Effective Date of Rule: Immediately.
Purpose: This rule replaces an expiring emergency rule implementing the federal reforms related to the Affordable Care Act provisions precluding health carriers and health benefit plans from using preexisting condition exclusions as a factor in coverage or eligibility determinations for persons under age nineteen. The permanent rule making for this subject is scheduled for completion in June 2011.
Statutory Authority for Adoption: RCW 48.02.060, 48.18.120(2), 48.20.450, 48.44.050, 48.46.200.
Other Authority: RCW 48.18.120(2), 48.20.450, 48.43.012, 48.43.015, 48.43.018, Pub. Law 111-148, sec. 2704.
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: The Affordable Care Act provisions affecting this practice became effective September 23, 2010.
Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 4, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.
Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.
Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.
Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 0, Repealed 0.
Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 0, Repealed 0.
Date Adopted: May 13, 2011.
Insurance CommissionerSUBCHAPTER J
HEALTH PLAN ENROLLMENT AND COVERAGE REQUIREMENTS
WAC 284-43-970 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 nineteen, based on section 2704 of the Public Health Service Act, as amended by section 1201 of the Patient Protection and Affordable Care Act, P.L. 111-148 and the interim final regulations interpreting it, 45 CFR 145.103 and 147.108 (2010), which provide that a carrier may not apply preexisting condition exclusions or coverage limitations for persons under age nineteen.
(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. For purposes of this subchapter J, a legal guardian is an applicant if they apply for an individual coverage on behalf of a person under age nineteen.
(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.
(2) A carrier must use the same method to establish the effective date of coverage for persons under age nineteen enrolling during either one of the open enrollment periods or a special enrollment period set forth in this rule.
(3) A carrier must make a special enrollment period of not less than thirty-one days available to any person under age nineteen who experiences a qualifying event. A qualifying event means the occurrence of one of the following:
(a) The discontinuation for any reason of employer sponsored insurance coverage of a person under age nineteen or the person under whose policy they were enrolled;
(b) The loss of eligibility of person under age nineteen for medicaid or a public program providing health benefits;
(c) The loss of coverage for a person under age nineteen 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. For newborns enrolled under an individual policy, coverage must be effective as of the moment of birth;
(f) Nothing in this rule is intended to alter or affect the application of RCW 48.43.517.
(4) During the enrollment periods described in subsections (1) through (3) of this section, 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.
(5) 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 nineteen.
(6) A carrier must not limit the choice of individual plan for which a person under age nineteen may apply based on the applicant's age.
(7) A carrier must prominently display on its web site information about open enrollment periods and special enrollment periods for persons under age nineteen.
(a) If a carrier elects to limit enrollment for persons under nineteen to the open enrollment periods or a special enrollment period triggered by a qualifying event, the carrier must:
(i) Explain that fact on its web site;
(ii) Promptly make application packets available to interested persons upon request, even if the request is made outside the open enrollment periods; and
(iii) Provide contact information for the Washington state high risk pool and the federally sponsored preexisting condition insurance pool - Washington.
(b) The web site information about special enrollment periods must include providing the ability to access or request and receive an application packet for enrollment at any time. The displayed information must also include details written in plain language explaining what constitutes a qualifying event for special enrollment.