Subject of Possible Rule Making: The commissioner will consider new rules to implement the recently enacted "patient bill of rights" chapter 5, Laws of 2000 (E2SSB 6199). The new law covers seven areas that will be the subject of rules: Health information privacy, information disclosure, access to health care services, insurer review of health care (utilization review), grievance processes, and independent review organizations. Several of the subjects require the commissioner to adopt rules.

⧫	Health Information Privacy

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State laws grant patients the right to obtain certain types of health care in complete confidentiality such as treatment for alcoholism or depression. What rules should the Office of the Insurance Commissioner (OIC) adopt to ensure that when benefits are paid for such treatment, no one other than the patient, the health care professional, and the payer know about treatment?

>	Congress and federal agencies are considering new laws affecting health care privacy. What areas of health information privacy should the OIC address irrespective of federal action and how should these rules anticipate federal action?

>	Consumers and health care professionals complain that payers request more information than is necessary to determine benefits and pay claims. What limits should the OIC place on payer access to health information?

>	The patient bill of rights (PBR) extends privacy standards to both health carriers and insurers. To what extent should rules that apply to health carriers differ from rules that apply to other insurers?

⧫	Health Information Disclosure

>	The OIC has adopted several rules in the past two years governing disclosure, a few of which have yet to take effect. How should the OIC proceed to integrate new disclosure standards with existing disclosure requirements?

>	The PBR permits insurers to withhold "proprietary" information. How should the OIC interpret this standard to ensure a uniform approach to information disclosure by all insurers?

>	The PBR requires disclosure in a manner that ensures that a substantial portion of enrollees can make use of the information. What standards should the OIC establish for the method and style of information disclosures?

⧫	Health Care Access Standards

>	The PBR requires that all health plans give consumers an "adequate choice among health care providers." What rules should the OIC adopt to assist in determinations as to whether plans have complied with this standard?

>	Consumers are permitted to obtain chiropractic care without a prior referral subject to managed care and cost containment processes. What rules should the OIC adopt to provide guidance on acceptable limitations on direct access to chiropractic care?

>	Consumers are permitted to continue treatment with a provider for sixty days following the provider's termination from a plan. What rules should the OIC adopt to govern the process of coverage of terminated providers?

⧫	Health Care Decisions

>	The PBR requires the OIC to adopt rules governing insurer standards for review of health care coverage which standards must be based upon "reasonable medical evidence." What rules should the OIC adopt to provide guidance for interpretation of this standard of medical evidence?

>	The PBR requires the OIC to adopt rules governing the ban on health plan denials of coverage when the insurer has already authorized care. How should the OIC interpret "prior authorization" and provide guidance for compliance?

⧫	Grievance Processes

>	The OIC has already adopted limited rules governing expedited review of the denial of health care. How should the OIC integrate these rules with new standards under the PBR?

>	The PBR establishes a process for independent review of consumer complaints. How should the OIC integrate the grievance process with this new independent review?

>	The PBR grants the OIC the ability to set standards for grievance processes. What rules should the OIC adopt to explain or clarify acceptable grievance processes?

⧫	Independent Review Organizations

>	The PBR requires the OIC to adopt rules to implement the independent review process. What standards should the OIC set to ensure implementation of this process by July 2001?

>	The PBR requires a consumer to exhaust the internal grievance process of an insurer before using the independent review process. What standards should the OIC set for insurers who wish to allow consumers quicker access to independent review by simplifying the internal grievance process?

>	The PBR permits consumers to be held responsible for health care costs if the independent reviewers uphold the insurer's position. What guidelines should the OIC establish to protect consumers from unexpected health care costs?

Statutes Authorizing the Agency to Adopt Rules on this Subject: RCW 48.02.060, 48.18.120, 48.20.450, 48.20.460, 48.30.010, 48.44.050, 48.46.100, 48.46.200, sections 5, 6, 7, 8, 9, 10 and 11, chapter 5, Laws of 2000.

Reasons Why Rules on this Subject may be Needed and What They Might Accomplish: The legislature granted rule-making authority or mandated rules to implement the patient bill of rights. Many of the subjects addressed by the new law cannot be implemented by their effective dates without rules. In each instance, the legislature expressly provided that the commissioner consider national and local standards to create more detailed guidance for insurers. Many of the provisions of the new law are general and leave to the commissioner the authority to establish comprehensive standards. More detailed guidance is particularly necessary for privacy, utilization review, and grievance processes in order to create uniform standards across all health plans.

Other Federal and State Agencies that Regulate this Subject and the Process Coordinating the Rule with These Agencies: Other state agencies are expressly subject to any rules adopted under the patient bill of rights. The commissioner will work with these state agencies to develop a coordinated approach to consumer protection. The commissioner will also consider relevant federal agency activity to avoid conflicting standards.

Process for Developing New Rule: Agency study; and the following fact-finding hearings have been scheduled: On July 10, 2000, at 9:00 a.m. - 12:00 p.m., Fidalgo Room in Northwest Rooms at Seattle Center, 305 Harrison Street, Seattle, WA 98109; on July 11, 2000, at 2:00 - 5:00 p.m., Spokane City Hall, Council Chamber, 808 West Spokane Falls Boulevard, Spokane, WA 99201-3301; and on July 13, 2000, at 2:00 - 5:00 p.m., Yakima Four Square Church, 1705 West Chestnut Avenue, Yakima, WA 98902.

Interested parties can participate in the decision to adopt the new rule and formulation of the proposed rule before publication by contacting Kacy Brandeberry, P.O. Box 40255, Olympia, WA 98504-0255, e-mail Kacyb@oic.wa.gov, fax (360) 664-2782, by July 9, 2000.

June 6, 2000

Robert A. Harkins

Chief Deputy Commissioner

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