WSR 99-19-032

PERMANENT RULES

INSURANCE COMMISSIONER'S OFFICE


[ Insurance Commissioner Matter No. R 98-7-- Filed September 8, 1999, 4:48 p.m. ]

Date of Adoption: September 8, 1999.

Purpose: Improve uniformity in the terminology used in the advertising of mental health benefits and increase the understanding of consumers who read, hear, or view the advertisement.

Citation of Existing Rules Affected by this Order: Amending WAC 284-43-130.

Statutory Authority for Adoption: RCW 48.02.060, 48.30.010, 48.44.050, 48.46.200.

Other Authority: RCW 48.30.040, 48.44.110, 48.46.400.

Adopted under notice filed as WSR 99-16-106 on August 4, 1999.

Changes Other than Editing from Proposed to Adopted Version: Several editing changes were made. Additionally, in WAC 284-43-810(2) changes were made to direct the information to the prospective contract holder in a form appropriate for distribution to prospective enrollees instead of directly to the prospective enrollee. Also, WAC 284-43-810 (2)(e) was changed so that the information will be based upon enrollees who have received mental health services rather than those who sought mental health services. These changes will make the rule easier and less costly to implement.

Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

Number of Sections Adopted on the Agency's Own Initiative: New 1, Amended 1, Repealed 0.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 0, Repealed 0.

Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 0, Repealed 0.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.

September 8, 1999

Robert A. Harkins

Chief Deputy Commissioner

OTS-2732.7


AMENDATORY SECTION(Amending Order R 97-3, filed 1/22/98, effective 2/22/98)

WAC 284-43-130
Definitions.

Except as defined in other subchapters and unless the context requires otherwise, the following definitions shall apply throughout this chapter.

(1) (("Covered benefits" means those health care services to which a covered person is entitled under the terms of a health plan.)) "Covered health condition" means any disease, illness, injury or condition of health risk covered according to the terms of any health plan.

(2) "Covered person" means an individual covered by a health plan including an enrollee, subscriber, policyholder, or beneficiary of a group plan.

(3) "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.

(4) "Emergency services" means otherwise covered health care services medically necessary to evaluate and treat an emergency medical condition, provided in a hospital emergency department.

(5) "Enrollee point-of-service cost-sharing" or "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.

(6) "Facility" means an institution providing health care services, including but not limited to hospitals and other licensed inpatient centers, ambulatory surgical or treatment centers, skilled nursing centers, residential treatment centers, diagnostic, laboratory, and imaging centers, and rehabilitation and other therapeutic settings.

(7) "Grievance" means a written complaint submitted by or on behalf of a covered person regarding:

(a) Denial of health care services or payment for health care services; or

(b) Issues other than health care services or payment for health care services including dissatisfaction with health care services, delays in obtaining health care services, conflicts with carrier staff or providers, and dissatisfaction with carrier practices or actions unrelated to health care services.

(8) "Health care provider" or "provider" means:

(a) A person regulated under Title 18 RCW 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.

(9) "Health care service" or "health 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.

(10) "Health carrier" or "carrier" means a disability insurance company regulated under chapter 48.20 or 48.21 RCW, a health care service contractor as defined in RCW 48.44.010, and a health maintenance organization as defined in RCW 48.46.020.

(11) "Health plan" or "plan" means any individual or group policy, contract, or agreement offered by a health carrier to provide, arrange, reimburse, or pay for health care service except the following:

(a) Long-term care insurance governed by chapter 48.84 RCW;

(b) Medicare supplemental health insurance governed by chapter 48.66 RCW;

(c) Limited health care service offered by limited health care service contractors in accordance with RCW 48.44.035;

(d) Disability income;

(e) Coverage incidental to a property/casualty liability insurance policy such as automobile personal injury protection coverage and homeowner guest medical;

(f) Workers' compensation coverage;

(g) Accident only coverage;

(h) Specified disease and hospital confinement indemnity when marketed solely as a supplement to a health plan;

(i) Employer-sponsored self-funded health plans;

(j) Dental only and vision only coverage; and

(k) 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.

(12) "Managed care plan" means a health plan that coordinates the provision of covered health care services to a covered person through the use of a primary care provider and a network.

(13) "Medically necessary" or "medical necessity" in regard to mental health services is a carrier determination as to whether a health service is a covered benefit if the service is consistent with generally recognized standards within a relevant health profession.

(14) "Mental health provider" means a health care provider or a health care facility authorized by state law to provide mental health services.

(15) "Mental health services" means in-patient or out-patient treatment, partial hospitalization or out-patient treatment to manage or ameliorate the effects of a mental disorder listed in the Diagnostic and Statistical Manual (DSM) IV published by the American Psychiatric Association, excluding diagnoses and treatments for substance abuse, 291.0 through 292.9 and 303.0 through 305.9.

(16) "Network" means the group of participating providers and facilities providing health care services to a particular health plan.  A health plan network for carriers offering more than one health plan may be smaller in number than the total number of participating providers and facilities for all plans offered by the carrier.

(((14))) (17) "Out-patient therapeutic visit" or "out-patient visit" means a clinical treatment session with a mental health provider of a duration consistent with relevant professional standards used by the carrier to determine medical necessity for the particular service being rendered, as defined in Physicians Current Procedural Terminology, published by the American Medical Association.

(18) "Participating provider" and "participating facility" means a facility or provider who, under a contract with the health carrier or with the carrier's contractor or subcontractor, has agreed to provide health care services to covered persons with an expectation of receiving payment, other than coinsurance, copayments, or deductibles, from the health carrier rather than from the covered person.

(((15))) (19) "Person" means an individual, a corporation, a partnership, an association, a joint venture, a joint stock company, a trust, an unincorporated organization, any similar entity, or any combination of the foregoing.

(((16))) (20) "Primary care provider" means a participating provider who supervises, coordinates, or provides initial care or continuing care to a covered person, and who may be required by the health carrier to initiate a referral for specialty care and maintain supervision of health care services rendered to the covered person.

(((17))) (21) "Preexisting condition" means any medical condition, illness, or injury that existed any time prior to the effective date of coverage.

(((18))) (22) "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.

(((19))) (23) "Small group" means a health plan issued to a small employer as defined under RCW 48.43.005(24) comprising from one to fifty eligible employees.

[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), 284-43-130, filed 1/22/98, effective 2/22/98.]


NEW SECTION
WAC 284-43-810
Coverage for mental health services.

(1) The commissioner may disapprove any contract issued or renewed after April 1, 2000, that includes coverage for mental health services, and those services are advertised, if it does not include the following statement:


MENTAL HEALTH SERVICES AND YOUR RIGHTS


(Health Carrier Name) and state law have established standards to assure the competence and professional conduct of mental health service providers, to guarantee your right to informed consent to treatment, to assure the privacy of your medical information, to enable you to know which services are covered under this plan and to know the limitations on your coverage. If you would like a more detailed description than is provided here of covered benefits for mental health services under this plan, or if you have a question or concern about any aspect of your mental health benefits, please contact us (the health carrier) at xxx-xxx-xxxx (current phone number).


If you would like to know more about your rights under the law, or if you think anything you received from this plan may not conform to the terms of your contract or your rights under the law, you may contact the Office of Insurance Commissioner at 800-562-6900. If you have a concern about the qualifications or professional conduct of your mental health service provider, please call the State Health Department at xxx-xxx-xxxx (current phone number suggested by State Health Department).


(2) The commissioner may disapprove any contract issued or renewed after April 1, 2000, that includes coverage for mental health services, and those services are advertised, if it does not pose and respond in writing to the following questions in language that complies with WAC 284-50-010 through 284-50-230 in or accompanying an invitation to contract which is given to each prospective contract holder with an offer to provide for distribution to prospective enrollees prior to enrollment.

(a) "What are the steps that must be taken to have outpatient mental health services paid for by my plan?"

Yes No
Direct self referral to a participating provider, with no prior authorization or approval.
Primary care provider referral required; Primary care provider may determine the number of visits.
Preauthorization, predetermination of medical necessity, preverification of benefits and eligibility or referral required.

(b) "What information about my mental condition will anyone other than my mental health provider see?"

No information, other than your diagnostic category and number of treatments you received.
Diagnostic details.
Treatment codes.
Treatment plans, including expected outcomes.
Progress notes.
Other.

(c) "Do I have to pay a higher co-pay, deductible or other charges than I pay for my other covered medical services to get mental health services under this plan?"

Same Less More
Deductibles.
Co-pays.
Co-insurance.
Other cost sharing.

(d) "What is the maximum number of medically necessary in-patient days and out-patient visits I can get each year under this plan?"

Inpatient Outpatient
Days Visits
Less than ten.
Eleven to twenty.
Twenty-one to thirty.
More than thirty.
Other.

(e) "What is the average number of outpatient visits this plan pays for people who have been provided mental health services?" (Note to carriers: This response must state the average outpatient visits per enrollee requesting these services during the most recent year for which data is available. This time period may begin no more than thirty-six months prior to the issue date of the policy being sold.)

Less than ten.
Eleven to twenty.
Twenty-one to thirty.
More than thirty.
Other.

(f) "In which of the following circumstances where I might need mental health services would I find them excluded or subject to restrictions or limitations other than medical necessity?"
Diagnostic testing to determine if a mental disorder exists.
A mental disorder has a congenital or physical basis, such as Tourette's Syndrome, or may be partially covered under the medical services portion of the health plan.
A court orders treatment.
Treatment surrounding self inflicted harm, such as a suicide attempt.
There are diagnosed learning disabilities.
There is a diagnosed eating disorder.
There is a diagnosed mental disorder related to sexual functioning, or a sex change.
Couples or marriage therapy.
Custodial care.

(g) "What is this plan's most common goal in financing treatment in adults? In children?"

Stabilization and symptom management.
Return to previous functioning.
Ongoing maintenance for long-term illness.

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Washington State Code Reviser's Office