WSR 03-09-142

PERMANENT RULES

OFFICE OF THE

INSURANCE COMMISSIONER

[ Insurance Commissioner Matter No. R 2003-01 -- Filed April 23, 2003, 10:42 a.m. ]

Date of Adoption: April 23, 2003.

Purpose: The adopted rule is intended to reduce the burden on network reporting and increase the consistency of data. The rule clarifies the information to be reported, limits the reporting to necessary information, extends the deadline for reporting, and changes the manner in which the reports must be filed.

Citation of Existing Rules Affected by this Order: Amending WAC 284-43-220.

Statutory Authority for Adoption: RCW 48.02.060, 48.18.120, 48.20.450, 48.20.460, 48.43.515, 48.44.050, 48.46.030, 48.46.200.

Other Authority: RCW 48.42.100, 48.43.515, 48.46.030.

Adopted under notice filed as WSR 03-03-134 on January 22, 2003.

Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 1, Repealed 0.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 1, Repealed 0.

Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 0, Repealed 0.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

April 23, 2003

Mike Kreidler

Insurance Commissioner

OTS-6089.3


AMENDATORY SECTION(Amending Matter No. R 99-2, filed 1/24/00, effective 1/1/01)

WAC 284-43-220   Network reports -- Format.   ((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)) must file with the commissioner an access plan, Provider Network Form A, Network Enrollment Form B and Geographic Network Report.

(1) ((Beginning January 1, 1999, each health carrier shall provide the insurance commissioner with:

(a) An annual)) Access plan. A health carrier must describe each of its networks in an access plan as prescribed by WAC 284-43-210.

(2) Provider Network Form A. A carrier must file an electronic ((or hard copy paper)) report of all participating providers by network ((and monthly updates)). This report ((shall)) must contain all ((the)) data items shown in ((the table. (Form A.))) Provider Network Form A prescribed by and available from the commissioner. Updated reports must be filed each month. 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)) (3) Network Enrollment Form B. By March 31, 2004, and every year thereafter, a carrier must prepare an electronic report showing 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)). A separate report must be filed for each network by line of business. The report must contain all data items shown in and conform to the format of Network Enrollment Form B prescribed by and available from the commissioner.

(4) Geographic Network Report. By March 31st of every year, a carrier also must file an electronic or hard copy paper report meeting the standards below. The carrier must update the reports whenever a material change in ((a)) the carrier's provider network occurs that significantly affects the ability of covered persons to access covered services. Each carrier ((shall)) must file for each 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:

(i) ((County.

(ii))) Total number of covered persons((.));

(((iii))) (ii) 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);

(((iv))) (iii) Number of covered persons meeting the carrier's self defined access standard((.));

(((v))) (iv) Percentage of covered persons meeting the carrier's self defined access standard((.)); and

(((vi))) (v) Average distance to at least one primary care provider for its covered persons((.)); and

(c) ((A list indicating alphabetically by county and by city:

(i) County;

(ii) City;

(iii))) An alphabetical list by county and city showing:

(i) Total number of covered persons;

(((iv))) (ii) 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))) (iii) Total number of obstetric and women's health care providers;

(((vi))) (iv) Total number of specialists;

(((vii))) (v) Total number of nonphysician providers by license type;

(((viii))) (vi) Total number of hospitals; and

(((ix))) (vii) Total number of pharmacies.

(((3))) (5) A carrier may vary the method of reporting required under subsection (((2))) (4) of this section upon written request and subsequent written approval by the commissioner ((after a showing by)). In the request, the carrier must show 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.

(6) For purposes of this section:

(a) "Line of business" means either individual, small group or large group coverage;

(b) "Network" means the group of participating providers and facilities providing health care services to a particular line of business.


(((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, 48.18.120, 48.20.450, 48.20.460, 48.30.010, 48.44.050, 48.46.030, 48.46.200. 00-04-034 (Matter No. R 99-2), 284 -43-220, filed 1/24/00, effective 1/1/01. 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 (Matter No. R 97-3), 284-43-220, filed 1/22/98, effective 2/22/98.]

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