WSR 16-03-018
PERMANENT RULES
OFFICE OF
INSURANCE COMMISSIONER
[Insurance Commissioner Matter No. R 2015-04—Filed January 8, 2016, 2:16 p.m., effective January 8, 2016, 2:16 p.m.]
Effective Date of Rule: Upon filing. The requirements of SSB 5023 apply to plans issued or renewed on or after January 1, 2016, so the office of insurance commissioner needs to complete the rule-making process immediately.
Purpose: This rule deletes two sections from chapter 284-43 WAC Subchapter I (WAC 284-43-920 and 284-43-950) and moves them to a new subchapter in chapter 284-43 WAC called Subchapter J, while modifying the language to incorporate the requirements of SSB 5023.
Reasons Supporting: During the 2015 legislative session, the state legislature passed SSB 5023, which became effective on July 24, 2015. The intent of the new law is to create regulatory uniformity for the filing requirements for large group health benefit plans, including large group disability plans, as well as stand-alone dental and vision plans.
Citation of Existing Rules Affected by this Order: Repealing WAC 284-43-920 and 284-43-950.
Statutory Authority for Adoption: RCW 48.02.060, 48.44.050, 48.46.200, 48.44.020 (2)(d), 48.44.022, 48.44.023, 48.46.060 (3)(d) and (5), 48.46.064, and 48.46.066.
Other Authority: SSB 5023 (chapter 19, Laws of 2015, effective July 24, 2015).
Adopted under notice filed as WSR 15-21-078 on October 20, 2015.
A final cost-benefit analysis is available by contacting Bianca Stoner, P.O. Box 40260, Olympia, WA 98504-0260, phone (360) 725-7041, fax (360) 586-3109, e-mail rulescoordinator@oic.wa.gov.
Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 4, Amended 0, Repealed 2.
Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.
Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.
Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 0, Repealed 0.
Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 4, Amended 0, Repealed 2.
Date Adopted: January 8, 2016.
Mike Kreidler
Insurance Commissioner
SUBCHAPTER J
HEALTH PLANS, STAND-ALONE DENTAL PLANS AND STAND-ALONE VISION PLANS—FILING REQUIREMENTS
NEW SECTION
WAC 284-43-6500 Applicability and scope.
This subchapter is adopted under the general authority of RCW 48.02.060. This subchapter applies to health benefit plans as defined in RCW 48.43.005 and contracts for limited health care services as defined in RCW 48.44.035. This subchapter also applies to plans issued or renewed on or after January 1, 2016, offered by carriers under the requirements of chapter 19, Laws of 2015.
NEW SECTION
WAC 284-43-6520 Definitions.
For the purpose of this subchapter:
(1) "Contract" means an agreement to provide health care services or pay health care costs for or on behalf of a "subscriber" or group of "subscribers" and such eligible dependents as may be included therein.
(2) "Contract form" means the prototype of a "contract" and any associated riders and endorsements filed with the commissioner by a carrier.
(3) "Covered person" or "enrollee" has the same meaning as that contained in RCW 48.43.005.
(4) "Dependent" has the same meaning as that contained in RCW 48.43.005.
(5) "Health carrier" or "carrier" means an insurer that issues disability insurance regulated under chapter 48.20 or 48.21 RCW, a health care service contractor as defined in RCW 48.44.010, or a health maintenance organization as defined in RCW 48.46.020, and includes "issuers" as that term is used in the federal Patient Protection and Affordable Care Act (Public Law 111-148).
(6) "Large group contracts" or "large group plans" include group health benefit plans and stand-alone dental plans or stand-alone vision plans that are not small group plans and are not individual plans.
(7) "Limited health care service contractor" means a health care service contractor that offers one and only one limited health care service.
(8) "Negotiated contract" form means a health benefit plan or stand-alone dental plan or stand-alone vision plan where benefits and other terms and conditions, including the applicable rate schedules, are negotiated and agreed to by the carrier or limited health care service contractor and the policy or contract holder. The only plans that carriers can negotiate are large group plans. The negotiated policy form and associated rate schedule must otherwise comply with state and federal laws governing the content and schedule of rates for the negotiated plans.
(9) "Premium" means all sums charged, received, or deposited as consideration for a contract or the continuance of a contract. Any assessment, or any "membership," "policy," "survey," "inspection," "service," or similar fee or charge made by the carrier in consideration for a contract is part of the premium. Premium does not include amounts paid as enrollee point-of-service cost-sharing.
(10) "Rate" or "rates" means all classification manuals, rate manuals, rating schedules, class rates, and rating rules.
(11) "Rate schedule" means the schedule of rates that includes the description of methodology used to obtain the premium rate for a specific individual or group, if given the necessary information such as the demographic data and plan design of the individual or group. For a single negotiated contract form, the rate schedule also includes the premium for the employer.
(12) "Small employer" means an employer that fits within the definition of small employer as that term is used in the federal Patient Protection and Affordable Care Act (Public Law 111-148).
(13) "Small group plans" means the class of "group contracts" issued to "small employers." For the purposes of this section, "small group contracts" and "small group plans" also apply to stand-alone dental plans or stand-alone vision plans.
(14) "Stand-alone dental plan" means coverage for a set of benefits limited to oral care including, but not necessarily limited to, pediatric oral care.
(15) "Stand-alone vision plan" means coverage for a set of benefits limited to vision care including, but not necessarily limited to, materials.
(16) "Subscriber" means a person on whose behalf a "contract" or "certificate" is issued.
NEW SECTION
WAC 284-43-6540 Summary for group contract filings other than small group contract filings.
Groups Other Than Small Groups Filing Summary
Carrier Name
 
Address
 
 
 
 
 
Contract Holder/Pool Category and Name (Check One Box)
□ Single Employer Group:
 
Employer Name:
 
□ Multiemployer other than Association/Trust Groups
 
Group Pool Name:
 
□ Association/Trust Groups
 
Association/Trust Group Name:
Contract Form Number
 
Rate Form Number (if different from Contract Form Number)
 
Product Name
 
If additional space is required to list the contract/rate form number and product name, attach a separate sheet.
Rate Renewal Period:
From:               
To:               
Date Submitted:
_____ 
Type of Filing (Check One Box)
□ New Group
Contract
 
□ Revision of Existing Group Contract
Proposed Rate Schedules: Attach a separate sheet to list all proposed tier rates.
Rate Summary
Current Rate (Composite per employee or per member)
$ per member per month
Percentage Rate Change
%
New Rate
$ per member per month
Average Number of Enrollees Each Month During the Experience Period (If the average number of enrollees is equal to or less than fifty, explain why this is not a small group, as defined in RCW 48.43.005.)
                         
Anticipated Loss Ratio
%
Portion of carrier's total enrollment affected
%
Portion of carrier's total premium revenue affected
%
Summary of Contract Experience
 
Experience Period
First Prior Period
Second Prior
Period
 
From To
From To
From To
Member Months
 
 
 
Billed Premium
 
 
 
Incurred Claims
 
 
 
Expenses
 
 
 
Gain/Loss
 
 
 
Experience Refund/Credit or Recoupment
 
 
 
Earned Premium (Billed Premium -/+ Refund/Credit or Recoupment)
 
 
 
Loss Ratio Percentage
 
 
 
Attach comments or additional information.
Preparer's Information
Name:
 
Title:
 
Telephone Number:
 
 
 
NEW SECTION
WAC 284-43-6560 When a carrier is required to file.
(1) All rates and forms of group health benefit plans other than small group plans and all stand-alone dental and stand-alone vision plans offered by a health carrier or limited health care service contractor as defined in RCW 48.44.035 and modification of a contract form or rate must be filed before the contract form is offered for sale to the public and before the rate schedule is used.
(2) Filings of negotiated contract forms for groups other than small groups, and applicable rate schedules, that are placed into effect at time of negotiation or that have a retroactive effective date are not required to be filed in accordance with subsection (1) of this section, but must be filed within thirty working days after the earlier of:
(a) The date group contract negotiations are completed; or
(b) The date renewal premiums are implemented.
(3) When a carrier submits a late filing, the carrier must include an explanation on the filing document describing why the carrier submitted the filing late.
(4) The negotiated policy form and associated rate schedule must otherwise comply with state and federal laws governing the content and schedule of rates for the negotiated plans.
(5) Stand-alone dental plans and stand-alone vision plans offered by a disability insurer to out-of-state groups specified by RCW 48.21.010(2) may be negotiated, but may not be offered in this state before the commissioner finds that the stand-alone dental plan or stand-alone vision plan otherwise meets the standards set forth in RCW 48.21.010 (2)(a) and (b).
REPEALER
The following sections of the Washington Administrative Code are repealed:
WAC 284-43-920
When a carrier is required to file.
WAC 284-43-950
Summary for group contract filings other than small group contract filings.