WSR 11-03-041

EMERGENCY RULES

OFFICE OF

INSURANCE COMMISSIONER

[ Insurance Commissioner Matter No. R 2011-02 -- Filed January 13, 2011, 8:36 a.m. , effective January 13, 2011, 8:36 a.m. ]


Effective Date of Rule: Immediately.

Purpose: The rule establishes the requirements health carriers must follow for open enrollment periods and special enrollment periods resulting from a qualifying event for persons under age nineteen.

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

Other Authority: RCW 48.20.450; Pub. Law 111-148, sec. 2704 (2010).

Under RCW 34.05.350 the agency for good cause finds that state or federal law or federal rule or a federal deadline for state receipt of federal funds requires immediate adoption of a rule.

Reasons for this Finding: Beginning September 23, 2010, the federal Patient Protection and Affordable Care Act requires that health carriers must not impose preexisting condition limitations on persons under age nineteen applying for health insurance as a condition of enrollment or the availability of coverage. In order to maintain the stability of the individual and small group health insurance markets in Washington, open enrollment periods are necessary to prevent adverse selection.

Number of Sections Adopted in Order to Comply with Federal Statute: New 4, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 0, Repealed 0.

Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 4, Amended 0, Repealed 0.

Date Adopted: January 13, 2011.

Mike Kreidler

Insurance Commissioner

SUBCHAPTER J


HEALTH PLAN ENROLLMENT AND COVERAGE REQUIREMENTS
NEW SECTION
WAC 284-43-1001   Purpose and scope.   These rules explain the requirements in effect in Washington governing the issue of individual health insurance or health benefit plans to persons under age 19, based on Section 2704 of the Patient Protection and Affordable Care Act, P.L. 111-148 and the interim final regulations interpreting it, 45 C.F.R. 145.103 and 147.108, which provide that a carrier may not apply preexisting condition exclusions for persons under age nineteen.

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NEW SECTION
WAC 284-43-1005   Definitions.   As used in this section, unless the context requires otherwise:

(1) "Applicant" means a person who applies for enrollment in an individual health plan as a subscriber or an enrollee, or the dependent or spouse of a subscriber or enrollee.

(2) "Carrier" has the same meaning as its definition in RCW 48.43.005(18) and includes "issuers" as that term is used in the Patient Protection and Affordable Care Act, P.L. 111-148.

(3) "Open enrollment" means a period of time as defined in these rules, held at the same time each year, during which applicants may enroll in the carrier's individual health benefit plan without being subject to health screening or otherwise required to provide evidence of insurability as a condition for enrollment.

(4) "Special enrollment" means a defined period of time of not less than thirty-one days, triggered by a specific qualifying event experienced by the applicant, during which applicants may enroll in the carrier's individual health benefit plan without being subject to health screening or otherwise required to provide evidence of insurability as a condition for enrollment.

(5) "Standard health questionnaire" means the standard health questionnaire designated under chapter 48.41 RCW.

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NEW SECTION
WAC 284-43-1010   Preexisting conditions.   For any individual health benefit plan, a carrier must waive any exclusion of benefits, including a denial of coverage, and may not otherwise limit coverage based upon a preexisting condition waiting period if the applicant or enrollee is a person under age 19. This requirement:

(1) Does not apply to an individual grandfathered plan under P.L. 111-148, the Patient Protection and Affordable Care Act;

(2) Includes those persons under age nineteen with a preexisting condition who seek coverage as the primary insured or as a dependent or as a spouse under individual health benefit plans that permit the enrollment of dependents, and enrolled persons under age nineteen who seek benefits for which they are otherwise eligible.

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NEW SECTION
WAC 284-43-1015   Enrollment of persons under age 19.   (1) For any individual health benefit plan offered after January 1, 2011, the carrier must conduct an open enrollment period for persons under age nineteen during two time periods each year. The first open enrollment must occur from March 15 through April 30 of each year, and the second open enrollment period must occur from September 15 through October 31.

(2) A carrier must make a special enrollment period of not less than thirty-one days available to any person under age 19 who experiences a qualifying event. A qualifying event means the occurrence of one of the following:

(a) The person under age nineteen or the person under whose policy they were enrolled loses employer sponsored insurance;

(b) The person under age nineteen loses eligibility under medicaid or other public program providing health benefits;

(c) The person under age nineteen or the person under whose policy they were enrolled loses coverage as the result of dissolution of marriage;

(d) The person under age nineteen or the person under whose policy they were enrolled changes residence, and the health plan under which they were covered does not provide coverage in that person's new service area.

(e) The person for whom coverage is sought was born, placed for adoption or adopted within sixty days of the application for enrollment.

(3) During the enrollment periods described in subsection (1) and (2), or any other enrollment period, a carrier must not require a person under age nineteen applying for an individual health benefit plan to complete the standard health questionnaire designated under chapter 48.41 RCW or otherwise provide evidence of insurability.

(4) A carrier may offer enrollment in an individual health benefit plan outside the open or special enrollment period, but must not require any evidence of insurability or completion of the standard health questionnaire if the applicant is a person under age 19.

(5) Each carrier must prominently display on its website information about open enrollment periods and special enrollment periods for persons under age 19, and if the carrier elects to limit enrollment to the open and special enrollment periods, explain that fact on the website and provide contact information for the Washington State High Risk Pool and the Pre-existing Condition Insurance Pools.

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Washington State Code Reviser's Office