Preproposal statement of inquiry was filed as WSR 12-15-088.
Title of Rule and Other Identifying Information: Commissioner's data submission requirements for K-12 public school district employee health benefit plans.
Hearing Location(s): Insurance Commissioner's Office, TR 120, 5000 Capitol Boulevard, Tumwater, WA 98504-0255, on December 27, 2012, at 1:00 p.m.
Date of Intended Adoption: January 7, 2012 .
Submit Written Comments to: Kacy Scott, P.O. Box 40258, Olympia, WA 98504-0258, e-mail email@example.com, Fax (360) 586-3109, by December 26, 2012.
Assistance for Persons with Disabilities: Contact Lorrie [Lorie] Villaflores by December 26, 2012, TTY (360) 586-0241 or (360) 725-7087.
Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: RCW 28A.400.275 requires K-12 public school districts and their benefit providers to annually submit data to the insurance commissioner regarding their employee health benefit plans. RCW 48.02.210 authorizes the commissioner to adopt rules necessary to implement the data submission requirements under RCW 28A.400.275. These proposed rules establish and implement the data submission requirements for carriers that provide health benefit plans for school district employees.
Reasons Supporting Proposal: RCW 28A.400.275 requires the insurance commissioner to receive health benefits information from school districts or their health benefit providers. The data requirements and submission process are not defined in the statute and carriers and school districts will benefit from the clarification provided by the rules.
Statutory Authority for Adoption: RCW 48.02.060 and 48.02.210(3).
Statute Being Implemented: RCW 28A.400.275.
Rule is not necessitated by federal law, federal or state court decision.
Name of Proponent: Mike Kreidler, insurance commissioner, governmental.
Name of Agency Personnel Responsible for Drafting and Implementation: Pete Cutler, P.O. Box 40258, Olympia, WA 98504-0258, (360) 725-9651; and Enforcement: Carol Sureau, P.O. Box 40255, Olympia, WA 98504-0255, (360) 725-7050.
No small business economic impact statement has been prepared under chapter 19.85 RCW. The entities that must comply with the proposed rule are not small businesses, pursuant to chapter 19.85 RCW.
A cost-benefit analysis is required under RCW 34.05.328. A preliminary cost-benefit analysis may be obtained by contacting Pete Cutler, P.O. Box 40258, Olympia, WA 98504-0258, phone (360) 725-9651, fax (360) 586-3109, e-mail firstname.lastname@example.org.
November 20, 2012
K-12 EMPLOYEE HEALTH INSURANCE DATA REPORTING RULES
(2) This chapter explains the K-12 public school district employee health benefit plan data submission requirements established pursuant to RCW 28A.400.275 and 48.02.210.
(1) "Association health plan" means a health benefit plan or policy issued through an association either pursuant to a master contract or through group contracts that predicate eligibility for enrollment in whole or in part on membership in an association.
(2) "Benefit package" has the same meaning as "health plan" or "health benefit plan."
(3) "Carrier" means, solely for the purpose of this chapter, health care service contractors, health maintenance organizations, and disability insurers that offer health benefit plans to K-12 public school district employees.
(4) "Commissioner" means the Washington state insurance commissioner.
(5) "Data call" means the commissioner's instructions to carriers for submission of information pursuant to RCW 28A.400.275 and 48.02.210.
(6) "Actual earned premium" means premium as defined in RCW 48.43.005, plus any rate credits or recoupment less any refunds, for the applicable period, whether received before, during or after the applicable period.
(7) "Enrollee" means a person entitled to coverage for benefits under a health benefit plan, including an enrollee, subscriber, policyholder, or a beneficiary of a group plan.
(8) "General administrative expenses" means actual paid expenses for administration, as reported to the commissioner and the National Association of Insurance Commissioners.
(9) "Health plan" or "health benefit plan" means any policy, contract or agreement offered to provide, arrange, reimburse or pay for medical services, as described in RCW 48.43.005(26).
(10) "Health plan premium" means the amount agreed upon as the health plan unit rate charged by the carrier for each plan participant for coverage under a comprehensive medical plan for a defined period of time, regardless of the entity responsible for paying the premium or its equivalent.
(11) "Health plan rate" means the unit rate used to calculate the premium charged, received or deposited as consideration for a health benefit plan or the continuance of a health benefit plan.
(12) "Submission" means the transfer to and actual receipt by the commissioner of data, documents and information, provided by the carrier consistent with the format, method and timing specified by the commissioner.
(13) "Total claim expenses" means the dollar amount of claims recorded as paid during the reporting period.
(2) The survey instrument will collect health plan earned premium and paid claims expenses on a monthly basis for each month of the calendar year, and may also collect those data on a plan year basis. The survey instrument will collect data regarding health plan administrative expenses and reserves for incurred but not reported expenses, on an annual and per-member, per-month (PMPM) basis.
(1) Data, supporting documents and any other information necessary to respond to the commissioner's data call must be submitted to the commissioner by the carrier at the address specified in the instructions not later than the deadline established in the data call.
(2) Carriers must use the survey template form posted on the commissioner's web site when responding to the data call, and follow the instructions, requirements and guidelines for the record layout format also posted on the web site. Carriers may submit additional documents or other explanatory information with the completed survey template. These additional documents must be submitted to the commissioner in compliance with any other record layout format requirements included in the instructions.
(3) Carriers must submit data for an individual company as one file. One individual must coordinate, compile and submit the complete package electronically, as directed in the instructions posted on the commissioner's web site.
(4) If a carrier retains the services of a third party to respond to the data call that entity must respond to the data call within the time frames required of the carrier, and follow the commissioner's instructions for submission. If the commissioner requires resubmission of the data, in whole or in part, the third party must respond within the time frame that the commissioner requires.
(5) The commissioner may contract with an entity to collect the data that must be reported pursuant to this chapter. In such a case carriers must submit the required data to that entity for use by the commissioner in carrying out the requirements of RCW 28A.400.275 and 48.02.210.
|Field||Description||Type (numeric or text)||Notes|
|(2)||Health benefit plan (HBP) name or plan identifier and policy number||text|
|HBP - Summary of benefit package - Covered benefits, deductibles, coinsurance, copayments||text|
|(3)||HBP monthly enrollment,
including employee and
dependent enrollment counts by
|(4)||HBP aggregate monthly total
and per-member, per-month
(PMPM) paid claims
|For data fields (#5-#10) report total paid expense; utilization/1000; and PMPM expense|
|(5)||HBP monthly paid inpatient
|(6)||HBP monthly paid outpatient
|(7)||HBP monthly paid physician
|(8)||HBP monthly paid pharmacy
|(9)||HBP monthly paid capitation
payments for medical care
|(10)||Other HBP monthly paid
|(11)||HBP - A list of plan deidentified
enrollees that had greater than
$100,000 paid claims in 2012; including for each: The total amount of paid claims, the enrollment status; and the survey instrument diagnosis code categories
|(12)||HBP actual earned premium
|(13)||HBP total premium or rate stabilization reserves for the plan year ending in 2012|
|(14)||HBP surplus or deficit as of the plan year ending in 2012|
|(15)||HBP total annual and PMPM general administrative expenses - 2012|
|(16)||HBP total annual and PMPM administrative expenses for premium taxes, WSHIP assessments, and other government taxes or assessments - 2012|
|(17)||HBP total annual and PMPM administrative expenses for commissions and consulting, including all direct or indirect producer compensation - 2012|
|(18)||HBP total annual and PMPM administrative expenses for PPO network access - 2012|
|(19)||HBP total annual and PMPM administrative expenses for all expenses not listed in data fields (16)-(18) - 2012|
|(20)||HBP total annual and PMPM expenses for disease management, wellness, and similar programs - 2012|
|(21)||Carrier progress toward health care cost savings and reduced administrative costs||text|
|(22)||Description of HBP use of innovative features to reduce premium growth and use of unnecessary health services||text|
|(23)||Data necessary for school districts to more effectively and competitively manage and procure health insurance plans for employees||text|
(2) Carriers that provide coverage to school district employees through association health plans must require the association to provide to a school district any health plan data in the possession of the association that is needed by the school district in order to respond to the district's data reporting requirements under RCW 28A.400.275 and 48.02.210.