reglab/statecodes huggingface dataset:
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-110 - Service Contracts and Protection Product Guarantees › Section 284-110-010 - Definitions

Current through Register Vol. 24-14, July 15, 2024
The definitions in this section apply throughout this
				chapter.
(1) "Most recent financial
			 statements" means a partial fiscal year financial statement to include year-end
			 totals, if available. For start-up applicants, formed less than one fiscal
			 year, partial fiscal year financial statements shall include the months from
			 formation to current.
(2)
			 "Statutory accounting principles" means the current year accounting practices
			 and procedures manual as adopted by the national association of insurance
			 commissioners. Service contract providers and protection product guarantee
			 providers must follow all statement of statutory accounting principles with a
			 type of issue of "common area" and "property and casualty." Any permitted
			 accounting practices from a domiciliary state regulator shall not be used in
			 determining minimum net worth. Only service contract providers relying on
			 RCW
			  48.110.050(2)(a) or
			 48.110.075(2)(a)
			 may elect to use statutory accounting principles.
(3) "Material changes or additions" as
			 referred to in
			 RCW
			  48.110.030(6) and
			 48.110.055(7)
			 means the following:
(a) Any financial
			 condition where the registrant, or its parent company if applicable, fails to
			 maintain the net worth requirements under
			 RCW
			  48.110.030(2)(c)(i) and (ii) 
			 and
			 48.110.055(3)(e).
(b) The information referred to in
			 RCW
			  48.110.030(2)(a) and
			 (b).
(c) Change of financial responsibility or
			 faithful performance requirements under
			 RCW
			  48.110.050(2)(a) through
			 (c).
(d) The information referred to in
			 RCW
			  48.110.055(2) (b) through
			 (3)(d).
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-110 - Service Contracts and Protection Product Guarantees › Section 284-110-020 - Certified financial statement

Current through Register Vol. 24-14, July 15, 2024
(1)RCW
			  48.110.030 and
			 48.110.055 permit service contract providers and protection product guarantee providers to
			 submit financial statements certified as accurate by two or more officers of
			 the service contract provider or protection product guarantee provider in lieu
			 of audited financial statements in certain circumstances. Certified financial
			 statements must include all the financial statements, notes, and information
			 that accurately present the financial position of the provider at the report
			 date. Management is responsible for the preparation and fair presentation of
			 these financial statements in conformity with the accounting practices
			 prescribed or permitted under chapter 48.110 RCW and this chapter.
(2) Only service contract providers and
			 protection product guarantee providers filing certified financial statements
			 must use the prescribed certification of financial statements form that is
			 available on the commissioner's website.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-110 - Service Contracts and Protection Product Guarantees › Section 284-110-030 - Parental guarantee

Current through Register Vol. 24-14, July 15, 2024
Service contract providers relying on
				RCW
				 48.110.050(2)(c) to
				demonstrate financial responsibility or assure faithful performance must use
				the prescribed parental guarantee form that is available on the commissioner's
				website.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-155 - Health care discount plan organization standards › Section 284-155-005 - Purpose

Current through Register Vol. 24-14, July 15, 2024
These regulations implement chapter 48.155 RCW and create the
				processes and procedures for licensing a discount plan
				organization.
Statutory Authority:
				  RCW
				  48.155.007 and
				  48.02.060. 09-22-064 (Matter No. R
				  2009-10), §
										284-155-005, filed 11/2/09,
				  effective 12/3/09.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-155 - Health care discount plan organization standards › Section 284-155-010 - Definitions

Current through Register Vol. 24-14, July 15, 2024
The definitions in this section apply throughout this chapter
				unless the context clearly requires otherwise:
"Applicant" means any discount plan organization applying for a
				license under these regulations, and includes a discount plan organization or
				person holding a license or other form of authority from another state to
				operate as a discount plan organization.
"Application" means the written request for a license and the
				information required by the commissioner to obtain a license to transact
				discount plan business.
"License" means the license issued by the commissioner required
				to transact discount plan business under these regulations.
"Renewal application" means the renewal application under these
				regulations.
Statutory Authority:
				  RCW
				  48.155.007 and
				  48.02.060. 09-22-064 (Matter No. R
				  2009-10), §
										284-155-010, filed 11/2/09,
				  effective 12/3/09.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-155 - Health care discount plan organization standards › Section 284-155-015 - Licensing forms and filing procedures

Current through Register Vol. 24-14, July 15, 2024
(1) An applicant applying for a new license
			 or a licensed discount plan organization applying for license renewal must
			 complete and file all required forms. All forms, including the application
			 form, the renewal form, and the annual report form required by this regulation
			 are available on the commissioner's web site at
www.insurance.wa.gov
. Applicants must
			 fully complete and file only forms approved by the commissioner.
(2) If a licensed discount plan organization
			 fails to file the renewal application or the renewal application fee sooner
			 than ninety days before its license expires, the license will expire on its
			 expiration date and the discount plan organization must complete and file a new
			 application and pay the fee for a new license.
(3) Upon the expiration of a discount plan
			 organization's license, all operations must be immediately suspended, including
			 any advertising, marketing, solicitation, enrollment, and renewal of contracts
			 or other activities specified under these regulations.
(4) Annual report filing requirements:
(a) Licensed discount plan organizations are
			 not required to prepare a separate annual report filing or pay the annual
			 report fee if they file the information required for their annual report at the
			 time they file their renewal application, but only if they do so prior to the
			 March 31st deadline for filing the annual report.
(b) If a licensed discount plan organization
			 does not include its annual report information with its renewal application, it
			 must file an annual report with the commissioner prior to the March 31st
			 deadline for filing an annual report. If the renewal application is due after
			 March 31st, a licensed discount plan organization must file an annual report by
			 March 31st, and may not defer filing the annual report on the basis that it
			 plans to include the annual report information with its renewal.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-155 - Health care discount plan organization standards › Section 284-155-020 - Audited financial statements

Current through Register Vol. 24-14, July 15, 2024
(1) All audited financial statements filed
			 with the commissioner under these regulations must:
(a) Be prepared in accordance with generally
			 accepted auditing principles;
(b)
			 Be certified by an independent certified public accountant; and
(c) Meet the standards and requirements of
			 WAC 284-07-100 through
			 284-07-230 to the extent
			 reasonably applicable, provided, that WAC
			 284-07-100(5), (6), and
			 (7)  shall not apply to discount plan
			 organizations; and provided further, that discount plan organizations shall not
			 be required to file any report, letter, or other document required to be filed
			 with the commissioner by WAC
			 284-07-100 through
			 284-07-230 with the National
			 Association of Insurance Commissioners (NAIC).
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-155 - Health care discount plan organization standards › Section 284-155-025 - Indemnity requirements for discount plan organizations

Current through Register Vol. 24-14, July 15, 2024
(1) A discount plan organization providing a
			 surety bond to protect the financial interests of Washington members must name
			 the state of Washington as the obligee, but the bond will be for the benefit of
			 the Washington members who have purchased the discount plan.
(2) All surety bonds obtained by discount
			 plan organizations for the purpose of complying with their financial
			 responsibility under this section must operate to ensure Washington consumers
			 provision of all terms of their discount plan membership, including
			 refunds.
(3) A discount plan
			 organization, in lieu of a surety bond, may provide a deposit in trust with the
			 commissioner to protect the financial interests of Washington members as set
			 forth in RCW  48.155.040.
(a) The deposit in trust must be in cash or
			 other investments specifically authorized and eligible for investment pursuant
			 to chapter 48.13
			 RCW.
(b) All deposits and
			 withdrawals must be made by using forms found on the commissioner's web site at
www.insurance.wa.gov
.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-155 - Health care discount plan organization standards › Section 284-155-030 - Discount plan organization - General requirements for records availability and form and report filing

Current through Register Vol. 24-14, July 15, 2024
(1) All
			 discount plan organization records and reports must be maintained at the
			 discount plan organization's principal business address and are subject to
			 review by the commissioner's representatives during the discount plan
			 organization's usual and customary business hours.
(2) The commissioner may require discount
			 plan organizations to provide copies of discount plan organization documents,
			 records, and reports in lieu of making the records available for on-site
			 review.
(3) All records, reports,
			 notices, or other documents required by this regulation must be transmitted
			 electronically in Adobe Acrobat PDF format.
(4) A discount plan organization must respond
			 promptly to any inquiry from the insurance commissioner relative to the
			 business of a discount plan organization. A lack of response within fifteen
			 business days from the receipt of an inquiry will be considered untimely. A
			 response must be in writing, unless otherwise indicated in the
			 inquiry.
Statutory Authority:
				  RCW
				  48.155.007 and
				  48.02.060. 09-22-064 (Matter No. R
				  2009-10), §
										284-155-030, filed 11/2/09,
				  effective 12/3/09.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-160 - Guaranteed asset protection waiver › RULES FOR THE GUARANTEED ASSET PROTECTION WAIVER PROGRAM › Section 284-160-010 - Purpose of this chapter

Current through Register Vol. 24-14, July 15, 2024
(1) The
				purpose of this chapter is to adopt processes and procedures for creditors to
				use when they register with the commissioner under chapter 48.160 RCW, and
				otherwise implement the chapter.
(2) This chapter is effective on January 1,
				2010. All guaranteed asset protection waiver creditors must comply with this
				chapter on or after that date. Applicants registered before the effective date
				of this chapter do not need to refile their application to be in
				compliance.
Statutory Authority:
					 RCW
					 48.02.060 and
					 48.160.070. 10-02-111 (Docket
					 Number R 2009-15), §
											284-160-010, filed 1/6/10,
					 effective 1/6/10.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-160 - Guaranteed asset protection waiver › RULES FOR THE GUARANTEED ASSET PROTECTION WAIVER PROGRAM › Section 284-160-020 - Definitions

Current through Register Vol. 24-14, July 15, 2024
For purposes of this chapter, unless the context requires
				  otherwise, the following definitions apply:
(1) "Complete filing" means the package of
				information containing the registration application, other supporting documents
				requested by the commissioner, and fees.
(2) "Creditor" means the same as in
				RCW
				 48.160.010(3), and includes
				any person acting as an obligor for a guaranteed asset protection
				waiver.
(3) "Days" means calendar
				days including Saturday and Sunday and holidays unless otherwise
				specified.
(4) "File" means a
				record in any retrievable format, and unless otherwise specified, includes
				paper and electronic formats.
(5)
				"Home state" means the District of Columbia and any state or territory of the
				United States or province of Canada in which a creditor maintains its principal
				place of residence or principal place of business and is licensed to do
				business.
(6) "Registrant" means a
				person registering with the commissioner under the guaranteed asset protection
				waiver program as required by chapter 48.160 RCW.
(7) "Written" or "in writing" means any
				retrievable method of recording an agreement or document, and unless otherwise
				specified, includes paper and electronic formats.
Statutory Authority:
					 RCW
					 48.02.060 and
					 48.160.070. 10-02-111 (Docket
					 Number R 2009-15), §
											284-160-020, filed 1/6/10,
					 effective 1/6/10.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-160 - Guaranteed asset protection waiver › RULES FOR THE GUARANTEED ASSET PROTECTION WAIVER PROGRAM › Section 284-160-030 - Persons required to register

Current through Register Vol. 24-14, July 15, 2024
Any person offering or selling guaranteed asset protection
				  waivers to residents of the state of Washington or borrowers in the state of
				  Washington, or acting as an obligor for guaranteed asset protection waivers
				  sold to residents of this state, must register with the commissioner as
				  required by
				  RCW
				   48.160.020 unless:
(1) The person is exempt under
				RCW
				 48.160.001(2);
(2) The person is a retail seller of motor
				vehicles assigning:
(a) More than eighty-five
				percent of guaranteed asset protection waiver agreements within thirty days of
				such agreements' effective date; and
(b) One hundred percent of guaranteed
				protection waiver agreements within forty-five days of each agreement's
				effective date; or
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-160 - Guaranteed asset protection waiver › RULES FOR THE GUARANTEED ASSET PROTECTION WAIVER PROGRAM › Section 284-160-050 - Use of legal name and address

Current through Register Vol. 24-14, July 15, 2024
(1) Every guaranteed asset protection waiver
				contract issued to a resident of Washington state or in Washington state must
				conspicuously disclose the legal name, home office address, and local contact
				address of the creditor.
(2) Upon
				any assignment or transfer of the waiver, as allowed under
				RCW
				 48.160.030, the disclosure provided to the
				consumer must conspicuously include:
(a) The
				legal name and home office address of both the person or entity transferring
				the obligation;
(b) The legal name
				and home office address of the assignee for the guaranteed asset protection
				waiver; and
(c) The local address,
				telephone and e-mail contact information for the assignee for the guaranteed
				asset protection waiver.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-160 - Guaranteed asset protection waiver › RULES FOR THE GUARANTEED ASSET PROTECTION WAIVER PROGRAM › Section 284-160-060 - Guaranteed asset protection waiver program registration requirements

Current through Register Vol. 24-14, July 15, 2024
(1) An applicant
				for registration to issue guaranteed asset protection waivers must file a
				completed application as required by the commissioner on the application form
				and its accompanying instructions. The application form and instructions for
				completing the form are available on the commissioner's web site at
www.insurance.wa.gov
. The application
				form and any required documents must be completed and submitted to the
				commissioner electronically, unless the applicant receives prior approval to
				file a paper copy of the application and documents.
(2) In order to transact the business of
				issuing and administering guaranteed asset protection waiver contracts in the
				state of Washington, the commissioner must have approved the registration
				application packets filed by an applicant for registration. Applicants must
				submit packets that comply with chapter 48.160 RCW and with these
				rules.
Statutory Authority:
					 RCW
					 48.02.060 and
					 48.160.070. 10-02-111 (Docket
					 Number R 2009-15), §
											284-160-060, filed 1/6/10,
					 effective 1/6/10.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-160 - Guaranteed asset protection waiver › RULES FOR THE GUARANTEED ASSET PROTECTION WAIVER PROGRAM › Section 284-160-070 - Required notices and disclosures

Current through Register Vol. 24-14, July 15, 2024
When a registrant under this chapter provides notice to a
				  borrower of the sale, transfer or any type of assignment of the waiver
				  obligation, they must comply with the requirements in
				  RCW
				   48.160.030.
(1) The selling, transferring or assigning
				creditor must mail the notice to the borrower's last known address using U.S.
				mail. The selling, transferring or assigning creditor may also provide
				electronic notice to the borrower, but such notice does not satisfy the notice
				requirement under the statute.
(2)
				The notice of transfer, assignment or sale of the waiver obligation must
				contain the legal name and official business address, and if different, the
				local business address of the new person or entity responsible to the borrower
				for waiver benefits. If that person or entity is different from the contact
				person or entity to apply to for benefits, then the notice must also contain
				the legal name, official business and local business addresses for the contact
				person.
Statutory Authority:
					 RCW
					 48.02.060 and
					 48.160.070. 10-02-111 (Docket
					 Number R 2009-15), §
											284-160-070, filed 1/6/10,
					 effective 1/6/10.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-160 - Guaranteed asset protection waiver › RULES FOR THE GUARANTEED ASSET PROTECTION WAIVER PROGRAM › Section 284-160-080 - Payment of refund on canceled guaranteed asset protection contracts

Current through Register Vol. 24-14, July 15, 2024
When a borrower cancels a guaranteed asset protection
				  contract and a refund is due that is payable to the borrower, the current
				  obligor on the guaranteed asset protection contract must refund the amount due,
				  and must not require the borrower to request the refund from the original or a
				  prior obligor on the contract.
Statutory Authority:
					 RCW
					 48.02.060 and
					 48.160.070. 10-02-111 (Docket
					 Number R 2009-15), §
											284-160-080, filed 1/6/10,
					 effective 1/6/10.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-160 - Guaranteed asset protection waiver › RULES FOR THE GUARANTEED ASSET PROTECTION WAIVER PROGRAM › Section 284-160-090 - Registrant documentation

Current through Register Vol. 24-14, July 15, 2024
For each guaranteed asset protection contract entered into,
				  registrants must retain records, preferably in electronic format, of all
				  transactions associated with the contract, including correspondence from the
				  borrower, notices sent to the borrower, and agreements or contracts associated
				  with the sale or transfer of the guaranteed asset protection obligation.
				  Creditors must retain the records for the duration of the waiver agreement and
				  for an additional two years after its termination date. Termination occurs when
				  a contract expires, is canceled by either party, or waiver under the agreement
				  on behalf of a borrower occurs.
Statutory Authority:
					 RCW
					 48.02.060 and
					 48.160.070. 10-02-111 (Docket
					 Number R 2009-15), §
											284-160-090, filed 1/6/10,
					 effective 1/6/10.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-160 - Guaranteed asset protection waiver › RULES FOR THE GUARANTEED ASSET PROTECTION WAIVER PROGRAM › Section 284-160-100 - Use of the term "insurance."

Current through Register Vol. 24-14, July 15, 2024
A guaranteed asset protection program must not use the term
				  "insurance" to describe the program in its advertisements, marketing efforts,
				  promotions, marketing materials, guaranteed asset protection program documents,
				  brochures, or contracts, except when referring to the borrower's automobile
				  insurance policy, or making the statement that the waiver is not insurance as
				  required in
				  RCW
				   48.160.050(10).
Statutory Authority:
					 RCW
					 48.02.060 and
					 48.160.070. 10-02-111 (Docket
					 Number R 2009-15), §
											284-160-100, filed 1/6/10,
					 effective 1/6/10.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-164 - Flood insurance › Section 284-164-100 - Voluntary flood market assistance plan (MAP)

Current through Register Vol. 24-14, July 15, 2024
If the commissioner determines that at least twenty-five or
				more insurers have volunteered to issue the coverage contemplated by chapter
				230, Laws of 2010, the commissioner may require the insurers to form a market
				assistance plan (MAP) under section 15, chapter 230, Laws of 2010 and this
				section. The commissioner will list the names of the insurers that have
				volunteered to participate in the MAP on the commissioner's web site,
www.insurance.wa.gov
.
Statutory Authority:
				  RCW
				  48.02.060 and   2010 c  230
										§§
											14 and  15. 10-16-131 (Matter No. R 2010-03), §
										284-164-100, filed 8/4/10,
				  effective 9/4/10.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-164 - Flood insurance › Section 284-164-200 - Compulsory participation in market assistance plan (MAP)

Current through Register Vol. 24-14, July 15, 2024
(1) Certain companies offering either
			 property insurance, or property and casualty insurance, or both, are required
			 to become members of the market assistance plan (MAP) as established by chapter
			 230, Laws of 2010.
(2) The number
			 of companies required to participate in the MAP must be sufficient to fulfill
			 the quota of twenty-five insurers participating in the MAP.
(3) If the commissioner determines that fewer
			 than twenty-five insurers have volunteered to issue the coverage contemplated
			 by chapter 230, Laws of 2010, the commissioner may require the insurers to
			 participate in a MAP under section 15, chapter 230, Laws of 2010 and this
			 section. The commissioner will identify and notify the additional companies
			 that are required to complete and participate in the MAP and will list their
			 names on the commissioner's web site,
www.insurance.wa.gov
.
Statutory Authority:
				  RCW
				  48.02.060 and   2010 c  230
										§§
											14 and  15. 10-16-131 (Matter No. R 2010-03), §
										284-164-200, filed 8/4/10,
				  effective 9/4/10.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-170 - Health benefit plan management › Subchapter A - GENERAL PROVISIONS › Section 284-170-001 - Transitional reinsurance program (Recodified)

Current through Register Vol. 24-14, July 15, 2024
Statutory Authority: RCW  48.02.060, 48.43.720. WSR
					 13-05-024 (Matter No. R 2012-09), § 284-170-001, filed 2/11/13, effective
					 3/14/13.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-170 - Health benefit plan management › Subchapter A - GENERAL PROVISIONS › Section 284-170-002 - Risk adjustment program (Recodified)

Current through Register Vol. 24-14, July 15, 2024
Statutory Authority: RCW  48.02.060, 48.43.720. WSR
					 13-05-025 (Matter No. R 2012-12), § 284-170-002, filed 2/11/13, effective
					 3/14/13.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-170 - Health benefit plan management › Subchapter A - GENERAL PROVISIONS › Section 284-170-110 - Purpose

Current through Register Vol. 24-14, July 15, 2024
The purpose of this chapter is to establish uniform
				  regulatory standards for health carriers and to create minimum standards for
				  health plans that ensure consumer access to the health care services promised
				  in these health plans.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-170 - Health benefit plan management › Subchapter A - GENERAL PROVISIONS › Section 284-170-120 - Applicability and scope

Current through Register Vol. 24-14, July 15, 2024
This chapter shall apply to all health plans and all health
				  carriers subject to the jurisdiction of the state of Washington except as
				  otherwise expressly provided in this chapter. Health carriers are responsible
				  for compliance with the provisions of this chapter and are responsible for the
				  compliance of any person or organization acting on behalf of or at the
				  direction of the carrier, or acting pursuant to carrier standards or
				  requirements concerning the coverage of, payment for, or provision of health
				  care services. A carrier may not offer as a defense to a violation of any
				  provision of this chapter that the violation arose from the act or omission of
				  a participating provider or facility, network administrator, claims
				  administrator, or other person acting on behalf of or at the direction of the
				  carrier, or acting pursuant to carrier standards or requirements under a
				  contract with the carrier rather than from the direct act or omission of the
				  carrier. Nothing in this chapter shall be construed to permit the direct
				  regulation of health care providers or facilities by the office of the
				  insurance commissioner.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-170 - Health benefit plan management › Subchapter A - GENERAL PROVISIONS › Section 284-170-125 - Compliance with state and federal laws

Current through Register Vol. 24-14, July 15, 2024
Health carriers shall comply with all Washington state and
				  federal laws relating to the acts and practices of carriers and laws relating
				  to health plan benefits.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-170 - Health benefit plan management › Subchapter A - GENERAL PROVISIONS › Section 284-170-130 - Definitions

Current through Register Vol. 24-14, July 15, 2024
Except as defined in other subchapters and unless the context
				  requires otherwise, the following definitions shall apply throughout this
				  chapter.
(1) "Adverse determination"
				has the same meaning as the definition of adverse benefit determination in
				RCW
				 48.43.005, and includes:
(a) The determination includes any decision
				by a health carrier's designee utilization review organization that a request
				for a benefit under the health carrier's health benefit plan does not meet the
				health carrier's requirements for medical necessity, appropriateness, health
				care setting, level of care, or effectiveness or is determined to be
				experimental or investigational and the requested benefit is therefore denied,
				reduced, or terminated or payment is not provided or made, in whole or in part
				for the benefit;
(b) The denial,
				reduction, termination, or failure to provide or make payment, in whole or in
				part, for a benefit based on a determination by a health carrier or its
				designee utilization review organization of a covered person's eligibility to
				participate in the health carrier's health benefit plan;
(c) Any prospective review or retrospective
				review determination that denies, reduces, or terminates or fails to provide or
				make payment in whole or in part for a benefit;
(d) A rescission of coverage determination;
				or
(e) A carrier's denial of an
				application for coverage.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-170 - Health benefit plan management › Subchapter B - HEALTH CARE NETWORKS › Section 284-170-210 - Alternate access delivery request

Current through Register Vol. 24-14, July 15, 2024
(1) Where an
				issuer's network meets one or more of the criteria in WAC
				284-170-200(15)(a) through
				(d), the issuer may submit an alternate
				access delivery request for the commissioner's review and approval. The
				alternate access delivery request must be made using the Alternate Access
				Delivery Request Form C, as provided in WAC
				284-170-280(3)(d).
				Amended alternate access delivery requests for services subject to the Balance
				Billing Protection Act are governed by WAC
				284-170-220 and are distinct from
				alternative access delivery system requests under this section.
(a) An alternate access delivery system must
				provide enrollees with access to medically necessary care on a reasonable basis
				without detriment to their health.
(b) The issuer must ensure that the enrollee
				obtains all covered services in the alternate access delivery system at no
				greater cost to the enrollee than if the service was obtained from network
				providers or facilities or must make other arrangements acceptable to the
				commissioner.
(i) Copayments and deductible
				requirements must apply to alternate access delivery systems at the same level
				they are applied to in-network services.
(ii) The alternate access delivery system may
				result in issuer payment of billed charges to ensure network access.
(c) An issuer must demonstrate in
				its alternate access delivery request a reasonable basis for not meeting a
				standard as part of its filing for approval of an alternate access delivery
				system, and include an explanation of why the alternate access delivery system
				provides a sufficient number or type of the provider or facility to which the
				standard applies to enrollees.
(d)
				An issuer must demonstrate a plan and practice to assist enrollees to locate
				providers and facilities in neighboring service areas in a manner that assures
				both availability and accessibility. Enrollees must be able to obtain health
				care services from a provider or facility within the closest reasonable
				proximity of the enrollee in a timely manner appropriate for the enrollee's
				health needs.
Alternate access delivery systems include, but are not
				  limited to, such provider network strategies as use of out-of-state and out of
				  county or service area providers, and exceptions to network standards based on
				  rural locations in the service area.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-170 - Health benefit plan management › Subchapter B - HEALTH CARE NETWORKS › Section 284-170-220 - Amended alternate access delivery request for services subject to the Balance Billing Protection Act

Current through Register Vol. 24-14, July 15, 2024
An issuer that meets the criteria in
				  RCW
				   48.49.135(2)(b) may submit
				  an amended alternate access delivery request to the commissioner for review and
				  approval. The amended alternate access delivery request must be made using the
				  Amended Alternate Access Delivery Request Form E, as provided in WAC
				  284-170-280(3)(f).
(1) An amended alternate access delivery
				request may be filed no sooner than three months after the effective date of
				the alternate access delivery request approval by the commissioner.
(2) The amended alternate access delivery
				request must demonstrate substantial evidence of good faith efforts by the
				issuer to contract between the effective date of the alternate access delivery
				request and the submission date of the Amended Alternate Access Delivery
				Request Form E.
(3) An amended
				alternate access delivery request must be for a specific service that is
				subject to
				RCW
				 48.49.020 and for a specific geographic
				location. Multiple services may not be combined into a singular request, for
				example an amended alternate access delivery request may not be for both
				radiology services and laboratory services. This requirement does not restrict
				an issuer from filing multiple amended alternate access delivery requests by
				service or geographic location during a plan year due to provider contract
				termination dates or execution of new or renewed provider contracts.
(4) The amended alternate access delivery
				request terminates on December 31st of the year that the request was approved
				or the effective date of a contract executed by the issuer and a provider who
				can deliver the service in the geographic location referenced in the amended
				alternate access delivery request, whichever occurs earlier.
(5) An issuer may not use the amended
				alternate access delivery request process to update a pending or approved
				Alternate Access Delivery Request Form C.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-170 - Health benefit plan management › Subchapter B - HEALTH CARE NETWORKS › Section 284-170-230 - Maintenance of sufficient provider networks

Current through Register Vol. 24-14, July 15, 2024
(1) An issuer must maintain and monitor its
				provider networks on an ongoing basis for compliance with the network access
				standards set forth in WAC
				284-170-200. This includes an
				issuer of a stand-alone dental plan offered through the exchange or a
				stand-alone dental plan offered outside the exchange for the purpose of
				providing the essential health benefit category of pediatric oral benefits,
				which must maintain and monitor its networks for compliance with WAC
				284-170-200(14).
				An issuer must report to the commissioner, within the time frames stated in
				this section, any changes affecting the ability of its network providers and
				facilities to furnish covered services to enrollees.
(2) An issuer must notify the OIC in writing
				within five business days of either receiving or issuing a written notice of
				potential contract termination that would affect the network's ability to meet
				the standards set forth in WAC
				284-170-200. Notice of potential
				termination must include an issuer's preliminary determination of whether an
				alternate access delivery request must be filed and the documentation
				supporting that determination. The issuer's notice must be submitted
				electronically following the submission instructions on the commissioner's web
				site.
(a) If the issuer determines that an
				alternate access delivery request must be submitted to comply with WAC
				284-170-200(15),
				the issuer has ten business days to submit the request and supporting
				documentation for the alternate access delivery request in accordance with WAC
				284-170-280(3)(d).
(b) If, after reviewing the issuer's
				preliminary determination that an alternate access delivery request is not
				necessary, the OIC determines that an alternate access delivery request is
				required to comply with WAC
				284-170-200(15),
				the issuer has five business days to submit the request and supporting
				documentation for the alternate access delivery request in accordance with WAC
				284-170-280(3)(d).
(c) If the OIC determines that a network is
				out of compliance with WAC
				284-170-200 and the issuer has
				failed to report this change to the OIC, the issuer must, within one business
				day of notification by the OIC, submit an alternate access delivery request in
				accordance with WAC
				284-170-200(15)
				 and supporting documentation for the alternate access delivery request in
				accordance with WAC
				284-170-280(3)(d).
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-170 - Health benefit plan management › Subchapter B - HEALTH CARE NETWORKS › Section 284-170-240 - Use of subcontracted networks

Current through Register Vol. 24-14, July 15, 2024
(1) The primary contractor with each provider
				and facility in an issuer's network must be specifically identified in network
				report filings with the commissioner. An issuer may use subcontracted networks
				as part of a provider network for a service area, subject to the following
				requirements:
(a) An issuer must not elect to
				use less than one hundred percent of the subcontracted network or networks in
				its service area.
(b) An issuer may
				use a combination of directly contracting with providers and use of a
				subcontracted network in the same service area.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-170 - Health benefit plan management › Subchapter B - HEALTH CARE NETWORKS › Section 284-170-250 - Geographic rating area factor development (Recodified)

Current through Register Vol. 24-14, July 15, 2024
Statutory Authority: RCW  48.02.060, 48.44.050, 48.46.200,
					 and  45 C.F.R. 147.102. WSR 13-11-003 (Matter No. R 2013-01), §
					 284-170-250, filed 5/1/13, effective
					 6/1/13.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-170 - Health benefit plan management › Subchapter B - HEALTH CARE NETWORKS › Section 284-170-252 - Geographic rating area designation (Recodified)

Current through Register Vol. 24-14, July 15, 2024
Statutory Authority: RCW  48.02.060, 48.44.050, 48.46.200,
					 and  45 C.F.R. 147.102. WSR 13-11-003 (Matter No. R 2013-01), §
					 284-170-252, filed 5/1/13, effective
					 6/1/13.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-170 - Health benefit plan management › Subchapter B - HEALTH CARE NETWORKS › Section 284-170-260 - Provider directories

Current through Register Vol. 24-14, July 15, 2024
(1) For
				each carrier that uses a provider network, the carrier must make information
				about that network available to the general public, prospective enrollees and
				enrollees, in the form of an easily accessible and searchable online provider
				directory. Easily accessible for the purposes of this section means:
(a) The general public is able to view all of
				the current providers for each plan in the provider directory on the carrier's
				public website through a clearly identifiable link or tab and without creating
				or accessing an account or entering a policy number; and
(b) If a carrier maintains multiple provider
				networks, the carrier must post the current provider directory for each plan so
				the general public is able to easily discern which providers participate in
				which plans and which provider networks.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-170 - Health benefit plan management › Subchapter B - HEALTH CARE NETWORKS › Section 284-170-280 - Network reports-Format

Current through Register Vol. 24-14, July 15, 2024
(1) An issuer must
				submit its provider network materials to the commissioner for approval prior to
				or at the time it files a newly offered health plan.
(a) For individual and small groups, the
				submission must occur when the issuer submits its plan under WAC
				284-43-0200. For groups other
				than individual and small, the submission must occur when the issuer submits a
				new health plan and as required in this section.
(b) The commissioner may extend the time for
				filing for good cause shown.
(c)
				For plan year 2015 only, the commissioner will permit a safe harbor standard.
				An issuer who can not meet the submission requirements in subsection (3)(f) and
				(g) of this subsection will be determined to meet the requirements of those
				subsections even if the submissions are incomplete, provided that the issuer:
(i) Identifies specifically each map required
				under subsection (3)(f)(i) of this section, or Access Plan component required
				under subsection (3)(g) of this section, which has not been included in whole
				or part;
(ii) Explains the specific
				reason each map or component has not been included; and
(iii) Sets forth the issuer's plan to
				complete the submission, including the date(s) by which each incomplete map and
				component will be completed and submitted.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-170 - Health benefit plan management › Subchapter B - HEALTH CARE NETWORKS › Section 284-170-300 - Essential community providers for exchange plans-Definition

Current through Register Vol. 24-14, July 15, 2024
"Essential community provider" means providers listed on the
				  Centers for Medicare and Medicaid Services Non-Exhaustive List of Essential
				  Community Providers. This list includes providers and facilities that have
				  demonstrated service to medicaid, low-income, and medically underserved
				  populations in addition to those that meet the federal minimum standard, which
				  includes:
(1) Hospitals and providers
				who participate in the federal 340B Drug Pricing Program;
(2) Disproportionate share hospitals, as
				designated annually;
(3) Those
				eligible for Section 1927 Nominal Drug Pricing;
(4) Those whose patient mix is at least
				thirty percent medicaid or medicaid expansion patients who have approved
				applications for the Electronic Medical Record Incentive Program;
(5) State licensed community clinics or
				health centers or community clinics exempt from licensure;
(6) Indian health care providers as defined
				in WAC 284-170-130(16);
(7) Long-term care facilities in which the
				average residency rate is fifty percent or more eligible for medicaid during
				the preceding calendar year;
(8)
				School-based health centers as referenced for funding in Sec. 4101 of Title IV
				of ACA;
(9) Providers identified as
				essential community providers by the U.S. Department of Health and Human
				Services through subregulatory guidance or bulletins;
(10) Facilities or providers who waive
				charges or charge for services on a sliding scale based on income and that do
				not restrict access or services because of a client's financial
				limitations;
(11) Title X Family
				Planning Clinics and Title X look-alike Family Planning Clinics;
(12) Rural based or free health centers as
				identified on the Rural Health Clinic and the Washington Free Clinic
				Association web sites; and
(13)
				Federal qualified health centers (FQHC) or FQHC look-alikes.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-170 - Health benefit plan management › Subchapter B - HEALTH CARE NETWORKS › Section 284-170-320 - Issuer recordkeeping-Provider networks

Current through Register Vol. 24-14, July 15, 2024
(1) An issuer must make available to the
				commissioner upon request its records, contracts, and agreements related to its
				provider networks.
(a) Records to support
				proof of good faith contracting efforts must be retained for seven
				years.
(b) Signed contracts,
				reimbursement agreements, and associated accounting records must be retained
				for ten years after the contract is terminated.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-170 - Health benefit plan management › Subchapter B - HEALTH CARE NETWORKS › Section 284-170-330 - Tiered provider networks

Current through Register Vol. 24-14, July 15, 2024
(1)
				"Tiered provider network" means a network that identifies and groups providers
				and facilities into specific groups to which different provider reimbursement,
				enrollee cost-sharing, or provider access requirements, or any combination
				thereof, apply as a means to manage cost, utilization, quality, or to otherwise
				incentivize enrollee or provider behavior.
(a) An issuer may use a term other than
				tiered network as long as the term is not misleading or susceptible to
				confusion with a specific licensee designation, such as accountable care
				organization.
(b) An issuer must
				not use tiered networks to limit access to certain categories of providers or
				facilities.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-170 - Health benefit plan management › Subchapter B - HEALTH CARE NETWORKS › Section 284-170-340 - Assessment of access

Current through Register Vol. 24-14, July 15, 2024
(1) The
				commissioner will assess whether an issuer's provider network access meets the
				requirements of WAC
				284-170-200,
				284-170-210, and
				284-170-270 such that all health
				plan services to enrollees will be accessible in a timely manner appropriate
				for the enrollee's condition. Factors considered by the commissioner will
				include the following:
(a) The location of
				the participating providers and facilities;
(b) The location of employers or enrollees in
				the health plan;
(c) The range of
				services offered by providers and facilities for the health plan;
(d) Health plan provisions that recognize and
				provide for extraordinary medical needs of enrollees that cannot be adequately
				treated by the network's participating providers and facilities;
(e) The number of enrollees within each
				service area living in certain types of institutions or who have chronic,
				severe, or disabling medical conditions, as determined by the population the
				issuer is covering and the benefits provided;
(f) The availability of specific types of
				providers who deliver medically necessary services to enrollees under the
				supervision of a provider licensed under
				Title
				18 RCW;
(g) The availability within the service area
				of facilities under
				Titles
				70 and
				71 RCW;
(h) Accreditation as to network access by a
				national accreditation organization including, but not limited to, the National
				Committee for Quality Assurance (NCQA), the Joint Commission, Accreditation
				Association of Ambulatory Health Care (AAAHC), or URAC.