rule: Thirty-one days after filing; except WAC 284-43-200 will become effective March 1, 2000; and WAC 284-43-210 and 284-43-220 will become effective January 1, 2001.
January 24, 2000
AMENDATORY SECTION(Amending Order R 97-3, filed 1/22/98, effective 2/22/98)
Applicability and scope.
This chapter shall apply to all health plans and all health carriers subject to the jurisdiction of the state of Washington except as otherwise expressly provided in this chapter. Health carriers are responsible for compliance with the provisions of this chapter and are responsible for the compliance of any person or organization acting on behalf of or at the direction of the carrier, or acting pursuant to carrier standards or requirements concerning the coverage of, payment for, or provision of health care services. A carrier may not offer as a defense to a violation of any provision of this chapter that the violation arose from the act or omission of a participating provider or facility, network administrator, claims administrator, or other person acting on behalf of or at the direction of the carrier, or acting pursuant to carrier standards or requirements under a contract with the carrier rather than from the direct act or omission of the carrier. Nothing in this chapter shall be construed to permit the direct regulation of health care providers or facilities by the office of the insurance commissioner.
[Statutory Authority: RCW 48.02.060, 48.20.450, 48.20.460, 48.30.010, 48.44.020, 48.44.050, 48.44.080, 48.46.030, 48.46.060(2), 48.46.200 and 48.46.243. 98-04-005 (Order R 97-3), § 284-43-120, filed 1/22/98, effective 2/22/98.]
Health carriers shall comply with all Washington state and federal laws relating to the acts and practices of carriers and laws relating to health plan benefits.
HEALTH CARE NETWORKS
AMENDATORY SECTION(Amending Order R 97-3, filed 1/22/98, effective 2/22/98)
(1) A health carrier
offering a managed care plan)) shall maintain each plan network
in a manner that is sufficient in numbers and types of providers
and facilities to assure that all health plan services to covered
persons will be accessible without unreasonable delay. In the
case of emergency services, covered persons shall have access
twenty-four hours per day, seven days per week. The carrier's
service area shall not be created in a manner designed to
discriminate against persons because of age, sex, family
structure, ethnicity, race, health condition, employment status,
or socioeconomic status. Each carrier shall ensure that its
networks will meet these requirements by the end of the first
year of operation; or, for those plans already in existence,
(( within six months after the effective date of this rule)) by
August 22, 1998.
(2) Sufficiency may be established by the carrier with reference to any reasonable criteria used by the carrier, including but not limited to: Provider-covered person ratios by specialty, primary care provider-covered person ratios, geographic accessibility, waiting times for appointments with participating providers, hours of operation, and the volume of technological and specialty services available to serve the needs of covered persons requiring technologically advanced or specialty care. Evidence of carrier compliance with network adequacy standards that are substantially similar to those standards established by state agency health care purchasers (e.g., the state health care authority and the department of social and health services) and by private managed care accreditation organizations may be used to demonstrate sufficiency. At a minimum, a carrier will be held accountable for meeting those standards described under WAC 284-43-220.
(3) In any case where the health carrier has an absence of or an insufficient number or type of participating providers or facilities to provide a particular covered health care service, the carrier shall ensure through referral by the primary care provider or otherwise that the covered person obtains the covered service from a provider or facility within reasonable proximity of the covered person at no greater cost to the covered person than if the service were obtained from network providers and facilities, or shall make other arrangements acceptable to the commissioner.
(4) The health carrier shall establish and maintain adequate arrangements to ensure reasonable proximity of network providers and facilities to the business or personal residence of covered persons. In determining whether a health carrier has complied with this provision, the commissioner will give due consideration to the relative availability of health care providers in the service area under consideration and to the standards established by state agency health care purchasers.
(5) A health carrier shall monitor, on an ongoing basis, the ability and clinical capacity of its network providers and facilities to furnish health plan services to covered persons.
(6) Beginning July 1, 2000, the health carrier shall disclose to covered persons that limitations or restrictions on access to participating providers and facilities may arise from the health service referral and authorization practices of participating providers and facilities. The carrier shall provide instructions to covered persons as to how they can receive details about such practices from their primary care provider or through other formally established processes. For example, a covered person relying on such instructions or processes could discover if the choice of a particular primary care provider would result in the covered person's inability to obtain a referral to certain other participating providers.
[Statutory Authority: RCW 48.02.060, 48.20.450, 48.20.460, 48.30.010, 48.44.020, 48.44.050, 48.44.080, 48.46.030, 48.46.060(2), 48.46.200 and 48.46.243. 98-04-005 (Order R 97-3), § 284-43-200, filed 1/22/98, effective 2/22/98.]
Beginning January 1, 1999, health carriers shall file with
the commissioner an access plan meeting the requirements of this
subchapter for each of the ((
managed care)) health plans that the
carrier offers in this state. The health carrier shall make the
access plans available on its business premises and shall provide
them to any interested party upon request. The carrier shall
prepare an access plan prior to offering a new (( managed care))
health plan, and shall update an existing access plan whenever it
makes any material change to an existing (( managed care)) health
plan. Upon written request and following written approval by the
agency, a carrier may file an access plan that applies to more
than one health plan in accordance with any conditions or
instructions contained in the written approval. The access plan
shall contain at least the following:
(1) A description of the health carrier's network of providers and facilities by license or certification type and by geographic location;
(2) The following provision is a restatement of a statutory requirement found in RCW 48.43.095 (1)(c) included here for ease of reference: "A full description of the procedures to be followed by an enrollee for consulting a provider other than the primary care provider and whether the enrollee's primary care provider, the carrier's medical director, or another entity must authorize the referral";
(3) A description of the health carrier's process for monitoring and assuring on an ongoing basis the sufficiency of the network to provide covered services that meet the health care needs of populations that enroll in managed care plans;
(4) A description of the health carrier's efforts to address the needs of covered persons with limited English proficiency and literacy, with diverse cultural and ethnic backgrounds, and with physical and mental disabilities;
(5) A description of the health carrier's methods for assessing the health care needs of covered persons and their satisfaction with services;
(6) A description of the health carrier's method of informing covered persons of the plan's services and features, including but not limited to, the plan's grievance procedures, its process for covered persons choosing and changing providers, and its procedures for providing and approving emergency and specialty care including the following restated statutory requirements found in RCW 48.43.095 (1)(e), (f), and (i) included here for ease of reference: "Procedures, if any, that an enrollee must first follow for obtaining prior authorization for health care services ..., and ... description of any reimbursement or payment arrangements, including, but not limited to, capitation provisions, fee-for-service provisions, and health care delivery efficiency provisions, between a carrier and a provider ..., and .... Descriptions and justifications for provider compensation programs, including any incentives or penalties that are intended to encourage providers to withhold services or minimize or avoid referrals to specialists";
(7) A description of the health carrier's system for ensuring the coordination and continuity of care for covered persons referred to specialty providers, for covered persons using ancillary services, including social services and other community resources, and for ensuring appropriate discharge planning;
(8) A description of the health carrier's proposed plan for
providing continuity of care in the event of contract termination
between the health carrier and any of its participating providers
and facilities, or in the event of the health carrier's
insolvency or other inability to continue operations. The
description shall explain how covered persons will be notified of
the contract termination, or the health carrier's insolvency or
other cessation of operations, and transferred to other providers
in a timely manner; ((
(9) A description of the health carrier's strategy for
integrating public health goals with health services offered to
covered persons under the managed care plans of the health
carrier, including a description of the health carrier's good
faith efforts to initiate or maintain communication with public
(10) A description of the health carrier's methods for assessing the health status of its covered persons including a description of how the carrier incorporates findings of local public health community assessments;
(11) A description of the health carrier's policy and procedures relating to health information privacy including information concerning any rights the covered person has to restrict access to health information and to obtain access to their own health information.
With respect to the above required elements of an access plan, each carrier shall provide sufficient information to allow the commissioner and consumers to determine the extent of a carrier's efforts. For example, if a carrier makes little or no effort to coordinate health plan services with public health goals, then the carrier shall report that it does not coordinate services with public health goals.
[Statutory Authority: RCW 48.02.060, 48.20.450, 48.20.460, 48.30.010, 48.44.020, 48.44.050, 48.44.080, 48.46.030, 48.46.060(2), 48.46.200 and 48.46.243. 98-04-005 (Order R 97-3), § 284-43-210, filed 1/22/98, effective 2/22/98.]
Beginning January 1, 1999, and by January 31st of every subsequent year, each health carrier shall provide a description of each of its networks to the commissioner. In describing its network, each carrier shall include an explanation of its established access standards, noting the criteria used to measure the standards. For example, a carrier should indicate whether travel distances or driving times are used to determine accessibility. In addition, each carrier shall indicate which providers are classified as primary care providers, obstetric and women's health care providers.
(1) Beginning January 1, 1999, each health carrier shall provide the insurance commissioner with:
(a) An annual electronic or hard copy paper report of all
participating providers by ((
managed care plan)) network and
monthly updates. This report shall contain all the data items
shown in the table. (Form A.) Filing of this data satisfies the
reporting requirements of RCW 48.44.080 and the requirements of
RCW 48.46.030 relating to filing of notices that describes
changes in the provider network.
(b) An annual electronic or hard copy paper report indicating the total number of covered persons who were entitled to health care services during each month of the year, excluding nonresidents, by line of business, by product (with identifying form number filed with this office, if appropriate), by county, and by sex. The report shall conform to the table. (Form B.)
(2) In addition to the provider and covered persons reports,
each carrier shall file annual reports meeting the standards
below and shall update the reports whenever a material change in
a carrier's provider network occurs that significantly affects
the ability of covered persons to access covered services. Each
carrier shall file for each ((
managed care plan)) network (with
identifying form number(s) filed with this office, if
appropriate), using a network accessibility analysis system, such
as GeoNetworks or any other similar system:
(a) A map showing the location of covered persons and primary care providers with a differentiation between single and multiple provider locations.
(b) An access table illustrating the relationship between primary care providers and covered persons as of December of each year by county, including at a minimum:
(ii) Total number of covered persons.
(iii) Total number of primary care providers.
(iv) Number of covered persons meeting the carrier's self defined access standard.
(v) Percentage of covered persons meeting the carrier's self defined access standard.
(vi) Average distance to at least one primary care provider for its covered persons.
(c) A list indicating alphabetically by county and by city:
(iii) Total number of covered persons;
(iv) Total number of primary care providers (or, if the plan is a Preferred Provider Organization style of managed care, the total number of contracted providers);
(v) Total number of obstetric and women's health care providers;
(vi) Total number of specialists;
(vii) Total number of nonphysician providers by license type;
(viii) Total number of hospitals; and
(ix) Total number of pharmacies.
(3) A carrier may vary the method of reporting required under subsection (2) of this section upon written request and subsequent written approval by the commissioner after a showing by the carrier that the carrier does not use or does not have easy access to electronic or data systems permitting the method of reporting required without incurring substantial costs.
|(WAC 284-43-220, Form A)
Place illustration here.
|(WAC 284-43-220, Form B, page 1)
Place illustration here.
|(WAC 284-43-220, Form B, page 2)
Place illustration here.
[Statutory Authority: RCW 48.02.060, 48.20.450, 48.20.460, 48.30.010, 48.44.020, 48.44.050, 48.44.080, 48.46.030, 48.46.060(2), 48.46.200 and 48.46.243. 98-04-005 (Order R 97-3), § 284-43-220, filed 1/22/98, effective 2/22/98.]
(1)(a) "Women's health care services" is defined to include, but need not be limited to, maternity care, reproductive health services, gynecological care, general examination, and preventive care as medically appropriate, and medically appropriate follow-up visits for these services. General examinations, preventive care, and medically appropriate follow-up care are limited to services related to maternity, reproductive health services, gynecological care, or other health services that are particular to women, such as breast examinations. Women's health care services also include any appropriate health care service for other health problems, discovered and treated during the course of a visit to a women's health care practitioner for a women's health care service, which is within the practitioner's scope of practice. For purposes of determining a woman's right to directly access health services covered by the plan, maternity care, reproductive health, and preventive services include, contraceptive services, testing and treatment for sexually transmitted diseases, pregnancy termination, breast-feeding, and complications of pregnancy.
(b) A carrier may not exclude or limit access to covered women's health care services offered by a particular type of women's health care practitioner in a manner that would unreasonably restrict access to that type of provider or covered service. For example, a carrier may not impose a limitation on maternity services that would require all child birth to occur in a hospital attended by a physician thus, preventing a woman from choosing and using the birthing services of an advanced registered nurse practitioner specialist in midwifery.
(c) A carrier may not impose notification or prior authorization requirements upon women's health care practitioners who render women's health care services or upon women who directly access such services unless such requirements are imposed upon other providers offering similar types of service. For example, a carrier may not require a directly accessed women's health care practitioner to notify the plan within seven days of providing direct women's health care services if a primary care provider would not also be required to provide seven-day notice to the carrier for the same or similar service.
(2) A health carrier shall not deny coverage for medically appropriate laboratory services, imaging services, diagnostic services, or prescriptions for pharmaceutical or medical supplies, which are ordered by a directly accessed women's health care practitioner, and which are within the practitioner's scope of practice, if such services would be covered when provided by another type of health care practitioner. A health carrier shall not require authorization by another type of health care practitioner for these services. For example, if the carrier would cover a prescription if the prescription had been written by the primary care provider, the carrier shall cover the prescription written by the directly accessed women's health care practitioner.
(3)(a) All health carriers shall permit each female policyholder, subscriber, enrolled participant, or beneficiary of carrier policies, plans, and programs written, amended, or renewed after July 23, 1995, to directly access the types of women's health care practitioners identified in RCW 48.42.100(2), for appropriate covered women's health care services without prior referral from another health care practitioner.
(b) Beginning July 1, 2000, direct access may be limited to those women's health care practitioners who have signed participating provider agreements with the carrier for a specific benefit plan network. Irrespective of the financial arrangements a carrier may have with participating providers, a carrier may not limit and shall not permit a network provider to limit access to a subset of participating women's health care practitioners within the network. Such an impermissible limitation might arise when a primary care provider's group practice receives a capitation payment for comprehensive care to a covered person and then represents to the covered person that only those gynecologists in the primary care provider's clinic are available for direct access. Nothing in this subsection shall be interpreted to prohibit a carrier from contracting with a provider to render limited health care services.
(c) Every carrier shall include in each provider network, a sufficient number of each type of practitioner included in the definition of women's health care practitioners in RCW 48.42.100(2) to ensure that enrollees can exercise their right of direct access.
(d) Beginning July 1, 2000, a woman's right to directly access practitioners for health care services as provided under RCW 48.42.100, includes the right to obtain appropriate women's health care services ordered by the practitioner from a participating facility used by the practitioner.
(4) To inform enrollees of their rights under RCW 48.42.100, all health carriers shall include in enrollee handbooks a written explanation of a woman's right to directly access women's health care practitioners for covered women's health care services. Enrollee handbooks shall include information regarding any limitations to direct access, including, but not limited to:
(a) Limited direct access based on a benefit plan's closed network of practitioners, if appropriate; and
(b) The carrier's right to limit coverage to medically necessary and appropriate women's health care services.
(5) No carrier shall impose cost-sharing, such as copayments or deductibles, for directly accessed women's health care services, that are not required for access to health care practitioners acting as primary care providers.
[Statutory Authority: RCW 48.02.060, 48.20.450, 48.20.460, 48.30.010, 48.44.020, 48.44.050, 48.44.080, 48.46.030, 48.46.060(2), 48.46.200 and 48.46.243. 98-04-005 (Order R 97-3), § 284-43-250, filed 1/22/98, effective 2/22/98.]SUBCHAPTER G
ISSUANCE, RENEWAL, AND PORTABILITY OF HEALTH PLANS
AMENDATORY SECTION(Amending Order R 97-3, filed 1/22/98, effective 2/22/98)
Portability of health insurance benefits.
(1) Every health carrier shall waive any preexisting condition exclusion or limitation for persons or groups who had similar health coverage under a different health plan at any time during the three-month period immediately preceding the date of application for the new health plan to the extent that such person was continuously covered under the immediately preceding health plan. If the person was continuously covered for at least three months under the immediately preceding health plan, the carrier may not impose a waiting period for coverage of preexisting conditions unless the plan is dissimilar to the immediately preceding plan as determined in accordance with subsection (4) of this section. If the person was continuously covered for less than three months under the immediately preceding health plan, the carrier may not impose a waiting period for a preexisting condition that exceeds the difference between the number of months the person was continuously covered under the immediately preceding health plan and any preexisting condition waiting period under the new health plan. For purposes of portability of benefits under this section and to meet federal requirements (adapted from the federal definition of "creditable coverage" under section 701 of Public Law 104-191, August 21, 1996), "health plan" includes:
(a) Employer provided health plans including self-funded plans;
(b) Part A or part B of Title XVIII of the Social Security Act;
(c) Title XIX of the Social Security Act, other than coverage consisting solely of benefits under section 1928 of the Act;
(d) Chapter 55 of Title 10, United States Code;
(e) A medical care program of the Indian Health Service or of a tribal organization;
(f) The Washington state health insurance pool created under RCW 48.41.040;
(g) A health plan offered under chapter 89 of Title 5, United States Code;
(h) The state basic health plan; and
(i) A health benefit plan under section 5(e) of the Peace Corps Act (22 U.S.C. Sec. 2504(e)).
(2) When an employer providing group health coverage to his or her employees imposes a probationary period or similar delay in eligibility for health plan coverage of new employees, the health carrier shall count the day of first employment with the new employer as the first day of coverage for purposes of applying the portability of benefit provisions of this section so that the new employees and dependents obtain the protections of this rule at the end of such probationary period.
(3) A carrier may not avoid the portability requirements of this section by taking into consideration, for rating purposes, the health condition or health experience of a person applying for an individual health plan or of a person being added to an existing group plan. For example, a person being added to a group or applying for an individual health plan who is availing himself or herself of the portability provisions of this section may not be rated based upon health conditions or past health experience.
(4) For purposes of this section only, a new health plan is similar to the immediately preceding health plan if the actuarial value of the benefits under the new health plan as a whole is not more than twenty-five percent greater than the benefits provided under the immediately preceding health plan when all cost-sharing and other benefit limitations are taken into consideration.
A health carrier asserting that the new health plan is dissimilar to the immediately preceding health plan of a person applying for coverage must provide such person with a written statement describing the basis for the carrier's determination.
(5) Nothing contained in this section requires a health carrier to amend a health plan to provide new benefits in its existing health plans. For example, if a person was provided maternity benefits under the immediately preceding health plan, the carrier need not amend the new health plan being purchased to provide such benefits if the new health plan being purchased does not include maternity benefits for any covered person. In addition, nothing in this section requires a carrier to waive benefit limitations not related to an individual or group's preexisting conditions or health history. For example, this rule does not apply to a one-year waiting period for use of a particular benefit (e.g., organ transplants) imposed equally upon all covered persons without regard to health condition. However, this rule does prohibit and a carrier may not apply any waiting period or similar exclusion for use of maternity benefits under a group plan whether or not related to preexisting health conditions.
[Statutory Authority: RCW 48.02.060, 48.20.450, 48.20.460, 48.30.010, 48.44.020, 48.44.050, 48.44.080, 48.46.030, 48.46.060(2), 48.46.200 and 48.46.243. 98-04-005 (Order R 97-3), § 284-43-710, filed 1/22/98, effective 2/22/98.]
(1) All health carriers shall accept for enrollment any state resident within the carrier's service area and provide or assure the provision of all covered services regardless of age, sex, family structure, ethnicity, race, health conditions, geographic location, employment status, socioeconomic status, other conditions or situation, or HIV status. Thus, health carriers may not reject health plan applicants and may not limit or exclude plan coverage for any reason associated with health risk or perceived health risk except for the imposition of a preexisting condition exclusion as permitted in this chapter.
(2) No carrier may reject an applicant for any health plan it offers based upon preexisting conditions of the applicant or in the case of a group applicant, individuals within the group and no carrier may deny, exclude, or otherwise limit coverage for an individual's preexisting health conditions; except that a carrier may impose a three-month benefit waiting period for preexisting conditions for which medical advice was given, or for which a provider recommended or provided treatment within the three months before the effective date of coverage.
When an employer providing group health coverage to his or her employees imposes a probationary period or similar delay in eligibility for health plan coverage of new employees, the health carrier shall count the day of first employment as the effective date of coverage for purposes of calculating the preexisting condition waiting period. However, if an employee who works in a job category that is excluded from coverage under the plan later enters a benefits eligible job category, then the carrier shall count from the date the employee first enters the benefits eligible job category. For example, if an employee starts as a benefits ineligible part-time employee and later becomes a benefits eligible full-time employee, the carrier shall count from the date the employee's status changes to full-time.
(3) Genetic information shall not be treated as a health condition in the absence of a diagnosis of the condition related to such information.
(4) A carrier may not impose any preexisting condition exclusion relating to pregnancy as a preexisting condition in group health plans.
(5) No carrier may avoid the requirements of this section through the creation of a new rate classification or the modification of an existing rate classification. A new or changed rate classification will be deemed an attempt to avoid the provisions of this section if the new or changed classification would substantially discourage applications for coverage from individuals or groups who are higher than average health risks. For example, a carrier could not create a new rate classification for "uninsurable risks."
(6) The guaranteed issue provisions of this section do not apply to health plans in which the carrier has zero enrollment.
[Statutory Authority: RCW 48.02.060, 48.20.450, 48.20.460, 48.30.010, 48.44.020, 48.44.050, 48.44.080, 48.46.030, 48.46.060(2), 48.46.200 and 48.46.243. 98-04-005 (Order R 97-3), § 284-43-720, filed 1/22/98, effective 2/22/98.]