reglab/statecodes huggingface dataset:
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-50 - Washington disability insurance regulations › MINIMUM STANDARDS FOR INDIVIDUAL POLICIES › Section 284-50-377 - Experimental and investigational prescriptions, treatments, procedures, or service - Definition required - Standard for definition - Written notice of denial required - Appeal process required

Current through Register Vol. 24-14, July 15, 2024
(1) Every individual disability insurance
				policy which excludes or limits, or reserves the right to exclude or limit,
				benefits for any treatment, procedure, facility, equipment, drug, drug usage,
				medical device, or supply (hereinafter individually and collectively referred
				to as services) for one or more medical condition or illness because such
				services are deemed to be experimental or investigational must include within
				the policy a definition of experimental or investigational.
(2) The definition of experimental or
				investigational services must include an identification of the authority or
				authorities which will make a determination of which services will be
				considered to be experimental or investiga-tional. If the individual disability
				insurer specifies that it, or an affiliated entity, is the authority making the
				determination, the criteria it will utilize to determine whether a service is
				experimental or investigational must be set forth in the policy. As an example,
				and not by way of limitation, the requirement to set forth criteria in the
				policy may be satisfied by using one or more of the following statements, or
				other similar statements:
(a) "In determining
				whether services are experimental or investigational, we will consider whether
				the services are in general use in the medical community in the state of
				Washington, whether the services are under continued scientific testing and
				research, whether the services show a demonstrable benefit for a particular
				illness or disease, and whether they are proven to be safe and
				efficacious."
(b) "In determining
				whether services are experimental or investigational, we will consider whether
				the services result in greater benefits for a particular illness or disease
				than other generally available services, and do not pose a significant risk to
				health or safety of the patient."
The supporting documentation upon which the criteria are
				  established must be made available for inspection upon written request in all
				  instances and may not be withheld as proprietary.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-50 - Washington disability insurance regulations › MINIMUM STANDARDS FOR INDIVIDUAL POLICIES › Section 284-50-380 - Outline of coverage requirements for individual coverages

Current through Register Vol. 24-14, July 15, 2024
(1) No individual
				disability insurance policy subject to this regulation shall be delivered or
				issued for delivery in this state unless an appropriate outline of coverage, as
				prescribed in WAC
				284-50-385 through
				284-50-425 is completed as to
				such policy and:
(a) Is either delivered with
				the policy; or
(b) Delivered to the
				applicant at the time application is made and acknowledgment of receipt or
				certification of delivery of such outline of coverage is provided to the
				insurer.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-50 - Washington disability insurance regulations › MINIMUM STANDARDS FOR INDIVIDUAL POLICIES › Section 284-50-385 - Basic hospital expense coverage, outline of coverage

Current through Register Vol. 24-14, July 15, 2024
An outline of coverage, in substantially the following form,
				  shall be issued in connection with policies meeting the standards of WAC
				  284-50-335.
(COMPANY NAME)
BASIC HOSPITAL EXPENSE COVERAGE -
OUTLINE OF COVERAGE
(1)
Read
				your policy carefully -
This outline of coverage provides a very brief
				description of the important features of your policy. This is not the insurance
				contract and only the actual policy provisions will control. The policy itself
				sets forth in detail the rights and obligations of both you and your insurance
				company. It is, therefore, important that you READ YOUR POLICY
				CAREFULLY!
(2)
Basic hospital
				expense coverage -
Policies of this category are designed to provide to
				persons insured coverage for hospital expenses incurred as a result of a
				covered accident or sickness. Coverage is provided for daily hospital room and
				board, miscellaneous hospital services, and hospital outpatient services,
				subject to any limitations, deductibles and copayment requirements set forth in
				the policy. Coverage is not provided for physicians or surgeons fees or
unlimited
hospital expenses.
(3) (A brief
specific
description of the benefits, including dollar amounts and number of days
				duration where applicable, contained in
this policy
, in the
				following order:
(a) Daily hospital room and
				board;
(b) Miscellaneous hospital
				services;
(c) Hospital outpatient
				services; and
(d) Other benefits,
				if any.)
(Note:
The above description of benefits shall be stated
								clearly and concisely, and shall include a description of any deductible or
								copayment provision applicable to the benefits described.)
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-50 - Washington disability insurance regulations › MINIMUM STANDARDS FOR INDIVIDUAL POLICIES › Section 284-50-390 - Basic medical-surgical expense coverage, outline of coverage

Current through Register Vol. 24-14, July 15, 2024
An outline of coverage, in substantially the following form,
				  shall be issued in connection with policies meeting the standards of WAC
				  284-50-340.
(COMPANY NAME)
BASIC MEDICAL-SURGICAL EXPENSE COVERAGE
OUTLINE OF COVERAGE
(1)
Read
				your policy carefully -
This outline of coverage provides a very brief
				description of the important features of your policy. This is not the insurance
				contract and only the actual policy provisions will control. The policy itself
				sets forth in detail the rights and obligations of both you and your insurance
				company. It is, therefore, important that you READ YOUR POLICY
				CAREFULLY!
(2)
Basic
				medical-surgical expense coverage -
Policies of this category are
				designed to provide to persons insured coverage for medical-surgical expenses
				incurred as a result of a covered accident or sickness. Coverage is provided
				for surgical services, anesthesia services, and in-hospital medical services,
				subject to any limitations, deductibles and copayment requirements set forth in
				the policy. Coverage is not provided for hospital expenses or unlimited
				medical-surgical expenses.
(3) (A
				brief
specific
description of the benefits, including dollar
				amounts and number of days duration where applicable, contained
in
				this
policy, in the following order:
(a) Surgical services;
(b) Anesthesia services;
(c) In-hospital medical services;
				and
(d) Other benefits, if any.
(Note:
The above description of benefits shall be stated
								clearly and concisely, and shall include a description of any deductible or
								copayment provision applicable to the benefits described.)
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-50 - Washington disability insurance regulations › MINIMUM STANDARDS FOR INDIVIDUAL POLICIES › Section 284-50-395 - Basic hospital and medical surgical expense coverage, outline of coverage

Current through Register Vol. 24-14, July 15, 2024
An outline of coverage, in substantially the following form,
				  shall be issued in connection with policies meeting the standards of WAC
				  284-50-335 and
				  284-50-340.
(COMPANY NAME)
BASIC HOSPITAL AND MEDICAL SURGICAL EXPENSE
								COVERAGE
OUTLINE OF COVERAGE
(1)
Read
				your policy carefully -
This outline of coverage provides a very brief
				description of the important features of your policy. This is not the insurance
				contract and only the actual policy provisions will control. The policy itself
				sets forth in detail the rights and obligations of both you and your insurance
				company. It is, therefore, important that you
read your policy
				carefully!
(2)
Basic
				hospital and medical surgical expense coverage -
Policies of this
				category are designed to provide, to persons insured, coverage for hospital and
				medical-surgical expenses incurred as a result of a covered accident or
				sickness. Coverage is provided for daily hospital room and board, miscellaneous
				hospital services, hospital outpatient services, surgical services, anesthesia
				services, and in-hospital medical services, subject to any limitations,
				deductibles and copayment requirements set forth in the policy. Coverage is not
				provided for
unlimited
hospital or medical-surgical
				expenses.
(3) (A brief specific
				description of the benefits, including dollar amounts and number of days
				duration where applicable, contained in
this policy
, in the
				following order:
(a) Daily hospital room and
				board;
(b) Miscellaneous hospital
				services;
(c) Hospital outpatient
				services;
(d) Surgical
				services;
(e) Anesthesia
				services;
(f) In-hospital medical
				services; and
(g) Other benefits,
				if any.
(Note:
The above description of benefits shall be stated
								clearly and concisely, and shall include a description of any deductible or
								copayment provision applicable to the benefits described.)
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-50 - Washington disability insurance regulations › MINIMUM STANDARDS FOR INDIVIDUAL POLICIES › Section 284-50-400 - Hospital confinement indemnity coverage, outline of coverage

Current through Register Vol. 24-14, July 15, 2024
An outline of coverage, in substantially the following form,
				  shall be issued in connection with policies meeting the standards of WAC
				  284-50-345.
(COMPANY NAME)
HOSPITAL CONFINEMENT INDEMNITY COVERAGE
OUTLINE OF COVERAGE
(1)
Read
				your policy carefully -
This outline of coverage provides a very brief
				description of the important features of your policy. This is not the insurance
				contract and only the actual policy provisions will control. The policy itself
				sets forth in detail the rights and obligations of both you and your insurance
				company. It is, therefore, important that you
read your policy
				carefully!
(2)
Hospital confinement indemnity coverage -
Policies of this
				category are designed to provide, to persons insured, coverage in the form of a
				fixed daily benefit during period of hospitalization resulting from a covered
				accident or sickness, subject to any limitations set forth in the policy. Such
				policies do not provide any benefits other than the fixed daily indemnity for
				hospital confinement and any additional benefit described below.
(3) (A brief
specific
description of the benefits contained in
this policy,
in the
				following order:
(a) Daily benefit payable
				during hospital confinement; and
(b) Duration of benefit described in
				(a).
(c) Any benefits provided in
				addition to the daily hospital benefit.
Note:
The above description of benefits shall be stated
								clearly and concisely.)
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-50 - Washington disability insurance regulations › MINIMUM STANDARDS FOR INDIVIDUAL POLICIES › Section 284-50-405 - Major medical expense coverage, outline of coverage

Current through Register Vol. 24-14, July 15, 2024
An outline of coverage, in substantially the following form,
				  shall be issued in connection with policies meeting the standards of WAC
				  284-50-350.
(COMPANY NAME)
MAJOR MEDICAL EXPENSE COVERAGE
OUTLINE OF COVERAGE
(1)
Read
				your policy carefully -
This outline of coverage provides a very brief
				description of the important features of your policy. This is not the insurance
				contract and only the actual policy provisions will control. The policy itself
				sets forth in detail the rights and obligations of both you and your insurance
				company. It is, therefore, important that you
read your policy
				carefully!
(2)
Major
				medical expense coverage -
Policies of this category are designed to
				provide, to persons insured, coverage for major hospital, medical, and surgical
				expenses incurred as a result of a covered accident or sickness. Coverage is
				provided for daily hospital room and board, miscellaneous hospital services,
				surgical services, anesthesia services, in-hospital medical services, and out
				of hospital care subject to any deductibles, copayment provisions, or other
				limitations which may be set forth in the policy.
Basic
hospital or
basic
medical insurance coverage is not
				provided.
(3) (A brief
specific
description of the benefits, including dollar
				amounts, contained in
this policy
, in the following order:
(a) Daily hospital room and board;
(b) Miscellaneous hospital
				services;
(c) Surgical
				services;
(d) Anesthesia
				services;
(e) In-hospital medical
				services;
(f) Out of hospital
				care;
(g) Maximum dollar amount for
				covered charges; and
(h) Other
				benefits, if any.
Note:
The above description of benefits shall be stated
								clearly and concisely, and shall include a description of any deductible or
								copayment provision applicable to the benefits described.)
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-50 - Washington disability insurance regulations › MINIMUM STANDARDS FOR INDIVIDUAL POLICIES › Section 284-50-410 - Disability income protection coverage, outline of coverage

Current through Register Vol. 24-14, July 15, 2024
An outline of coverage, in substantially the following form,
				  shall be issued in connection with policies meeting the standards of WAC
				  284-50-355.
(COMPANY NAME)
DISABILITY INCOME PROTECTION COVERAGE
OUTLINE OF COVERAGE
(1)
Read
				your policy carefully -
This outline of coverage provides a very brief
				description of the important features of your policy. This is not the insurance
				contract and only the actual policy provisions will control. The policy itself
				sets forth in detail the rights and obligations of both you and your insurance
				company. It is, therefore, important that you
read your policy
				carefully!
(2)
Disability income protection coverage -
Policies of this category
				are designed to provide, to persons insured, coverage for disabilities
				resulting from a covered accident or sickness, subject to any limitations set
				forth in the policy. Coverage is not provided for basic hospital, basic
				medical-surgical, or major-medical expenses.
(3) (A brief
specific
description of the benefits contained in
this policy
:
Note:
The above description of benefits shall be stated
								clearly and concisely.)
(4)
				(A description of any policy provisions which exclude, eliminate, restrict,
				reduce, limit, delay, or in any other manner operate to qualify payment of the
				benefits described in (3) above.)
(5) (A description of policy provisions
				respecting renewability or continuation of coverage, including age restrictions
				or any reservation of right to change premiums.)
Order R-76-4, §
											284-50-410, filed 10/29/76,
					 effective 3/1/77.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-50 - Washington disability insurance regulations › MINIMUM STANDARDS FOR INDIVIDUAL POLICIES › Section 284-50-415 - Accident only coverage, outline of coverage

Current through Register Vol. 24-14, July 15, 2024
An outline of coverage, in substantially the following form,
				  shall be issued in connection with policies meeting the standards of WAC
				  284-50-360.
(COMPANY NAME)
ACCIDENT ONLY COVERAGE
OUTLINE OF COVERAGE
(1)
Read your policy carefully -
This outline of coverage provides a very brief description of the
				important features of your policy. This is not the insurance contract and only
				the actual policy provisions will control. The policy itself sets forth in
				detail the rights and obligations of both you and your insurance company. It
				is, therefore, important that you
read your policy
				carefully!
(2)
Accident only coverage -
Policies of this category are designed to
				provide, to persons insured, coverage for certain losses resulting from a
				covered accident
only
,
subject to any limitations
				contained in the policy. Coverage is not provided for basic hospital, basic
				medical-surgical, or major-medical expenses.
(3) (A brief
specific
description of the benefits contained in
this policy
:
Note:
The above description of benefits shall be stated
								clearly and concisely, and shall include a description of any deductible or
								copayment provision applicable to the benefits described. Proper disclosure of
								benefits which vary according to accidental cause shall be made in accordance
								with WAC 284-50-325(13)
								 of this regulation.)
(4)
				(A description of any policy provisions which exclude, eliminate, restrict,
				reduce, limit, delay, or in any other manner operate to qualify payment of the
				benefits described in (3) above.)
(5) (A description of policy provisions
				respecting renewability or continuation of coverage, including age restrictions
				or any reservation of right to change premiums.)
Order R-76-4, §
											284-50-415, filed 10/29/76,
					 effective 3/1/77.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-50 - Washington disability insurance regulations › MINIMUM STANDARDS FOR INDIVIDUAL POLICIES › Section 284-50-420 - Specified disease or specified accident coverage, outline of coverage

Current through Register Vol. 24-14, July 15, 2024
An outline of coverage in substantially the following form,
				  shall be issued in connection with policies meeting the standards of WAC
				  284-50-365.
(COMPANY NAME)
(SPECIFIED DISEASE) (SPECIFIED ACCIDENT)
								COVERAGE
OUTLINE OF COVERAGE
(1)
Read
				your policy carefully -
This outline of coverage provides a very brief
				description of the important features of your policy. This is not the insurance
				contract and only the actual policy provisions will control. The policy itself
				sets forth in detail the rights and obligations of both you and your insurance
				company. It is, therefore, important that you
read your policy
				carefully!
(2)
(Specified disease) (specified accident) coverage -
Policies of
				this category are designed to provide, to persons insured, restricted coverage
				paying benefits
only
when certain losses occur as
				a result of (specified diseases) or (specified accidents). Coverage is not
				provided for basic hospital, basic medical-surgical, or major-medical
				expenses.
(3) (A brief
specific
description of the benefits, including dollar
				amounts, contained in
this policy
:
Note:
The above description of benefits shall be stated
								clearly and concisely, and shall include a description of any deductible or
								copayment provisions applicable to the benefits described. Proper disclosure of
								benefits which vary according to accidental cause shall be made in accordance
								with WAC 284-50-325(13).
(4)
				(A description of any policy provisions which exclude, eliminate, restrict,
				reduce, limit, delay, or in any other manner operate to qualify payment of the
				benefits described in (3) above.)
(5) (A description of policy provisions
				respecting renewability or continuation of coverage, including age restrictions
				or any reservation of right to change premiums.)
Order R-76-4, §
											284-50-420, filed 10/29/76,
					 effective 3/1/77.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-50 - Washington disability insurance regulations › MINIMUM STANDARDS FOR INDIVIDUAL POLICIES › Section 284-50-425 - Limited benefit health coverage, outline of coverage

Current through Register Vol. 24-14, July 15, 2024
An outline of coverage, in substantially the following form,
				  shall be issued in connection with policies which do not meet the minimum
				  standards of WAC
				  284-50-335 through
				  284-50-365.
(COMPANY NAME)
LIMITED BENEFIT HEALTH COVERAGE
OUTLINE OF COVERAGE
(1)
Read
				your policy carefully -
This outline of coverage provides a very brief
				description of the important features of your policy. This is not the insurance
				contract and only the actual policy provisions will control. The policy itself
				sets forth in detail the rights and obligations of both you and your insurance
				company. It is, therefore, important that you
read your policy
				carefully!
(2)
Limited
				benefit health coverage -
Policies of this category are designed to
				provide, to persons insured, limited or supplemental coverage.
(3) (A brief specific description of the
				benefits, including dollar amounts, contained in this policy.)
Note:
The above description of benefits shall be stated
								clearly and concisely, and shall include a description of any deductible or
								copayment provisions applicable to the benefits described. Proper disclosure of
								benefits which vary according to accidental cause shall be made in accordance
								with subsection (13) of WAC
								284-50-330.
(4)
				(A description of any policy provisions which exclude, eliminate, restrict,
				reduce, limit, delay, or in any other manner operate to qualify payment of the
				benefits described in (3) above.)
(5) (A description of policy provisions
				respecting renewability or continuation of coverage, including age restrictions
				or any reservation of right to change premiums.)
Order R-76-4, §
											284-50-425, filed 10/29/76,
					 effective 3/1/77.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-51 - Standards for coordination of benefits › Section 284-51-190 - Purpose

Current through Register Vol. 24-14, July 15, 2024
(1) The purpose of
			 this chapter is to:
(a) Establish a uniform
			 order of benefit determination under which plans pay claims;
(b) Reduce duplication of benefits by
			 permitting a reduction of the benefits to be paid by plans that, under rules
			 established by this chapter, do not have to pay their benefits first;
			 and
(c) Provide greater efficiency
			 in the processing of claims when a person is covered under more than one
			 plan.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-51 - Standards for coordination of benefits › Section 284-51-200 - Use of model COB contract provision

Current through Register Vol. 24-14, July 15, 2024
(1) WAC
			 284-51-255, Appendix A contains a
			 model COB provision for use in contracts. The use of this model COB provision
			 is subject to the provisions of subsections (2), (3), and (4) of this section
			 and to the provisions of this chapter.
(2) WAC
			 284-51-260, Appendix B is a plain
			 language description of the COB process that explains to the covered person how
			 health plans will implement coordination of benefits. It is not intended to
			 replace or change the provisions that are in the contract. Its purpose is to
			 explain the process to be used by two or more plans to pay for or provide
			 benefits as allowed by the provisions of this chapter.
(3) Issuers need not use the specific words
			 and format provided in WAC
			 284-51-255 and the plain language
			 explanation in WAC
			 284-51-260. Editing changes may
			 be made by the issuer to fit the language and style of the rest of its contract
			 or to reflect differences among plans that provide services, that pay benefits
			 for expenses incurred and that indemnify. Modifications may be made provided
			 they do not conflict with the requirements of this chapter.
(4) A COB provision may not be used that
			 permits a plan to reduce its benefits on the basis that:
(a) Another plan exists and the covered
			 person did not enroll in that plan;
(b) A person could have been covered under
			 another plan; or
(c) A person has
			 elected an option under another plan providing a lower level of benefits than
			 another option that could have been elected.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-51 - Standards for coordination of benefits › Section 284-51-205 - Rules for coordination of benefits

Current through Register Vol. 24-14, July 15, 2024
(1) When a person is covered by two or more
			 plans, the rules for determining the order of benefit payments are as follows:
(a) The primary plan must pay or provide its
			 benefits as if the secondary plan or plans did not exist.
(b) If the primary plan is a closed panel
			 plan and the secondary plan is not a closed panel plan, the secondary plan must
			 pay or provide benefits as if it were the primary plan when a covered person
			 uses a nonpanel provider, except for emergency services or authorized referrals
			 that are paid or provided by the primary plan.
(c) When multiple contracts providing
			 coordinated coverage are treated as a single plan under this chapter, this
			 section applies only to the plan as a whole, and coordination among the
			 component contracts is governed by the terms of the contracts. If more than one
			 issuer pays or provides benefits under the plan, the issuer designated as
			 primary within the plan is responsible for the plan's compliance with this
			 chapter.
(d) If a person is covered
			 by more than one secondary plan, the order of benefit determination rules of
			 this chapter decide the order in which secondary plans' benefits are determined
			 in relation to each other. Each secondary plan must take into consideration the
			 benefits of the primary plan or plans and the benefits of any other plan,
			 which, under the rules of this chapter, has its benefits determined before
			 those of that secondary plan.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-51 - Standards for coordination of benefits › Section 284-51-210 - Coordination procedures

Current through Register Vol. 24-14, July 15, 2024
Issuers must use the following claims administration practices
				to expedite claim payments where coordination of benefits is involved:
(1) Claim personnel must participate in
			 continuing education programs.
(2)
			 All requests for information must be handled in an accurate and prompt manner
			 by the inquiring issuer and the responding issuer, including the disclosure of
			 the amounts allowed and paid or to be paid by the primary plan for each
			 claim.
(3) Claim personnel of all
			 issuers, whether primary or secondary, must make every reasonable effort,
			 including use of the telephone or e-mail, to speed up exchange of coordination
			 of benefits information. Delay of payment for lack of complete coordination of
			 benefits information does not constitute a reasonable effort and compliance
			 with WAC 284-51-215 is required.
Statutory Authority: RCW 48.20.60 [48.20.060],
				  48.21.200,48.44.050, and 48.46.200. 07-13-008 (Matter No. R 2005-07), §
										284-51-210, filed 6/8/07,
				  effective 7/9/07.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-51 - Standards for coordination of benefits › Section 284-51-220 - Facility of payment

Current through Register Vol. 24-14, July 15, 2024
A plan providing for coordination of benefits must contain a
				"facility of payment" provision substantially as follows: "If payments that
				should have been made under this plan are made by another plan, the issuer has
				the right, at its discretion, to remit to the other plan the amount it
				determines appropriate to satisfy the intent of this provision. To the extent
				of such payments, the issuer is fully discharged from liability under this
				plan."
Statutory Authority: RCW 48.20.60 [48.20.060],
				  48.21.200,48.44.050, and 48.46.200. 07-13-008 (Matter No. R 2005-07), §
										284-51-220, filed 6/8/07,
				  effective 7/9/07.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-51 - Standards for coordination of benefits › Section 284-51-225 - Right of recovery

Current through Register Vol. 24-14, July 15, 2024
A plan providing for coordination of benefits must contain a
				"right of recovery" provision substantially as follows: "The issuer has the
				right to recover excess payment whenever it has paid allowable expenses in
				excess of the maximum amount of payment necessary to satisfy the intent of this
				provision. The issuer may recover excess payment from any person, other issuer
				or plan that has received payment.
Statutory Authority: RCW 48.20.60 [48.20.060],
				  48.21.200,48.44.050, and 48.46.200. 07-13-008 (Matter No. R 2005-07), §
										284-51-225, filed 6/8/07,
				  effective 7/9/07.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-51 - Standards for coordination of benefits › Section 284-51-230 - Procedure to be followed by secondary plan to calculate benefits and pay a claim

Current through Register Vol. 24-14, July 15, 2024
(1) In determining
			 the amount to be paid by the secondary plan on a claim, should the plan wish to
			 coordinate benefits, the secondary plan must make payment in an amount so that,
			 when combined with the amount paid by the primary plan, the total benefits paid
			 or provided by all plans for the claim equal one hundred percent of the total
			 allowable expense for that claim. However, in no event shall the secondary
			 carrier be required to pay an amount in excess of its maximum benefit plus
			 accrued savings. In no event should the enrollee be responsible for a
			 deductible amount greater than the highest of the two deductibles.
(2) If a plan by its terms contains
			 gatekeeper requirements as defined in subsection (3) of this section, and a
			 person fails to comply with such requirements, these provisions will have the
			 following effect in the absence of an alternative procedure agreed upon between
			 both plans and the covered person:
(a) If the
			 plan is secondary, all secondary gatekeeper requirements will be waived if the
			 gatekeeper requirements of the primary plan have been met.
(b) If the primary plan becomes secondary
			 during a course of treatment, the new primary plan must make reasonable
			 provision for continuity of care if one or more treating providers are not in
			 the new primary plan's network.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-51 - Standards for coordination of benefits › Section 284-51-235 - Notice to covered persons

Current through Register Vol. 24-14, July 15, 2024
A plan must include the following statement in the enrollee
				contract or booklet provided to covered persons:
"If you are covered by more than one health benefit plan, and
				you do not know which is your primary plan, you or your provider should contact
				any one of the health plans to verify which plan is primary. The health plan
				you contact is responsible for working with the other plan to determine which
				is primary and will let you know within thirty calendar days.
CAUTION: All health plans have timely claim filing
				requirements. If you or your provider fail to submit your claim to a secondary
				health plan within that plan's claim filing time limit, the plan can deny the
				claim. If you experience delays in the processing of your claim by the primary
				health plan, you or your provider will need to submit your claim to the
				secondary health plan within its claim filing time limit to prevent a denial of
				the claim.
To avoid delays in claims processing, if you are covered by
				more than one plan you should promptly report to your providers and plans any
				changes in your coverage."
Statutory Authority:
				  RCW
				  48.02.060,
				  48.21.200,
				  48.44.050, and
				  48.46.200. 09-16-073 (Matter No. R
				  2008-20), §
										284-51-235, filed 7/30/09,
				  effective 9/1/09; 07-13-008 (Matter No. R 2005-07), §
										284-51-235, filed 6/8/07,
				  effective 7/9/07.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-51 - Standards for coordination of benefits › Section 284-51-240 - Small claim waivers

Current through Register Vol. 24-14, July 15, 2024
In appropriate cases, issuers are encouraged to waive the
				investigation of possible other plan coverage on claims less than fifty
				dollars. However, if additional liability is incurred which raises the claim
				above fifty dollars, the entire liability may be included in the coordination
				of benefits computation.
Statutory Authority: RCW 48.20.60 [48.20.060],
				  48.21.200,48.44.050, and 48.46.200. 07-13-008 (Matter No. R 2005-07), §
										284-51-240, filed 6/8/07,
				  effective 7/9/07.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-51 - Standards for coordination of benefits › Section 284-51-245 - Miscellaneous provisions

Current through Register Vol. 24-14, July 15, 2024
(1) A
			 secondary plan that provides benefits in the form of services may recover the
			 reasonable cash value of the services from the primary plan, to the extent that
			 benefits for the services are covered by the primary plan and have not already
			 been paid or provided by the primary plan. Nothing in this provision requires a
			 plan to reimburse a covered person in cash for the value of services provided
			 by a plan that provides benefits in the form of services.
(2)
(a) A
			 plan with order of benefit determination rules that comply with this chapter
			 (complying plan) may coordinate its benefits with a plan that is "excess" or
			 "always secondary" or that uses order of benefit determination rules that are
			 inconsistent with those contained in this chapter (noncomplying plan) on the
			 following basis:
(i) If the complying plan is
			 the primary plan, it must pay or provide its benefits first;
(ii) If the complying plan is the secondary
			 plan under the order of benefit determination in this chapter, it must pay or
			 provide its benefits first, but the amount of the benefits payable must be
			 determined as if the complying plan were the secondary plan. In this situation,
			 the payment is the limit of the complying plan's liability; and
(iii) If the noncomplying plan does not
			 provide the information needed by the complying plan to determine its benefits
			 within forty-five days after the date on the letter making the request, the
			 complying plan may assume the benefits of the noncomplying plan are identical
			 to its own, and pay its benefits accordingly. If, within twenty-four months
			 after payment, the complying plan receives information as to the actual
			 benefits of the noncomplying plan, it must adjust payments accordingly between
			 the plans.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-51 - Standards for coordination of benefits › Section 284-51-250 - Applicability and scope - Effective date for existing contracts

Current through Register Vol. 24-14, July 15, 2024
This chapter applies to all plans, as defined in WAC
				284-51-195 that are issued,
				amended or renewed after December 31, 2007. All plans issued prior to January
				1, 2008 must be compliant with this chapter on that date.
Statutory Authority: RCW 48.20.60 [48.20.060],
				  48.21.200,48.44.050, and 48.46.200. 07-13-008 (Matter No. R 2005-07), §
										284-51-250, filed 6/8/07,
				  effective 7/9/07.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-51 - Standards for coordination of benefits › Section 284-51-255 - Appendix A - Model COB contract provisions

Current through Register Vol. 24-14, July 15, 2024
COORDINATION OF THIS CONTRACT'S BENEFITS WITH OTHER
				BENEFITS
WITH OTHER BENEFITS
The coordination of benefits (COB) provision applies when a
				person has health care coverage under more than one
plan. Plan
is
				defined below.
The order of benefit determination rules govern the order in
				which each
plan
will pay a claim for benefits. The
plan
that pays first is called the
primary plan.
The
primary plan
must pay benefits according to its policy terms
				without regard to the possibility that another
plan
may cover some
				expenses. The
plan
that pays after the
primary plan
is the
secondary plan.
The
secondary plan
may reduce
				the benefits it pays so that payments from all
plans
do not exceed
				100% of the total
allowable expense.
DEFINITIONS
A.A
plan
is any of the following
			 that provides benefits or services for medical or dental care or treatment. If
			 separate contracts are used to provide coordinated coverage for members of a
			 group, the separate contracts are considered parts of the same plan and there
			 is no COB among those separate contracts. However, if COB rules do not apply to
			 all contracts, or to all benefits in the same contract, the contract or benefit
			 to which COB does not apply is treated as a separate plan.
(1)
Plan
includes: Group,
			 individual or blanket disability insurance contracts, and group or individual
			 contracts issued by health care service contractors or health maintenance
			 organizations (HMO), closed panel plans or other forms of group coverage;
			 medical care components of long-term care contracts, such as skilled nursing
			 care; and medicare or any other federal governmental plan, as permitted by
			 law.
(2)
Plan
does not
			 include: Hospital indemnity or fixed payment coverage or other fixed indemnity
			 or fixed payment coverage; accident only coverage; specified disease or
			 specified accident coverage; limited benefit health coverage, as defined by
			 state law; school accident type coverage; benefits for nonmedical components of
			 long-term care policies; automobile insurance policies required by statute to
			 provide medical benefits; medicare supplement policies; medicaid coverage; or
			 coverage under other federal governmental plans, unless permitted by law.
Each contract for coverage under (1) or (2) is a separate
plan.
If a
plan
has two parts and COB rules apply
				only to one of the two, each of the parts is treated as a separate
plan.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-52 - Conversion regulation › Section 284-52-010 - Purpose

Current through Register Vol. 24-14, July 15, 2024
(1) The purpose of
			 this chapter is to establish rules pertaining to mandated conversion plans, and
			 their specific standards and minimum benefits, to effectuate the provisions of
			 RCW
			  48.21.260,
			 48.21.270,
			 48.44.370,
			 48.44.380,
			 48.46.450, and
			 48.46.460 (sections 3, 4, 6, 7, 9
			 and 10, chapter 190, Laws of 1984).
(2) Other conversion plans in addition to
			 those required by this chapter may also be offered.
Statutory Authority:
				  RCW
				  48.02.060,
				  48.44.050 and
				  48.46.200. 84-19-055 (Order R
				  84-4), §
										284-52-010, filed
				  9/19/84.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-52 - Conversion regulation › Section 284-52-030 - Other provisions applicable to mandated conversion plans

Current through Register Vol. 24-14, July 15, 2024
Except as otherwise required or permitted by this chapter,
				mandated conversion plans shall:
(1)
			 Use a format no less favorable to the covered individual than those set forth
			 in RCW
			  48.20.012, with respect to insurers, or WAC
			 284-44-030, with respect to
			 health care service contractors and health maintenance organizations;
(2) Contain a provision providing for the
			 return of the contract for a refund of payment, consistent with
			 RCW
			  48.20.013,
			 48.44.230 or
			 48.46.260, as
			 appropriate;
(3) Contain provisions
			 consistent with and no less favorable to the covered individual than the
			 following laws and regulations thereunder:
(a) With respect to insurers, the
			 requirements and standard provisions set forth in
			 chapter
			 48.20 RCW;
(b) With respect to health care service
			 contractors, the requirements of
			 chapter
			 48.44 RCW and WAC
			 284-44-040, except that lifetime
			 maximum benefits under a conversion plan are not required to be renewed or
			 restored;
(c) With respect to
			 health maintenance organizations, the requirements of
			 chapter
			 48.46 RCW;
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-52 - Conversion regulation › Section 284-52-040 - Basic medical plan

Current through Register Vol. 24-14, July 15, 2024
A basic medical plan shall have an annual deductible amount of
				no less than five hundred dollars or more than one thousand dollars per person
				and shall provide at least the following benefits:
(1) A lifetime maximum amount of benefits of
			 seventy-five thousand dollars per person.
(2) Daily hospital room and board expenses in
			 an amount not less than one hundred eighty dollars per day for at least seventy
			 days per calendar or contract year.
(3) Ancillary hospital expenses up to a
			 maximum of eighteen hundred dollars per calendar or contract year.
(4) Surgeons' fees at the usual and customary
			 charge up to a maximum of at least fifteen hundred dollars per surgical
			 procedure.
(5) Usual and customary
			 assistant surgeons' fees.
(6) Usual
			 and customary anesthesiologists' and anesthetists' fees.
(7) Inpatient and outpatient physician
			 services at the usual and customary charge.
Statutory Authority:
				  RCW
				  48.02.060,
				  48.44.050 and
				  48.46.200. 84-19-055 (Order R
				  84-4), §
										284-52-040, filed
				  9/19/84.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-52 - Conversion regulation › Section 284-52-050 - Major medical plan

Current through Register Vol. 24-14, July 15, 2024
A major medical plan shall have an annual deductible amount of
				no less than one thousand dollars or more than five thousand dollars per person
				and shall provide at least the following benefits:
(1) A lifetime maximum amount of benefits of
			 two hundred fifty thousand dollars.
(2) Payment of at least seventy-five percent
			 of the usual and customary charges for the following:
(a) Daily hospital room and board expenses
			 not less than the semi-private room rate or less than one hundred twenty days
			 per calendar or contract year.
(b)
			 Ancillary hospital expenses.
(c)
			 Surgeons' fees.
(d) Assistant
			 surgeons' fees.
(e)
			 Anesthesiologists' and anesthetists' fees.
(f) Inpatient and outpatient physician
			 services.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-52 - Conversion regulation › Section 284-52-060 - Comprehensive medical plan

Current through Register Vol. 24-14, July 15, 2024
Except as provided in subsection (3) of this section, a
				comprehensive medical plan shall have an annual deductible amount of five
				hundred dollars per person and shall provide at least the following
				benefits:
(1) A lifetime maximum
			 amount of benefits of five hundred thousand dollars per person.
(2) Payment of at least eighty percent of the
			 usual and customary charges for the following:
(a) Daily hospital room and board expenses
			 not less than the semi-private room rate nor less than one hundred eighty days
			 per calendar or contract year.
(b)
			 Ancillary hospital expenses.
(c)
			 Surgeons' fees.
(d) Assistant
			 surgeons' fees.
(e)
			 Anesthesiologists' and anesthetists' fees.
(f) Inpatient and outpatient physician
			 services.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-52 - Conversion regulation › Section 284-52-070 - Exclusions

Current through Register Vol. 24-14, July 15, 2024
No policy or contract set forth in WAC
				284-52-040,
				284-52-050, and
				284-52-060 may exclude coverage
				by type of illness, injury, accident, treatment, or medical condition, except
				with respect to the following:
(1)
			 Alcoholism and drug addiction.
(2)
			 Pregnancy, except for complications of pregnancy.
(3) Illness, treatment or medical condition
			 arising out of:
(a) War or act of war (whether
			 declared or undeclared); participation in a felony, riot or insurrection;
			 service in the armed forces or units auxiliary thereto.
(b) Suicide (sane or insane), attempted
			 suicide or intentionally self-inflicted injury.
(c) Aviation.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-53 - Standards for coverage of chemical dependency › Section 284-53-005 - Definitions (Repealed)

Current through Register Vol. 24-14, July 15, 2024
Statutory Authority:
				  RCW
				   48.02.060,
				  48.21.197, and Mental Health
				  Parity and Addiction Equity Act of 2008, Pub. L No 110-343 (Oct. 3, 2008).
				  09-15-023 (Matter No. R 2008-27), §
										284-53-005, filed 7/7/09,
				  effective 8/7/09. Statutory Authority:
				  RCW
				   48.02.060,
				  48.21.197,
				  48.44.050, and
				  48.46.200. 04-22-051 (Matter No. R
				  2003-08), §
										284-53-005, filed 10/28/04,
				  effective 11/28/04. Statutory Authority:
				  RCW
				   48.02.060,
				  48.44.050,
				  48.46.200,
				  48.21.160,
				  48.21.180,
				  48.21.197,
				  48.44.240 and
				  48.46.350. 99-16-005 (Matter No. R
				  97-8), §
										284-53-005, filed 7/22/99,
				  effective 8/22/99.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-53 - Standards for coverage of chemical dependency › Section 284-53-010 - Standards for coverage of chemical dependency (Repealed)

Current through Register Vol. 24-14, July 15, 2024
Statutory Authority:
				  RCW
				   48.02.060,
				  48.21.197, and Mental Health
				  Parity and Addiction Equity Act of 2008, Pub. L No 110-343 (Oct. 3, 2008).
				  09-15-023 (Matter No. R 2008-27), §
										284-53-010, filed 7/7/09,
				  effective 8/7/09. Statutory Authority:
				  RCW
				   48.02.060,
				  48.21.197,
				  48.44.050, and
				  48.46.200. 04-22-051 (Matter No. R
				  2003-08), §
										284-53-010, filed 10/28/04,
				  effective 11/28/04. Statutory Authority:
				  RCW
				   48.02.060,
				  48.44.050,
				  48.46.200,
				  48.21.160,
				  48.21.180,
				  48.21.197,
				  48.44.240 and
				  48.46.350. 99-16-005 (Matter No. R
				  97-8), §
										284-53-010, filed 7/22/99,
				  effective 8/22/99. Statutory Authority:
				  RCW
				   48.02.060,
				  48.44.050 and
				  48.46.200. 87-18-050 (Order R
				  87-10), §
										284-53-010, filed 8/31/87,
				  effective 1/1/88; 86-18-027 (Order R 86-2), §
										284-53-010, filed 8/27/86,
				  effective 1/1/87.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-54 - Long-term care insurance rules › Section 284-54-010 - Purpose and authority

Current through Register Vol. 24-14, July 15, 2024
The purpose of this chapter, is to effectuate
				chapter
				48.84 RCW, the Long-Term
				Care Insurance Act, by establishing minimum standards and disclosure
				requirements to be met by insurers, health care service contractors, health
				maintenance organizations, and fraternal benefit societies with respect to
				long-term care insurance and long-term care benefit policies and contracts
				issued for delivery in this state before January 1, 2009.
Statutory Authority:
				  RCW
				  48.02.060,
				  48.83.070,
				  48.83.110,
				  48.83.120,
				  48.83.130(1), and
				  48.83.140(4)(a).
				  08-24-019 (Matter No. R 2008-09), §
										284-54-010, filed 11/24/08,
				  effective 12/25/08. Statutory Authority:
				  RCW
				   48.02.060(3), 48.30.010 and
				  48.84.910. 87-15-027 (Order R
				  87-7), §
										284-54-010, filed
				  7/9/87.