reglab/statecodes huggingface dataset:
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-44 - Health care services contractors-Agents-Contract formats-Standards › Section 284-44-300 - Purpose and applicability

Current through Register Vol. 24-14, July 15, 2024
(1) The
			 purpose of this regulation, WAC
			 284-44-300 through 284-44-360, is
			 to establish indemnity requirement rules and procedures for the effectuation of
			 RCW
			  48.44.030 and to aid in the administration
			 thereof.
(2) This regulation
			 applies to every health care service contractor registered pursuant to
			 chapter
			 48.44 RCW.
Statutory Authority:
				  RCW
				  48.44.050. 82-23-010 (Order R 82-6), §
										284-44-300, filed 11/5/82,
				  effective 1/1/83.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-44 - Health care services contractors-Agents-Contract formats-Standards › Section 284-44-310 - Agreement underwritten by insurance

Current through Register Vol. 24-14, July 15, 2024
(1) If, pursuant to
			 RCW
			  48.44.030, the agreement is underwritten by a
			 contract or policy of insurance, such contract or policy shall:
(a) Have a continuous term;
(b) Fully insure the benefits of the persons
			 who have paid for or contracted for covered health care services, which persons
			 shall be designated as beneficiaries, when such services are not performed by
			 the health care service contractor or a participant;
(c) Contain a provision that, in the event of
			 cancellation, the coverage shall continue with respect to services provided
			 prior to the effective date of such cancellation;
(d) Contain a provision that it may not be
			 cancelled without ninety days advance written notice to the insured or insurer
			 by the cancelling party; and
(e)
			 Contain a provision requiring not less than sixty days advance notice to the
			 insurance commissioner, health care services division, by the insurer of any
			 cancellation.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-44 - Health care services contractors-Agents-Contract formats-Standards › Section 284-44-320 - Agreement guaranteed by a surety company

Current through Register Vol. 24-14, July 15, 2024
(1) If, pursuant to
			 RCW
			  48.44.030, the agreement is guaranteed by a
			 surety company, such agreement shall:
(a) Be
			 in an amount equal to the greater of (i) one hundred fifty thousand dollars, or
			 (ii) one-twelfth of the total sum of money received during the preceding
			 calendar year as prepayment for health care services, except as provided by WAC
			 284-44-340;
(b) Contain a provision that the bond will be
			 for the benefit of the persons who have paid for or contracted for the health
			 care services;
(c) Contain a
			 provision that in the event of cancellation, the bond will continue to cover
			 liabilities for services provided prior to the effective date of such
			 cancellation;
(d) Contain a
			 provision that it may not be cancelled or terminated without ninety days
			 advance written notice to the assured or surety company by the cancelling
			 party;
(e) Contain a provision
			 requiring not less than sixty days advance notice to the insurance
			 commissioner, health care services division, by the surety company of any
			 cancellation of such surety agreement.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-44 - Health care services contractors-Agents-Contract formats-Standards › Section 284-44-330 - Agreement guaranteed by a deposit of cash or securities

Current through Register Vol. 24-14, July 15, 2024
(1) If, pursuant to
			 RCW
			  48.44.030, the agreement is guaranteed by a
			 deposit of cash or securities, the deposit must be in an amount equal to the
			 greater of (i) one hundred fifty thousand dollars, or (ii) one-twelfth of the
			 total sum of money received during the preceding calendar year as prepayment
			 for health care services, except as provided by WAC
			 284-44-340.
(2) Securities eligible for the deposit are
			 those set forth in
			 RCW
			  48.13.009(12), (14), and
			 48.13.061(2) and
			 (4).
(3) In determining the value to be assigned
			 to securities for compliance with the depository requirements, market value is
			 the measurement.
Statutory Authority:
				  RCW
				   48.44.050. 82-23-010 (Order R 82-6), §
										284-44-330, filed 11/5/82,
				  effective 1/1/83.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-44 - Health care services contractors-Agents-Contract formats-Standards › Section 284-44-340 - Modification of amount of reimbursement or indemnity

Current through Register Vol. 24-14, July 15, 2024
(1) Reduced deposit requirements may be
			 permitted when data satisfactory to the commissioner are provided which
			 indicate an amount less than that set forth in WAC
			 284-44-320 and
			 284-44-330 is adequate to cover
			 incurred but unpaid reimbursement or indemnity benefits. In determining a
			 lesser requirement, the commissioner will include in his consideration:
(a) The overall adequacy of the contractor's
			 reserves for future benefits;
(b)
			 The relationship between indemnity claims and claims covered by contractual
			 agreements with providers;
(c) The
			 overall financial stability of the contractor; and
(d) A reasonable projection of any increase
			 or decrease of such benefits.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-44 - Health care services contractors-Agents-Contract formats-Standards › Section 284-44-350 - Records and reporting

Current through Register Vol. 24-14, July 15, 2024
(1) Each health
			 care service contractor shall maintain records which separately reflect the
			 amount of service benefits and the amount of reimbursement or indemnity
			 benefits. Reasonable approximation based on paid claims data may be used to
			 project incurred indemnity benefits. Such amounts shall be reported to the
			 commissioner on forms prescribed by the commissioner and shall be filed with
			 the annual statement and at such other times as the commissioner may require.
			 The report shall be accompanied by an inventory and valuation of any securities
			 which are used to satisfy the depository requirement. If the amount of the
			 guarantee is not sufficient to satisfy the requirements, an appropriate
			 additional amount shall be obtained, and shall be deposited with, or evidenced
			 to, the commissioner within thirty days of the filing of the report.
(2) A health care service contractor using
			 either a policy of insurance or a surety bond to provide for indemnification
			 shall notify the insurance commissioner, health care services division, sixty
			 days in advance of termination or cancellation of the contract or policy of
			 insurance or surety bond.
Statutory Authority:
				  RCW
				  48.44.050. 82-23-010 (Order R 82-6), §
										284-44-350, filed 11/5/82,
				  effective 1/1/83.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-44 - Health care services contractors-Agents-Contract formats-Standards › Section 284-44-450 - PKU formula coverage requirements and exceptions

Current through Register Vol. 24-14, July 15, 2024
(1) The purpose of this section is to
			 effectuate the provisions of section 3, chapter 173, Laws of 1988, by
			 establishing the requirements and exceptions with respect to coverage for the
			 formulas necessary for the treatment of phenylketonuria (PKU), applicable to
			 health care service contractors registered pursuant to
			 RCW
			  48.44.015.
(2) Each contract for health care services
			 which is delivered or issued for delivery or renewed in this state on or after
			 September 1, 1988, shall provide coverage for the formulas necessary for the
			 treatment of phenylketonuria, subject to the following exceptions:
(a) A contract that is subject to chapter
			 48.66 RCW and provides medicare supplemental insurance need not provide the PKU
			 formula coverage;
(b) A contract
			 that is subject to
			 chapter
			 48.84 RCW and provides
			 long-term care insurance need not provide the PKU formula coverage;
(c) A contract that provides benefits for
			 hospital services only or for custodial services only may limit the coverage
			 for PKU formulas to a benefit that supplies the formula needed, or pays for the
			 formula used, during time such services are provided.
(d) A contract which provides services or
			 reimbursement exclusively for optometric or vision care services, dental or
			 orthodontic services, podiatric services, ambulance services, mental health
			 services, or chiropractic services need not provide coverage for PKU
			 formula.
(e) A contract that is
			 governed by 5 U.S.C. chapter 89 or  42 U.S.C. section 1395mm  need not provide
			 the PKU formula coverage.
(f) In
			 response to the written request of a contractor, other contracts may exclude
			 coverage for the PKU formula with the written consent of the commissioner upon
			 a finding that such coverage would be inappropriate.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-44 - Health care services contractors-Agents-Contract formats-Standards › Section 284-44-500 - Alternative care - General rules as to minimum standards

Current through Register Vol. 24-14, July 15, 2024
(1) As an alternative to hospitalization or
			 institutionalization of an insured and with the intent to cover placement of
			 the insured patient in the most appropriate and cost-effective setting, every
			 individual or group contract of a health care service contractor issued,
			 amended, or renewed on or after January 1, 1995, which provides coverage for
			 hospitalization or other institutional expenses to a resident of this state
			 shall include substitution of home health care, provided in lieu of
			 hospitalization or other institutional care, furnished by home health, hospice
			 and home care agencies licensed under chapter 70.127 RCW, at equal or lesser
			 cost.
(2) In addition, such
			 expenses may include coverage for durable medical equipment which permits the
			 insured to stay at home, care provided in Alzheimer's centers, adult family
			 homes, assisted living facilities, congregate care facilities, adult day health
			 care, home health, hospice and home care, or similar alternative care
			 arrangements which provide necessary care in less restrictive or less expensive
			 environments.
(3) Substitution of
			 less expensive or less intensive services shall be made only with the consent
			 of the insured and upon the recommendation of the insured's attending physician
			 or licensed health care provider that such services will adequately meet the
			 insured patient's needs. The decision to substitute less expensive or less
			 intensive services shall be determined based on the medical needs of the
			 individual insured patient.
(4) A
			 health care service contractor may require that home health agencies or similar
			 alternative care providers have written treatment plans which are approved by
			 the insured patient's attending physician or other licensed health care
			 provider.
(5) Coverage may be
			 limited to no less than the maximum benefits which would be payable for
			 hospital or other institutional expenses under the contract, and may include
			 all deductibles and coinsurances which would be payable by the insured under
			 the hospital or other institutional expense coverage of the insured's
			 contract.
(6) This section shall
			 not apply to long-term care or medicare supplement insurance contracts. This
			 section shall not apply to guaranteed renewable contracts issued prior to
			 January 1, 1995.
Statutory Authority:
				  RCW
				  48.01.030,
				  48.02.060,
				  48.44.050,
				  48.44.020,
				  48.46.200 and
				  48.46.060. 94-19-015 (Order R
				  94-16), §
										284-44-500, filed 9/9/94,
				  effective 10/10/94.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-44A - Health care service contractor general rules for electronic filing of forms and rates in SERFF › Section 284-44A-010 - Definitions that apply to this chapter

Current through Register Vol. 24-14, July 15, 2024
The definitions in this section apply throughout this
				chapter.
(1) "Complete filing" means a
			 package of information containing forms, supporting information, documents and
			 exhibits submitted to the commissioner electronically using the system for
			 electronic rate and form filing (SERFF).
(2) "Date filed" means the date a complete
			 filing has been received and accepted by the commissioner.
(3) "Filer" means:
(a) A person, organization or other entity
			 that files forms or rates with the commissioner for an HCSC; or
(b) A person employed by the HCSC to file
			 under this chapter.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-44A - Health care service contractor general rules for electronic filing of forms and rates in SERFF › Section 284-44A-020 - Purpose of this chapter

Current through Register Vol. 24-14, July 15, 2024
The purpose of this chapter is to:
(1) Adopt processes and procedures for filers
			 and HCSCs to use when submitting electronic forms and rates to the commissioner
			 by way of SERFF.
(2) Effective July
			 1, 2010, designate SERFF as the method by which filers and HCSCs must submit
			 all forms and rates to the commissioner.
Statutory Authority:
				  RCW
				  48.02.060,
				  48.44.050, and
				  48.46.200. 10-01-118 (Matter No. R
				  2009-04), §
										284-44A-020, filed 12/17/09,
				  effective 1/17/10.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-44A - Health care service contractor general rules for electronic filing of forms and rates in SERFF › Section 284-44A-030 - Scope of this chapter

Current through Register Vol. 24-14, July 15, 2024
This chapter applies to all HCSCs that must file forms and
				rates under
				RCW
				 48.44.040,
				48.44.070, and
				48.66.035.
Statutory Authority:
				  RCW
				  48.02.060,
				  48.44.050, and
				  48.46.200. 10-01-118 (Matter No. R
				  2009-04), §
										284-44A-030, filed 12/17/09,
				  effective 1/17/10.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-44A - Health care service contractor general rules for electronic filing of forms and rates in SERFF › Section 284-44A-040 - Filing instructions that are incorporated into this chapter

Current through Register Vol. 24-14, July 15, 2024
SERFF is a dynamic application that the NAIC will revise and
				enhance over time. To be consistent with NAIC filing standards and provide
				timely instructions to filers, the commissioner will incorporate documents
				posted on the SERFF website into this chapter. By reference, the commissioner
				incorporates these documents into this chapter:
(1) The
SERFF Industry
			 Manual
available within the SERFF application; and
(2) State specific rate and form filing
			 instructions posted on the commissioner's website (
www.insurance.wa.gov
), including the:
(a)
Washington State SERFF Life and
			 Disability Form Filing General Instructions
;
(b)
Washington State SERFF Life,
			 Health and Disability Rate Filing General Instructions
;
(c)
Washington State SERFF Health and
			 Disability Form Filing General Instructions
;
(d)
Washington State SERFF Health and
			 Disability Binder Filing General Instructions
(also called "plan
			 management instructions"); and
(e)
Washington State SERFF Carrier Provider Agreement and HCBM Contract
			 Filing General Instructions
.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-44A - Health care service contractor general rules for electronic filing of forms and rates in SERFF › Section 284-44A-050 - General form and rate filing rules

Current through Register Vol. 24-14, July 15, 2024
(1) Each form or rate filing must be
			 submitted to the commissioner electronically using SERFF.
(a) Every form filed in SERFF must:
(i) Be attached to the form schedule;
			 and
(ii) Have a unique identifying
			 number and a way to distinguish it from other versions of the same
			 form.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-44A - Health care service contractor general rules for electronic filing of forms and rates in SERFF › Section 284-44A-060 - Specific rate filing rules

Current through Register Vol. 24-14, July 15, 2024
(1) If a
			 rate filing is required under
			 RCW
			  48.44.040 or
			 48.66.035, the filer must submit
			 it:
(a) Separate from any corresponding form
			 filing; and
(b) Concurrently with
			 the corresponding form filing if new forms are being introduced.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-44A - Health care service contractor general rules for electronic filing of forms and rates in SERFF › Section 284-44A-070 - The commissioner may reject filings

Current through Register Vol. 24-14, July 15, 2024
(1) The commissioner may reject and close any
			 filing that does not comply with WAC
			 284-44A-040,
			 284-44A-050, or
			 284-44A-060. If the commissioner
			 rejects a filing, the filer has not filed forms or rates with the
			 commissioner.
(2) If the
			 commissioner rejects a filing and the filer resubmits it as a new filing, the
			 date filed will be the date the commissioner receives and accepts the new
			 filing.
Statutory Authority:
				  RCW
				  48.02.060,
				  48.44.050, and
				  48.46.200. 10-01-118 (Matter No. R
				  2009-04), §
										284-44A-070, filed 12/17/09,
				  effective 1/17/10.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-44A - Health care service contractor general rules for electronic filing of forms and rates in SERFF › Section 284-44A-080 - Filing authorization rules

Current through Register Vol. 24-14, July 15, 2024
A HCSC may authorize a third-party filer to file forms or rates
				on its behalf. For the purposes of this section, a "third-party filer" means a
				person or entity in the business of providing regulatory compliance
				services.
(1) If an HCSC delegates
			 filing authority to a third-party filer, each filing must include a letter as
			 supporting documentation signed by an officer of the HCSC authorizing the
			 third-party filer to make filings on behalf of the HCSC.
(2) The HCSC may not delegate responsibility
			 for the content of a filing to a third-party filer. The commissioner considers
			 errors and omissions made by the third-party filer to be errors and omissions
			 of the HCSC.
(3) If a third-party
			 filer has a pattern of making filings that do not comply with this chapter, the
			 commissioner may reject a delegation of filing authority from the
			 HCSC.
Statutory Authority:
				  RCW
				  48.02.060,
				  48.44.050, and
				  48.46.200. 10-01-118 (Matter No. R
				  2009-04), §
										284-44A-080, filed 12/17/09,
				  effective 1/17/10.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-44A - Health care service contractor general rules for electronic filing of forms and rates in SERFF › Section 284-44A-090 - Rules for responding to an objection letter

Current through Register Vol. 24-14, July 15, 2024
An objection letter may ask the filer to revise a noncompliant
				form or rate filing or provide clarification or additional information. The
				objection letter will state the reason(s) for disapproval, including relevant
				case law, statutes and rules. Filers must:
(1) Provide a complete response to an
			 objection letter. A complete response must include:
(a) A separate response to each objection,
			 and if appropriate;
(b) A
			 description of changes proposed to noncompliant forms, and a replacement form
			 attached to the form schedule; or
(c) Revised exhibits and supporting
			 documentation.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-44A - Health care service contractor general rules for electronic filing of forms and rates in SERFF › Section 284-44A-100 - Rules for revised or replaced forms

Current through Register Vol. 24-14, July 15, 2024
If an HCSC files a revised or replaced form, the filer must
				provide the supporting documentation described below:
(1) If a form is revised due to an
			 objection(s) from the commissioner, the filer must provide a detailed
			 explanation of all material changes to the disapproved form.
(2) If a form which received final action is
			 replaced with a new version, the filer must submit an exhibit that marks and
			 identifies each change or revision to the replaced form using one of these
			 methods:
(a) A draft form that strikes
			 through deletions and underlines additions or changes in the form;
(b) A draft form that includes comments in
			 the margins explaining the changes in the form; or
(c) A side-by-side comparison of current and
			 proposed language.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-44A - Health care service contractor general rules for electronic filing of forms and rates in SERFF › Section 284-44A-110 - Effective date rules

Current through Register Vol. 24-14, July 15, 2024
(1)
			 Filers must include a common implementation date for all forms or rates
			 submitted in a filing.
(2) Filers
			 may submit a request to change the implementation date of a filing as a note to
			 reviewer.
Statutory Authority:
				  RCW
				  48.02.060,
				  48.44.050, and
				  48.46.200. 10-01-118 (Matter No. R
				  2009-04), §
										284-44A-110, filed 12/17/09,
				  effective 1/17/10.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-44A - Health care service contractor general rules for electronic filing of forms and rates in SERFF › Section 284-44A-120 - Rules that apply to forms translated from English to another language

Current through Register Vol. 24-14, July 15, 2024
HCSCs may issue forms written in languages other than
				English.
(1) If the HCSC translates
			 the form from English to another language, the HCSC must:
(a) File the translated version of the
			 form.
(b) Include written
			 disclosure statements on the translated contract indicating that it is issuing
			 the translated form on an informational basis and the English version is
			 controlling for the purposes of application and interpretation. The disclosure
			 statements must be in English and the language of the translated form and
			 printed in bold face type of at least twelve-point font.
(c) Submit a certification with the filing by
			 an officer employed by the HCSC that they will issue the English version of the
			 form with the translated form.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-46 - Health maintenance organizations › Section 284-46-015 - Discretionary clauses prohibited

Current through Register Vol. 24-14, July 15, 2024
(1) No contract may contain a discretionary
			 clause. "Discretionary clause" means a provision that purports to reserve
			 discretion to a health maintenance organization, its agents, officers,
			 employees, or designees in interpreting the terms of a contract or deciding
			 eligibility for benefits, or requires deference to such interpretations or
			 decisions, including a provision that provides for any of the following
			 results:
(a) That the carrier's
			 interpretation of the terms of the contract is binding;
(b) That the carrier's decision regarding
			 eligibility or continued receipt of benefits is binding;
(c) That the carrier's decision to deny,
			 modify, reduce or terminate payment, coverage, authorization, or provision of
			 health care service or benefits, is binding;
(d) That there is no appeal or judicial
			 remedy from a denial of a claim;
(e) That deference must be given to the
			 carrier's interpretation of the contract or claim decision; and
(f) That the standard of review of a
			 carrier's interpretation of the contract or claim decision is other than a de
			 novo review.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-46 - Health maintenance organizations › Section 284-46-025 - General contents of all rate or forms of contract filings

Current through Register Vol. 24-14, July 15, 2024
Each filing made of a rate or contract form shall be submitted
				with the filing transmittal form prescribed by and available from the
				commissioner. Use of a standardized transmittal form makes it easier for the
				commissioner to identify filings, issuers, and other important identifying
				information; permits more efficient tracking of filings; and makes it less
				difficult to provide status reports of filings to persons outside the office.
				The form will include the name of the filing entity, its address,
				identification number, the type of filing being submitted, the form name or
				group name and number, and other relevant information.
Statutory Authority:
				  RCW
				  48.02.060,
				  48.44.050,
				  48.46.200,
				  48.18.100,
				  48.19.040,
				  48.19.050,
				  48.19.070,
				  48.20.012,
				  48.21.045(2),
				  48.29.140,
				  48.43.055,
				  48.44.023(2),
				  48.44.040,
				  48.44.070,
				  48.46.030,
				  48.46.060,
				  48.46.066(2),
				  48.46.243, 48.96.025, 48.102.020.
				  96-11-004 (Matter No. R 96-1), §
										284-46-025, filed 5/2/96,
				  effective 6/2/96.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-46 - Health maintenance organizations › Section 284-46-100 - PKU formula coverage requirements

Current through Register Vol. 24-14, July 15, 2024
(1) The purpose of this section is to
			 effectuate the provisions of section 4, chapter 173, Laws of 1988, by
			 establishing the requirements with respect to coverage for the formulas
			 necessary for the treatment of phenylketonuria (PKU), applicable to health
			 maintenance organizations.
(2) Any
			 agreement for health care services delivered or issued for delivery or renewed
			 in this state on or after September 1, 1988, shall provide coverage for the
			 formulas necessary for the treatment of phenylketonuria, subject to the
			 following exceptions:
(a) A contract that is
			 subject to chapter 48.66 RCW and provides medicare supplemental insurance need
			 not provide the PKU formula coverage;
(b) A contract that is subject to
			 chapter
			 48.84 RCW and provides
			 long-term care insurance need not provide the PKU formula coverage;
(c) A contract that is governed by 5 U.S.C.
			 chapter 89 or  42 U.S.C. section 1395mm  need not provide the PKU formula
			 coverage; and
(d) In response to
			 the written request of a health maintenance organization, other contracts may
			 exclude coverage for the PKU formula with the written consent of the
			 commissioner upon a finding that such coverage would be
			 inappropriate.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-46 - Health maintenance organizations › Section 284-46-110 - Mammography coverage

Current through Register Vol. 24-14, July 15, 2024
(1) The purpose of
			 this regulation is to effectuate the provisions of
			 RCW
			  48.43.076, by requiring coverage and
			 prohibiting cost-sharing for certain types of mammography services.
(2) Except as provided in subsection (3) of
			 this section, for nongrandfathered health plans issued or renewed on or after
			 January 1, 2024, that include coverage of supplemental and diagnostic breast
			 examinations, health carriers may not impose cost-sharing for such
			 examinations.
(3) For a health plan
			 that provides coverage of supplemental and diagnostic breast examinations and
			 is offered as a qualifying health plan for a health savings account, the health
			 carrier shall establish the plan's cost-sharing for the coverage of the
			 services described in this section at the minimum level necessary to preserve
			 the enrollee's ability to claim tax exempt contributions from their health
			 savings account under Internal Revenue Service laws and regulations.
(4) For purposes of this section:
(a) "Diagnostic breast examination" means a
			 medically necessary and appropriate examination of the breast, as defined in
			 RCW
			  48.43.076. Diagnostic breast examinations are
			 used to evaluate an abnormality either seen or suspected from a breast cancer
			 screening examination, or detected by another means of examination.
(b) "Supplemental breast examination" has the
			 meaning set forth in
			 RCW
			  48.43.076.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-46 - Health maintenance organizations › Section 284-46-500 - Alternative care - General rules as to minimum standards

Current through Register Vol. 24-14, July 15, 2024
(1) As an alternative to hospitalization or
			 institutionalization of an insured and with the intent to cover placement of
			 the insured patient in the most appropriate and cost-effective setting, every
			 individual or group agreement of a health maintenance organization issued,
			 amended, or renewed on or after January 1, 1995, which provides coverage for
			 hospitalization or other institutional expenses to a resident of this state
			 shall include substitution of home health care, provided in lieu of
			 hospitalization or other institutional care by home health, hospice and home
			 care agencies licensed under chapter 70.127 RCW at equal or lesser cost, or by
			 employees of the health maintenance organization.
(2) In addition, such expenses may include
			 coverage for durable medical equipment which permits the insured to stay at
			 home, care provided in Alzheimer's centers, adult family homes, assisted living
			 facilities, congregate care facilities, adult day health care, home health,
			 hospice, or home care, or similar alternative care arrangements which provide
			 necessary care in less restrictive or less expensive environments.
(3) Substitution of less expensive or less
			 intensive services shall be made only with the consent of the insured and upon
			 the recommendation of the insured's attending physician or licensed health care
			 provider that such services will adequately meet the insured patient's needs.
			 The decision to substitute less expensive or less intensive services shall be
			 determined based on the medical needs of the individual insured
			 patient.
(4) A health maintenance
			 organization may require that home health agencies or similar alternative care
			 providers have written treatment plans which are approved by the insured
			 patient's attending physician or other licensed health care provider.
(5) Coverage may be limited to no less than
			 the maximum benefits which would be payable for hospital or other institutional
			 expenses under the agreement, and may include all deductibles and coinsurances
			 which would be payable by the insured under the hospital or other institutional
			 expense coverage of the insured's agreement.
(6) This section shall not apply to long-term
			 care or medicare supplement insurance contracts. This section shall not apply
			 to guaranteed renewable agreements issued prior to January 1, 1995.
Statutory Authority:
				  RCW
				  48.01.030,
				  48.02.060,
				  48.44.050,
				  48.44.020,
				  48.46.200 and
				  48.46.060. 94-19-015 (Order R
				  94-16), §
										284-46-500, filed 9/9/94,
				  effective 10/10/94.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-46 - Health maintenance organizations › Section 284-46-506 - Temporomandibular joint disorders - Specified offer of coverage required - Terms of specified offer defined - Proof of offer must be maintained - Discrimination prohibited - Terms defined

Current through Register Vol. 24-14, July 15, 2024
(1)
			 Pursuant to
			 RCW
			  48.46.530, each offer of new or renewal group
			 and individual coverage made on or after January 1, 1993, must include one or
			 more offers of optional coverage for the treatment of temporomandibular joint
			 disorders. Health maintenance organizations are encouraged to exercise broad
			 flexibility in designing benefits for these optional temporomandibular joint
			 disorder coverage offerings. However, compliance with the statute shall be
			 demonstrated only when one of the optional temporomandibular joint disorder
			 coverage offerings provides benefits as follows:
(a) Offers limited to only medical coverage
			 shall provide coverage for medical services related to the treatment of
			 temporomandibular joint disorders in the amount of one thousand dollars per
			 covered individual, after the application of deductibles, coinsurance, and
			 copayments, in any calendar year, and a lifetime benefit of five thousand
			 dollars per covered individual, after the application of deductibles,
			 coinsurance, and copayments. Other than the benefit amount, coverage for
			 medical services shall be the same as are generally provided in the health
			 maintenance agreement for other injuries or musculoskeletal disorders. The
			 coverage provisions may require:
(i) That
			 services either be rendered or referred by the covered individual's primary
			 care physician; and
(ii) A second
			 opinion, provided that the covered individual shall not be financially
			 responsible for any costs relating to this second opinion and that such costs
			 shall be in excess of the required benefit levels; and
(iii) Prenotification or preauthorization.
Except
that the coverage provisions shall not require either
							 a second opinion or prenotification or preauthorization for treatment
							 commencing within forty-eight hours, or as soon as is reasonably possible,
							 after the occurrence of an accident or trauma to the temporomandibular
							 joint.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-46 - Health maintenance organizations › Section 284-46-507 - Experimental and investigational prescriptions, treatments, procedures, or services - Definition required - Standard for definition - Written notice of denial required - Appeal process required

Current through Register Vol. 24-14, July 15, 2024
(1) Every health maintenance agreement 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 agreement and any
			 certificate of coverage issued thereunder, 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 health
			 maintenance organization 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
			 agreement and any certificate of coverage issued thereunder. As an example, and
			 not by way of limitation, the requirement to set forth criteria in the
			 agreement or any certificate of coverage thereunder 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, the plan 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, the plan 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 284-46A - Health maintenance organization general rules for electronic filing of forms and rates in SERFF › Section 284-46A-010 - Definitions that apply to this chapter

Current through Register Vol. 24-14, July 15, 2024
The definitions in this section apply throughout this
				chapter.
(1) "Complete filing" means a
			 package of information containing forms, supporting information, documents and
			 exhibits submitted to the commissioner electronically using the system for
			 electronic rate and form filing (SERFF).
(2) "Date filed" means the date a complete
			 filing has been received and accepted by the commissioner.
(3) "Filer" means:
(a) A person, organization or other entity
			 that files forms or rates with the commissioner for an HMO; or
(b) A person employed by the HMO to file
			 under this chapter.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-46A - Health maintenance organization general rules for electronic filing of forms and rates in SERFF › Section 284-46A-020 - Purpose of this chapter

Current through Register Vol. 24-14, July 15, 2024
The purpose of this chapter is to:
(1) Adopt processes and procedures for filers
			 and HMOs to use when submitting electronic forms and rates to the commissioner
			 by way of SERFF.
(2) Effective July
			 1, 2010, designate SERFF as the method by which filers and HMOs must submit all
			 forms and rates to the commissioner.
Statutory Authority:
				  RCW
				  48.02.060,
				  48.44.050, and
				  48.46.200. 10-01-118 (Matter No. R
				  2009-04), §
										284-46A-020, filed 12/17/09,
				  effective 1/17/10.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-46A - Health maintenance organization general rules for electronic filing of forms and rates in SERFF › Section 284-46A-030 - Scope of this chapter

Current through Register Vol. 24-14, July 15, 2024
This chapter applies to all HMOs that must file forms and rates
				under RCW
				 48.46.060,
				48.46.243, and
				48.66.035.
Statutory Authority:
				  RCW
				  48.02.060,
				  48.44.050, and
				  48.46.200. 10-01-118 (Matter No. R
				  2009-04), §
										284-46A-030, filed 12/17/09,
				  effective 1/17/10.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-46A - Health maintenance organization general rules for electronic filing of forms and rates in SERFF › Section 284-46A-040 - Filing instructions that are incorporated into this chapter

Current through Register Vol. 24-14, July 15, 2024
SERFF is a dynamic application that the NAIC will revise and
				enhance over time. To be consistent with NAIC filing standards and provide
				timely instructions to filers, the commissioner will incorporate documents
				posted on the SERFF website into this chapter. By reference, the commissioner
				incorporates these documents into this chapter:
(1) The
SERFF Industry
			 Manual
available within the SERFF application; and
(2) State specific rate and form filing
			 instructions posted on the commissioner's website (
www.insurance.wa.gov
), including the:
(a)
Washington State SERFF Life and
			 Disability Form Filing General Instructions
;
(b)
Washington State SERFF Life,
			 Health and Disability Rate Filing General Instructions
;
(c)
Washington State SERFF Health and
			 Disability Form Filing General Instructions;
(d)
Washington State SERFF Health and
			 Disability Binder Filing General Instructions
(also called "plan
			 management instructions"); and
(e)
Washington State SERFF Carrier Provider Agreement and HCBM Contract
			 Filing General Instructions
.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-46A - Health maintenance organization general rules for electronic filing of forms and rates in SERFF › Section 284-46A-050 - General form and rate filing rules

Current through Register Vol. 24-14, July 15, 2024
(1) Each form or rate filing must be
			 submitted to the commissioner electronically using SERFF.
(a) Every form filed in SERFF must:
(i) Be attached to the form schedule;
			 and
(ii) Have a unique identifying
			 number and a way to distinguish it from other versions of the same
			 form.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-46A - Health maintenance organization general rules for electronic filing of forms and rates in SERFF › Section 284-46A-060 - Specific rate filing rules

Current through Register Vol. 24-14, July 15, 2024
(1) If a
			 rate filing is required under
			 RCW
			  48.46.060, or
			 48.66.035, the filer must submit
			 it:
(a) Separate from any corresponding form
			 filing; and
(b) Concurrently with
			 the corresponding form filing if new forms are being introduced.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-46A - Health maintenance organization general rules for electronic filing of forms and rates in SERFF › Section 284-46A-070 - The commissioner may reject filings

Current through Register Vol. 24-14, July 15, 2024
(1) The commissioner may reject and close any
			 filing that does not comply with WAC
			 284-46A-040,
			 284-46A-050, or
			 284-46A-060. If the commissioner
			 rejects a filing, the filer has not filed forms or rates with the
			 commissioner.
(2) If the
			 commissioner rejects a filing and the filer resubmits it as a new filing, the
			 date filed will be the date the commissioner receives and accepts the new
			 filing.
Statutory Authority:
				  RCW
				  48.02.060,
				  48.44.050, and
				  48.46.200. 10-01-118 (Matter No. R
				  2009-04), §
										284-46A-070, filed 12/17/09,
				  effective 1/17/10.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-46A - Health maintenance organization general rules for electronic filing of forms and rates in SERFF › Section 284-46A-080 - Filing authorization rules

Current through Register Vol. 24-14, July 15, 2024
An HMO may authorize a third-party filer to file forms or rates
				on its behalf. For the purposes of this section, a "third-party filer" means a
				person or entity in the business of providing regulatory compliance
				services.
(1) If an HMO delegates
			 filing authority to a third-party filer, each filing must include a letter as
			 supporting documentation signed by an officer of the HMO authorizing the
			 third-party filer to make filings on behalf of the HMO.
(2) The HMO may not delegate responsibility
			 for the content of a filing to a third-party filer. The commissioner considers
			 errors and omissions made by the third-party filer to be errors and omissions
			 of the HMO.
(3) If a third-party
			 filer has a pattern of making filings that do not comply with this chapter, the
			 commissioner may reject a delegation of filing authority from the
			 HMO.
Statutory Authority:
				  RCW
				  48.02.060,
				  48.44.050, and
				  48.46.200. 10-01-118 (Matter No. R
				  2009-04), §
										284-46A-080, filed 12/17/09,
				  effective 1/17/10.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-46A - Health maintenance organization general rules for electronic filing of forms and rates in SERFF › Section 284-46A-090 - Rules for responding to an objection letter

Current through Register Vol. 24-14, July 15, 2024
An objection letter may ask the filer to revise a noncompliant
				form or rate filing or provide clarification or additional information. The
				objection letter will state the reason(s) for disapproval, including relevant
				case law, statutes and rules. Filers must:
(1) Provide a complete response to an
			 objection letter. A complete response must include:
(a) A separate response to each objection,
			 and if appropriate;
(b) A
			 description of changes proposed to noncompliant forms, and a replacement form
			 attached to the form schedule; or
(c) Revised exhibits and supporting
			 documentation.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-46A - Health maintenance organization general rules for electronic filing of forms and rates in SERFF › Section 284-46A-100 - Rules for revised or replaced forms

Current through Register Vol. 24-14, July 15, 2024
If an HMO files a revised or replaced form, the filer must
				provide the supporting documentation described below:
(1) If a form is revised due to an
			 objection(s) from the commissioner, the filer must provide a detailed
			 explanation of all material changes to the disapproved form.
(2) If a form which received final action is
			 replaced with a new version, the filer must submit an exhibit that marks and
			 identifies each change or revision to the replaced form using one of these
			 methods:
(a) A draft form that strikes
			 through deletions and underlines additions or changes in the form;
(b) A draft form that includes comments in
			 the margins explaining the changes in the form; or
(c) A side-by-side comparison of current and
			 proposed language.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-46A - Health maintenance organization general rules for electronic filing of forms and rates in SERFF › Section 284-46A-110 - Effective date rules

Current through Register Vol. 24-14, July 15, 2024
(1)
			 Filers must include a common implementation date for all forms or rates
			 submitted in a filing.
(2) Filers
			 may submit a request to change the implementation date of a filing as a note to
			 reviewer.
Statutory Authority:
				  RCW
				  48.02.060,
				  48.44.050, and
				  48.46.200. 10-01-118 (Matter No. R
				  2009-04), §
										284-46A-110, filed 12/17/09,
				  effective 1/17/10.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-46A - Health maintenance organization general rules for electronic filing of forms and rates in SERFF › Section 284-46A-120 - Rules that apply to forms translated from English to another language

Current through Register Vol. 24-14, July 15, 2024
HMOs may issue forms written in languages other than
				English.
(1) If the HMO translates the
			 form from English to another language, the HMO must:
(a) File the translated version of the
			 form.
(b) Include written
			 disclosure statements on the translated contract indicating that it is issuing
			 the translated form on an informational basis and the English version is
			 controlling for the purposes of application and interpretation. The disclosure
			 statements must be in English and the language of the translated form and
			 printed in bold face type of at least twelve-point font.
(c) Submit a certification with the filing by
			 an officer employed by the HMO that they will issue the English version of the
			 form with the translated form.