reglab/statecodes huggingface dataset:
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-54 - Long-term care insurance rules › Section 284-54-015 - Applicability and scope

Current through Register Vol. 24-14, July 15, 2024
(1) Except as
			 otherwise specifically provided, this chapter shall apply to every policy,
			 contract, or certificate, and riders pertaining thereto, of an insurer,
			 fraternal benefit society, health care service contractor, or health
			 maintenance organization, if such contract is primarily advertised, marketed,
			 or designed to provide long-term care services over a prolonged period of time,
			 which services may range from direct skilled medical care performed by trained
			 medical professionals as prescribed by a physician or qualified case manager in
			 consultation with the patient's attending physician to rehabilitative services
			 and assistance with the basic necessary functions of daily living for people
			 who have lost some or complete capacity to function on their own. Such contract
			 is "long-term care insurance" or a "long-term care contract," and is subject to
			 this chapter.
(2) Pursuant to
			 RCW
			  48.84.020, this chapter shall not apply to
			 medicare supplement insurance; nor shall it apply to a contract between a
			 continuing care retirement community and its residents.
(3) Long-term care contracts not meeting the
			 requirements of this chapter, may not be issued or delivered in this state
			 after December 31, 1987.
(4) This
			 chapter is applicable only to long-term care policies, contracts, or
			 certificates issued prior to January 1, 2009. Long-term care policies,
			 contracts, or certificates delivered under policies issued on or after January
			 1, 2009, are governed by chapters 48.83 RCW and 284-83 WAC.
Statutory Authority:
				  RCW
				  48.02.060,
				  48.83.070,
				  48.83.110,
				  48.83.120,
				  48.83.130(1), and
				  48.83.140(4)(a).
				  08-24-019 (Matter No. R 2008-09), §
										284-54-015, filed 11/24/08,
				  effective 12/25/08. Statutory Authority:
				  RCW
				   48.02.060(3), 48.30.010 and
				  48.84.910. 87-15-027 (Order R
				  87-7), §
										284-54-015, filed
				  7/9/87.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-54 - Long-term care insurance rules › Section 284-54-040 - Minimum standards for benefit triggers - Physician certification, activities of daily living, and cognitive impairments

Current through Register Vol. 24-14, July 15, 2024
(1)
(a)
			 Except as provided in (b) of this subsection, every long-term care insurance
			 contract or certificate issued on or after January 1, 1996, which provides
			 coverage to a resident of this state, shall require certification by the
			 insured's attending physician that the services are appropriate due to illness
			 or infirmity, or include provisions which condition the payment of benefits on
			 an assessment of the insured's ability to perform specific activities of daily
			 living or the insured's cognitive impairment.
(b) Certificates issued on or after January
			 1, 1996, under a group long-term care insurance contract that was in force on
			 December 31, 1995, need not meet the standards of this section.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-54 - Long-term care insurance rules › Section 284-54-050 - Exclusions

Current through Register Vol. 24-14, July 15, 2024
No contract shall limit or exclude coverage by type of illness,
				accident, treatment, or medical condition, except with respect to the
				following:
(1) Conditions arising out
			 of war or act of war (whether declared or undeclared);
(2) Conditions arising out of participation
			 in the commission of a felony, riot or insurrection;
(3) Conditions resulting from suicide,
			 attempted suicide (while sane or insane) or intentionally self-inflicted
			 injury;
(4) Benefits available
			 under any state or federal workers' compensation, employer's liability or
			 occupational disease law, or any motor vehicle no-fault law;
(5) Services performed by a member of the
			 covered person's immediate family;
(6) Services for which no charge is made in
			 the absence of insurance;
(7)
			 Dental care or treatment;
(8) Eye
			 glasses, hearing aids and examination for the prescription or fitting
			 thereof;
(9) Rest cures and routine
			 physical examinations;
(10)
			 Chemical dependency;
(11) Treatment
			 in a government hospital or in a government facility unless required by
			 law;
(12) Benefits provided under
			 medicare or other governmental programs (except medicaid);
(13) Experimental treatments, supplies, or
			 services;
(14) Other exclusions
			 appropriate to the particular contract, justified to the satisfaction of the
			 commissioner, in connection with the filing of the contract form, may be
			 permitted by prior written agreement.
Statutory Authority:
				  RCW
				  48.02.060(3),
				  48.30.010 and
				  48.84.910. 87-15-027 (Order R
				  87-7), §
										284-54-050, filed
				  7/9/87.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-54 - Long-term care insurance rules › Section 284-54-100 - Renewability

Current through Register Vol. 24-14, July 15, 2024
No insurer shall refuse to renew any long-term care contract or
				coverage thereunder: Provided, That after written approval of the commissioner,
				an insurer may discharge its obligation to renew by obtaining for the insured
				coverage with another insurer which coverage provides equivalent benefits for
				value paid.
Statutory Authority:
				  RCW
				  48.02.060(3),
				  48.30.010 and
				  48.84.910. 87-15-027 (Order R
				  87-7), §
										284-54-100, filed
				  7/9/87.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-54 - Long-term care insurance rules › Section 284-54-160 - Minimum standards - Gatekeeping provisions

Current through Register Vol. 24-14, July 15, 2024
Any gatekeeper provisions must be reasonable in relation to the
				benefits promised in the contract. It must be demonstrated to the satisfaction
				of the commissioner that a reasonable number of insureds who can be expected to
				receive benefit or contract payments because of an illness, injury or
				condition, are not precluded by the gatekeeper from receiving said benefits.
				Policies or contracts providing long-term care benefits following
				institutionalization shall not condition such benefits upon admission to the
				long-term care facility within a period of fewer than thirty days after
				discharge from the institution.
Statutory Authority:
				  RCW
				  48.02.060(3),
				  48.30.010 and
				  48.84.910. 87-15-027 (Order R
				  87-7), §
										284-54-160, filed
				  7/9/87.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-54 - Long-term care insurance rules › Section 284-54-180 - Reduction of coverage

Current through Register Vol. 24-14, July 15, 2024
Effective January 1, 1996, every person purchasing a long-term
				care insurance contract in this state shall have the right to reduce the
				benefits of a long-term care contract without providing evidence of
				insurability. Such a reduction may include, for example, changes which result
				in a contract with a longer elimination period, a lower daily benefit, or a
				shorter benefit period: Provided, however, That an insurer shall not reduce
				benefits to a level below the minimum level which has been approved by the
				commissioner on the date the reduction of coverage is
				requested.
Statutory Authority:
				  RCW
				  48.02.060,
				  48.84.030 and
				  48.84.050. 95-19-028 (Order R
				  95-5), §
										284-54-180, filed 9/11/95,
				  effective 10/12/95.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-54 - Long-term care insurance rules › Section 284-54-190 - Nonduplication with state or national health care benefits

Current through Register Vol. 24-14, July 15, 2024
In the event that a state or federal program is enacted which
				substantially duplicates all or part of the coverage of an in-force long-term
				care insurance contract or certificate, current benefits or features which are
				duplicated by a state or national program shall be revised or eliminated
				promptly and in an orderly manner, subject to prior approval by the
				commissioner.
Statutory Authority:
				  RCW
				  48.02.060,
				  48.84.030 and
				  48.84.050. 95-19-028 (Order R
				  95-5), §
										284-54-190, filed 9/11/95,
				  effective 10/12/95.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-54 - Long-term care insurance rules › Section 284-54-200 - Prohibition against preexisting conditions and probationary periods in replacement policies or certificates

Current through Register Vol. 24-14, July 15, 2024
If a long-term care insurance contract or certificate replaces
				another long-term care insurance contract or certificate, the replacing insurer
				shall waive any time periods applicable to preexisting conditions and
				probationary periods in the new long-term care insurance contract for similar
				benefits to the extent that similar exclusions have been satisfied under the
				original contract.
Statutory Authority:
				  RCW
				  48.02.060,
				  48.84.030,
				  48.01.030. 94-14-100 (Order R
				  94-10), §
										284-54-200, filed 7/6/94,
				  effective 8/6/94.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-54 - Long-term care insurance rules › Section 284-54-210 - Minimum standards for community based care benefits in long-term care insurance policies

Current through Register Vol. 24-14, July 15, 2024
(1) No long-term
			 care insurance contract or certificate which provides benefits for community
			 based care services may limit or exclude benefits:
(a) By requiring care in a skilled nursing
			 facility before covering community based care services;
(b) By requiring that the insured first or
			 simultaneously receive nursing or therapeutic services in a home, community or
			 institutional setting before community based care services are
			 covered;
(c) By limiting eligible
			 services to services provided by registered nurses or licensed practical
			 nurses;
(d) By requiring that
			 community based care services may be delivered only by licensed nurses or
			 therapists when the type of services to be provided comes within the authorized
			 scope of license of other regulated health care providers;
(e) By excluding coverage for personal care
			 services provided by a home health aide;
(f) By requiring that the delivery of
			 community based care services be at a level of certification or licensure
			 greater than that required for the eligible service;
(g) By requiring that the insured have an
			 acute condition before community based care services are covered;
(h) By limiting benefits to services provided
			 by medicare-certified agencies or providers; or
(i) By excluding coverage for adult day care
			 services.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-54 - Long-term care insurance rules › Section 284-54-250 - Grace period

Current through Register Vol. 24-14, July 15, 2024
Every long-term care contract must contain a grace period of no
				fewer than thirty-one days following the due date for the payment of
				premiums.
Statutory Authority:
				  RCW
				  48.02.060(3),
				  48.30.010 and
				  48.84.910. 87-15-027 (Order R
				  87-7), §
										284-54-250, filed
				  7/9/87.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-54 - Long-term care insurance rules › Section 284-54-253 - Unintentional lapse

Current through Register Vol. 24-14, July 15, 2024
The purpose of this section is to protect insureds from
				unintentional lapse by establishing standards for notification of a designee to
				receive notice of lapse for nonpayment of premiums at least thirty days prior
				to the termination of coverage and to provide for a limited right to
				reinstatement of coverage unintentionally lapsed by a person with a cognitive
				impairment or loss of functional capacity. These are minimum standards and do
				not prevent an insurer from including benefits more favorable to the insured.
				This section applies to every insurer providing long-term care coverage to a
				resident of this state, which coverage is issued for delivery or renewed on or
				after January 1, 1996, through December 31, 2008.
(1) Every insurer shall permit an insured to
			 designate at least one additional person to receive notice of lapse or
			 termination for nonpayment of premium, if the premium is not paid on or before
			 its due date. The designation shall include the designee's full name and home
			 address.
(a) The notice shall provide that
			 the contract or certificate will not lapse until at least thirty days after the
			 issuer sends the notice to the insured's designee.
(i) Issuers must be able to show:
(A) Proof that they produced the
			 notice;
(B) Proof that they sent
			 the notice;
(C) The name and
			 address of the person or persons to whom they sent the notice. The address may
			 consist of either:
(I) A physical mailing
			 address; or
(II) An electronic
			 mailing address for delivery by electronic means under the requirements of
			 RCW
			  48.185.005.
(D) The date that they sent the
			 notice.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-54 - Long-term care insurance rules › Section 284-54-260 - Extension of benefits

Current through Register Vol. 24-14, July 15, 2024
Termination of long-term care insurance shall be without
				prejudice to any benefits payable for institutionalization if such
				institutionalization began while the long-term care insurance was in force and
				continues without interruption after termination. Such extension of benefits
				beyond the period the long-term care insurance was in force may be limited to
				the duration of the benefit period, if any, or to payment of the maximum
				benefits and may be subject to any applicable waiting period, and all other
				applicable provisions of the contract or certificate.
Statutory Authority:
				  RCW
				  48.02.060,
				  48.84.030,
				  48.01.030. 94-14-100 (Order R
				  94-10), §
										284-54-260, filed 7/6/94,
				  effective 8/6/94.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-54 - Long-term care insurance rules › Section 284-54-270 - Requirement to offer inflation protection

Current through Register Vol. 24-14, July 15, 2024
(1) No insurer may offer a long-term care
			 insurance contract unless, in addition to any other inflation protection
			 option, the insurer offers to the policyholder the option to purchase a
			 contract that provides for benefit levels to increase with benefit maximums or
			 reasonable durations which are meaningful to account for reasonably anticipated
			 increases in the costs of long-term care services covered by the contract.
			 Insurers must offer to each applicant, at the time of purchase, the option to
			 purchase a contract with an inflation protection feature no less favorable than
			 one of the following:
(a) Increases benefit
			 levels annually in a manner so that the increases are compounded annually at a
			 rate not less than five percent;
(b) Guarantees the insured individual the
			 right to periodically increase benefit levels without providing evidence of
			 insurability or health status so long as the option for the previous period has
			 not been declined. The amount of the additional benefit shall be no less than
			 the difference between the existing policy benefit and that benefit compounded
			 annually at a rate of at least five percent for the period beginning with the
			 purchase of the existing benefit and extending until the year in which the
			 offer is made; or
(c) Covers a
			 specified percentage of actual or reasonable charges and does not include a
			 maximum specified indemnity amount or limit.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-54 - Long-term care insurance rules › Section 284-54-500 - Format of long-term care contracts

Current through Register Vol. 24-14, July 15, 2024
No long-term care contract shall be delivered or issued for
				delivery to any person in this state if it fails to comply with the
				following:
(1) The style, arrangement,
			 and over-all appearance of the policy shall give no undue prominence to any
			 portion of the text (except as required by this chapter). Every printed portion
			 of the text of the contract and of any amendment or attached papers shall be
			 plainly printed in easily read type.
(2) Limitations, exclusions, exceptions, and
			 reductions of coverage or benefits shall be set forth in the policy and shall
			 be printed, at the insurer's option, either included with the benefit provision
			 to which they apply, or under an appropriate caption such as "LIMITATIONS and
			 EXCEPTIONS," or "EXCLUSIONS and REDUCTIONS," except that if a limitation,
			 exclusion, exception, or reduction specifically applies only to a particular
			 benefit of the policy, a statement of such limitation, exclusion, exception, or
			 reduction shall be included with the benefit provision to which it
			 applies.
(3) Each contract
			 delivered or issued for delivery to any person in this state shall clearly
			 indicate on its first page that it is a "LONG-TERM CARE INSURANCE" contract. In
			 addition, the contract shall contain a table of contents which shall clearly
			 identify the location within the contract of each of the provisions of the
			 contract with particular attention to the location of contract provisions for
			 (a) limitations, exclusions, exceptions or reductions of coverage, (b)
			 renewability, (c) definitions, (d) gatekeeping provisions, and (e) any unique
			 provisions or circumstances such as elimination periods, or minimum or maximum
			 limits. The term "contract" or "certificate" may be substituted on the first
			 page of the contract for the word "insurance" where appropriate.
Statutory Authority:
				  RCW
				  48.02.060(3),
				  48.30.010 and
				  48.84.910. 87-15-027 (Order R
				  87-7), §
										284-54-500, filed
				  7/9/87.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-54 - Long-term care insurance rules › Section 284-54-600 - Loss ratio requirements

Current through Register Vol. 24-14, July 15, 2024
(1) The
			 provisions of chapter 284-60 WAC shall apply to every contract of long-term
			 care issued by a disability insurer and fraternal benefit society. The
			 provisions of WAC
			 284-54-610 through
			 284-54-680 shall apply to every
			 long-term care contract issued by a health care service contractor or health
			 maintenance organization.
(2)
			 Benefits for all long-term care contracts shall be reasonable in relation to
			 the premium or price charged.
Statutory Authority:
				  RCW
				  48.02.060(3),
				  48.30.010 and
				  48.84.910. 87-15-027 (Order R
				  87-7), §
										284-54-600, filed
				  7/9/87.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-54 - Long-term care insurance rules › Section 284-54-610 - Loss ratio definitions

Current through Register Vol. 24-14, July 15, 2024
The following definitions apply to WAC
				284-54-610 through
				284-54-680:
(1) "Loss ratio" means the claims incurred
			 plus or minus the increase or decrease in reserves as a percentage of the
			 earned premiums, or the projected incurred claims plus or minus the increase or
			 decrease in projected reserves as a percentage of projected earned premiums, as
			 defined by the commissioner.
(2)
			 "Claims" shall mean the cost of health care services paid to or provided on
			 behalf of covered individuals in accordance with the terms of contracts issued
			 by health care service contractors or health maintenance organizations or
			 capitation payments made to providers of long-term care.
(3) The "expected loss ratio" is a
			 prospective calculation and shall be calculated as the projected "benefits
			 incurred" divided by the projected "premiums earned" and shall be based on the
			 pricing actuary's best projections of the future experience within the
			 "calculating period."
(4) The
			 "actual loss ratio" is a retrospective calculation and shall be calculated as
			 the "benefits incurred" divided by the "premiums earned," both measured from
			 the beginning of the "calculating period" to the date of the loss ratio
			 calculations.
(5) The "overall loss
			 ratio" shall be calculated as the "benefits incurred" divided by the "premiums
			 earned" over the entire "calculating period" and may involve both retrospective
			 and prospective data.
(6) The
			 "calculating period" shall be the time span over which the pricing actuary
			 expects the premium rates whether level or increasing, to remain adequate in
			 accordance with his best estimate of future experience and during which the
			 pricing actuary does not expect to request a rate increase.
(7) The "benefits incurred" shall be the
			 "claims incurred" plus any increase (or less any decrease) in the
			 "reserves."
(8) The "claims
			 incurred" shall mean:
(a) Claims paid during
			 the accounting period; plus
(b) The
			 change in the liability for claims which have been reported but not paid;
			 plus
(c) The change in the
			 liability for claims which have not been reported but which may reasonably be
			 expected.
The "claims incurred" shall not include expenses incurred in
				processing the claims, home office or field overhead, acquisition and selling
				costs, taxes or other expenses, contributions to surplus, or profit.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-54 - Long-term care insurance rules › Section 284-54-650 - Loss ratio experience records

Current through Register Vol. 24-14, July 15, 2024
Health care service contractors and health maintenance
				organizations shall maintain records of earned premiums and incurred benefits
				for each contract year for each contract, rider, endorsement, amendment and
				similar form which were combined for purposes of premium calculations,
				including the reserves. Records shall also be maintained of the experience
				expected in the premium calculations. Notwithstanding the foregoing, with
				proper justification, the commissioner may accept approximation of contract
				year experience based on calendar year data.
Statutory Authority:
				  RCW
				  48.02.060(3),
				  48.30.010 and
				  48.84.910. 87-15-027 (Order R
				  87-7), §
										284-54-650, filed
				  7/9/87.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-54 - Long-term care insurance rules › Section 284-54-660 - Evaluating loss ratio experience data

Current through Register Vol. 24-14, July 15, 2024
In determining the credibility and appropriateness of
				experience data, due consideration shall be given to all relevant factors
				including:
(1) Statistical credibility
			 of premiums and benefits such as low exposure or low loss frequency;
(2) Past and projected trends relative to the
			 kind of coverage, such as inflation in medical expenses, inflation in expense
			 charges and others;
(3) The
			 concentration of experience at early contract durations where select morbidity
			 and preliminary term reserves are applicable and where loss ratios are expected
			 to be substantially higher or lower than in later contract durations;
(4) The mix of business by risk
			 classification;
(5) The expected
			 lapses and antiselection at the time of rate increases.
Statutory Authority:
				  RCW
				  48.02.060(3),
				  48.30.010 and
				  48.84.910. 87-15-027 (Order R
				  87-7), §
										284-54-660, filed
				  7/9/87.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-54 - Long-term care insurance rules › Section 284-54-680 - Loss ratio - Special circumstances

Current through Register Vol. 24-14, July 15, 2024
Loss ratios other than those indicated in WAC
				284-54-630 may be approved by the
				commissioner with satisfactory actuarial demonstrations. Examples of coverage
				where the commissioner may grant special considerations are:
(1) Contract forms exposed to high risk of
			 claim fluctuation because of the low loss frequency, or the catastrophic or
			 experimental nature of the coverage.
(2) Individual situations where higher than
			 usual expenses are expected because of peculiar administrative or geographic
			 circumstances.
Statutory Authority:
				  RCW
				  48.02.060(3),
				  48.30.010 and
				  48.84.910. 87-15-027 (Order R
				  87-7), §
										284-54-680, filed
				  7/9/87.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-54 - Long-term care insurance rules › Section 284-54-700 - Advertising

Current through Register Vol. 24-14, July 15, 2024
In addition to this chapter, specific applicable standards for
				the regulation of advertisements relating to individual, group, blanket, and
				franchise and individual and group health care service contractors' agreements,
				are included in WAC
				284-50-010 through
				284-50-230, and are applicable to
				the advertisement of all long-term care insurance contracts.
Statutory Authority:
				  RCW
				  48.02.060(3),
				  48.30.010 and
				  48.84.910. 87-15-027 (Order R
				  87-7), §
										284-54-700, filed
				  7/9/87.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-54 - Long-term care insurance rules › Section 284-54-900 - Chapter not exclusive

Current through Register Vol. 24-14, July 15, 2024
Nothing contained in this chapter shall be construed to limit
				the authority of the commissioner to regulate a long-term care contract under
				other sections of
				Title
				48 RCW.
Statutory Authority:
				  RCW
				  48.02.060(3),
				  48.30.010 and
				  48.84.910. 87-15-027 (Order R
				  87-7), §
										284-54-900, filed
				  7/9/87.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-55 - Medicare supplement insurance regulation › Section 284-55-010 - Limited purpose of this chapter

Current through Register Vol. 24-14, July 15, 2024
(1) Regulation of medicare supplemental
			 insurance policies under chapter 284-55 WAC is limited to those guaranteed
			 renewable policies which were delivered to residents of this state prior to
			 January 1, 1989. Such guaranteed renewable policies shall also be subject to
			 the requirements of chapter 284-66 WAC as provided at WAC
			 284-66-020(2)(a).
			 All medicare supplemental insurance policies delivered to residents of this
			 state after December 31, 1988, are regulated by the provisions of chapter
			 284-66 WAC, adopted March 16, 1990. Policies that are not guaranteed renewable
			 and which were delivered to residents of this state prior to January 1, 1990,
			 are also subject to the provisions of chapter 284-66 WAC.
(2) The purpose of this regulation, chapter
			 284-55 WAC, is to effectuate the provisions of
			 RCW
			  48.20.450,
			 48.20.460 and
			 48.20.470, and to supplement the
			 requirements of chapter 48.66 RCW, the Medicare Supplemental Health Insurance
			 Act, by establishing minimum standards for benefits and specific standards for
			 medicare supplement insurance, by prescribing the "outline of coverage" to be
			 used in the sale of medicare supplemental insurance, by establishing other
			 disclosure requirements, by prohibiting the use of certain provisions in
			 medicare supplement insurance policies, by defining and prohibiting certain
			 practices as unfair acts and practices, and establishing loss ratio
			 requirements; to assure the orderly implementation and conversion of medicare
			 supplement insurance benefits and premiums due to changes in the federal
			 medicare program; to provide for the reasonable standardization of the
			 coverage, terms, and benefits of medicare supplement insurance policies; to
			 eliminate policy provisions which may duplicate medicare benefits; and to
			 provide for refunds of premiums associated with benefits duplicating medicare
			 program benefits.
Statutory Authority:
				  RCW
				  48.02.060 and
				  48.66.041. 90-17-038 (Order R
				  90-7), §
										284-55-010, filed 8/10/90,
				  effective 9/10/90. Statutory Authority:
				  RCW
				   48.02.060(3)(a) and
				  48.30.010(2).
				  88-22-061 (Order R 88-9), §
										284-55-010, filed 11/1/88.
				  Statutory Authority:
				  RCW
				   48.66.100,
				  48.20.470 and 1982 c 200 § 1.
				  82-12-032 (Order R 82-3), §
										284-55-010, filed 5/26/82.
				  Statutory Authority:
				  RCW
				   48.02.060,
				  48.44.050 and
				  48.46.200. 82-01-016 (Order R
				  81-6), §
										284-55-010, filed
				  12/9/81.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-55 - Medicare supplement insurance regulation › Section 284-55-020 - Applicability and scope

Current through Register Vol. 24-14, July 15, 2024
(1) This chapter
			 applies to guaranteed renewable medicare supplemental insurance policies
			 delivered to residents of this state prior to January 1, 1989, including every
			 such group and individual policy of disability insurance and to every such
			 subscriber contract of an insurer, fraternal benefit society, health care
			 service contractor, or health maintenance organization, which relates its
			 benefits to medicare, or which is advertised, marketed, or designed primarily
			 as a supplement to reimbursements under medicare for the hospital, medical or
			 surgical expenses of persons eligible for medicare by reason of age. Such
			 policy or contract is referred to in this chapter as "medicare supplemental
			 insurance" or "medicare supplement insurance policy."
(2) Except as required by federal law, this
			 regulation shall not apply to:
(a) A policy
			 or contract of one or more employers or labor organizations, or of the trustees
			 of a fund established by one or more employers or labor organizations, or
			 combination thereof, for employees or former employees, or combination thereof,
			 or for members or former members, or combination thereof, of the labor
			 organizations;
(b) A policy or
			 contract of any professional, trade, or occupational association for its
			 members or former members, or combination thereof, if such association:
(i) Is composed of individuals all of whom
			 are or have been actively engaged in the same profession, trade or
			 occupation;
(ii) Has been
			 maintained in good faith for purposes other than obtaining insurance;
			 and
(iii) Has been in existence for
			 at least two years prior to the date of initial offering of such policy or plan
			 to its members;
(c)
			 Individual policies or contracts issued pursuant to a conversion privilege
			 under a policy or contract of group or individual insurance when such group or
			 individual policy or contract includes provisions which are inconsistent with
			 the requirements of this regulation;
(d) Policies issued to employees or members
			 as additions to franchise plans in existence on the effective date of this
			 regulation, or
(e) Health
			 maintenance organization contracts specified in
			 RCW
			  48.66.160, to the extent they may be in
			 conflict with this regulation.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-55 - Medicare supplement insurance regulation › Section 284-55-030 - Definitions

Current through Register Vol. 24-14, July 15, 2024
For purposes of this regulation:
(1) "Applicant" means:
(a) In the case of an individual medicare
			 supplement insurance policy or subscriber contract, the person who seeks to
			 contract for insurance benefits, and
(b) In the case of a group medicare
			 supplement insurance policy or subscriber contract, the proposed certificate
			 holder.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-55 - Medicare supplement insurance regulation › Section 284-55-035 - Policy definitions and terms

Current through Register Vol. 24-14, July 15, 2024
No insurance policy or subscriber contract may be advertised,
				solicited, or issued for delivery in this state as a medicare supplement policy
				unless such policy or contract contains definitions or terms which conform to
				the requirements of this section.
(1)
			 "Accident," "accidental injury," or "accidental means" shall be defined to
			 employ "result" language and shall not include words which establish an
			 accidental means test or use words such as "external, violent, visible wounds"
			 or similar words of description or characterization.
(a) The definition shall not be more
			 restrictive than the following: "Injury or injuries for which benefits are
			 provided means accidental bodily injury sustained by the insured person which
			 is the direct result of an accident, independent of disease or bodily infirmity
			 or any other cause, and occurs while insurance coverage is in force."
(b) Such definition may provide that injuries
			 shall not include injuries for which benefits are provided under any workers'
			 compensation, employer's liability or similar law, motor vehicle no-fault plan,
			 unless prohibited by law.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-55 - Medicare supplement insurance regulation › Section 284-55-045 - Minimum benefit standards

Current through Register Vol. 24-14, July 15, 2024
Except as permitted by WAC
				284-55-040(3),
				no insurance policy or subscriber contract may be advertised, solicited, or
				issued for delivery in this state as a medicare supplement policy which does
				not meet the following minimum benefit standards. Except in subsection (1) of
				this section which requires fixed benefits, these are minimum standards and do
				not preclude the inclusion of other provisions or benefits which are not
				inconsistent with these standards.
(1)
			 Coverage for either all or none of the medicare Part A inpatient hospital
			 deductible amount.
(2) Coverage for
			 the daily copayment amount of medicare Part A eligible expenses for the first
			 eight days per calendar year incurred for skilled nursing facility
			 care.
(3) Coverage for the
			 reasonable cost of the first three pints of blood (or equivalent quantities of
			 packed red blood cells, as defined under federal regulations) under medicare
			 Part A not replaced in accordance with federal regulations.
(4)
(a)
			 Until January 1, 1990, coverage of twenty percent of the amount of medicare
			 eligible expenses under Part B regardless of hospital confinement, subject to a
			 maximum calendar year out-of-pocket deductible of two hundred dollars of such
			 expenses and to a maximum benefit of at least five thousand dollars per
			 calendar year.
(b) Effective
			 January 1, 1990, coverage for the copayment amount of medicare eligible
			 expenses (excluding outpatient prescription drugs) under medicare Part B up to
			 the maximum out-of-pocket amount for medicare Part B after the medicare
			 deductible amount.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-55 - Medicare supplement insurance regulation › Section 284-55-050 - Outline of coverage required

Current through Register Vol. 24-14, July 15, 2024
(1) An
			 agent or insurer initiating a sale of an individual or group medicare
			 supplement insurance policy in this state shall complete and sign a disclosure
			 form, and deliver the completed form to the applicant not later than the time
			 of application for the policy.
(2)
			 The disclosure form to be used shall be the "outline of coverage," which is set
			 forth in WAC
			 284-55-060. The form of outline
			 shall be filed with the commissioner prior to use in this state.
(3) Except for direct response insurers, an
			 insurer shall obtain an acknowledgement of receipt of such outline from the
			 applicant.
Statutory Authority:
				  RCW
				  48.02.060(3)(a) and
				  48.66.050. 89-11-096 (Order R
				  89-7), §
										284-55-050, filed 5/24/89.
				  Statutory Authority:
				  RCW
				   48.02.060(3)(a) and
				  48.30.010(2).
				  88-22-061 (Order R 88-9), §
										284-55-050, filed 11/1/88.
				  Statutory Authority:
				  RCW
				   48.02.060,
				  48.44.050 and
				  48.46.200. 82-01-016 (Order R
				  81-6), §
										284-55-050, filed
				  12/9/81.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-55 - Medicare supplement insurance regulation › Section 284-55-060 - Form for "outline of coverage."

Current through Register Vol. 24-14, July 15, 2024
(COMPANY NAME)
OUTLINE OF MEDICARE
SUPPLEMENT COVERAGE
(1) Read your policy carefully - This outline
			 of coverage provides a very brief description of the important features of your
			 policy. This is not the insurance contract and only the actual policy
			 provisions will control. The policy itself sets forth in detail the rights and
			 obligations of both you and your insurance company. It is, therefore, important
			 that you READ YOUR POLICY CAREFULLY!
(2) Medicare supplement coverage - Policies
			 of this category are designed to supplement medicare by covering some hospital,
			 medical, and surgical services which are partially covered by medicare.
			 Coverage is provided for hospital inpatient charges and some physician charges,
			 subject to any deductibles and copayment provisions which may be in addition to
			 those provided by medicare, and subject to other limitations which may be set
			 forth in the policy. The policy does not provide benefits for custodial care
			 such as help in walking, getting in and out of bed, eating, dressing, bathing
			 and taking medicine (delete if such coverage is provided).
(3)
(a)
			 (for agents:)
Neither
(Insert company's name)
nor its agents
are connected with medicare.
(b)
			 (for direct responses:)
(Insert company's name)
is not connected with
medicare.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-55 - Medicare supplement insurance regulation › Section 284-55-065 - Buyer's guide

Current through Register Vol. 24-14, July 15, 2024
(1) Insurers
			 issuing accident and sickness policies, certificates, or subscriber contracts
			 that provide hospital or medical expense coverage on an expense incurred or
			 indemnity basis, other than incidentally, to persons eligible for medicare by
			 reason of age must provide to all applicants a medicare supplement "buyer's
			 guide."
(2) The "buyer's guide"
			 required to be provided is the pamphlet
Guide to Health Insurance for
			 People with Medicare
, developed jointly by the National Association of
			 Insurance Commissioners and Health Care Financing Administration of the United
			 States Department of Health and Human Services, or any reproduction or official
			 revision of that pamphlet. Specimen copies may be obtained from the
			 Superintendent of Documents, United States Government Printing Office,
			 Washington, D.C.
(3) Delivery of
			 the "buyer's guide" must be made whether or not such policies, certificates, or
			 subscriber contracts are advertised, solicited, or issued as medicare
			 supplement insurance policies. Except in the case of direct response insurers,
			 delivery of the "buyer's guide" must be made to the applicant at the time of
			 application and acknowledgement of receipt of the "buyer's guide" must be
			 obtained by the insurer. Direct response insurers must deliver the "buyer's
			 guide" to the applicant upon request but not later than at the time the policy
			 is delivered.
Statutory Authority:
				  RCW
				  48.02.060(3)(a) and
				  48.30.010(2).
				  88-22-061 (Order R 88-9), §
										284-55-065, filed 11/1/88.
				  Statutory Authority:
				  RCW
				   48.66.100,
				  48.20.470 and 1982 c 200 § 1.
				  82-12-032 (Order R 82-3), §
										284-55-065, filed
				  5/26/82.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-55 - Medicare supplement insurance regulation › Section 284-55-067 - Notice regarding policies or subscriber contracts which are not medicare supplement policies

Current through Register Vol. 24-14, July 15, 2024
Any accident and sickness insurance policy or subscriber
				contract, other than a medicare supplement policy, disability income policy,
				basic, comprehensive, or major medical expense policy, single premium
				nonrenewable policy or other policy identified in WAC
				284-55-020(2)(c) and
				(d), issued for delivery in this state to
				persons eligible for medicare by reason of age, shall notify insureds under the
				policy or subscriber contract that the policy or subscriber contract is not a
				medicare supplement insurance policy. Such notice shall either be printed or
				attached to the first page of the outline of coverage delivered to insureds
				under the policy or subscriber contract, or if no outline of coverage is
				delivered, to the first page of the policy, certificate or subscriber contract
				delivered to insureds. Such notice shall be in no less than twelve point type
				and shall contain the following language: "THIS (POLICY, CERTIFICATE OR
				SUBSCRIBER CONTRACT) IS NOT A MEDICARE SUPPLEMENT (POLICY OR CERTIFICATE). If
				you are eligible for medicare, review the Medicare Supplement Buyers Guide
				available from the company."
Statutory Authority:
				  RCW
				  48.02.060(3)(a) and
				  48.30.010(2).
				  88-22-061 (Order R 88-9), §
										284-55-067, filed 11/1/88.
				  Statutory Authority:
				  RCW
				   48.66.100,
				  48.20.470 and 1982 c 200 § 1.
				  82-12-032 (Order R 82-3), §
										284-55-067, filed
				  5/26/82.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-55 - Medicare supplement insurance regulation › Section 284-55-070 - Requirements for application forms, replacement

Current through Register Vol. 24-14, July 15, 2024
(1) Application forms shall include a
			 question designed to elicit information as to whether a medicare supplement
			 insurance policy or certificate is intended to replace any other health care
			 service contract, health maintenance organization contract, disability
			 insurance policy or certificate presently in force. A supplementary application
			 or other form to be signed by the applicant containing such a question may be
			 used.
(2) Upon determining that a
			 sale will involve replacement, the insurer, other than a direct response
			 insurer, or its agent, shall furnish the applicant, prior to issuance or
			 delivery of the medicare supplement insurance policy or certificate, a notice
			 regarding replacement of accident and sickness coverage. One copy of such
			 notice shall be provided to the applicant and an additional copy signed by the
			 applicant shall be retained by the insurer. A direct response insurer shall
			 deliver to the applicant at the time of the issuance of the policy the notice
			 regarding replacement of accident and sickness coverage. The form shall be
			 filed with the commissioner prior to use in this state.
(3) The notice required by subsection (2) of
			 this section for an insurer, other than a direct response insurer, shall be
			 provided in substantially the form set forth in WAC
			 284-55-080.
(4) The notice required by subsection (2) of
			 this section for a direct response insurer shall be in substantially the form
			 set forth in WAC
			 284-55-090.
(5) The application form shall also contain
			 questions as to whether, as of the date of the application, the applicant:
(a) Has any other health care service
			 contract, health maintenance organization contract, disability insurance policy
			 or certificate in force, and
(b) Is
			 eligible for state medical assistance coupons (medicaid).
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-55 - Medicare supplement insurance regulation › Section 284-55-080 - Form for "replacement notice."

Current through Register Vol. 24-14, July 15, 2024
NOTICE TO APPLICANT REGARDING REPLACEMENT OF ACCIDENT AND
				SICKNESS INSURANCE
According to (your application) (information you have
				furnished), you intend to lapse or otherwise terminate existing accident and
				sickness insurance and replace it with a policy to be issued by (company name)
				insurance company. Federal and state law provides thirty days within which you
				may decide without cost whether you desire to keep the policy. For your own
				information and protection, you should be aware of and seriously consider
				certain factors which may affect the insurance protection available to you
				under the new policy.
(1) Health
			 conditions which you may presently have (preexisting conditions) may not be
			 immediately or fully covered under the new policy. This could result in denial
			 or delay of a claim for benefits under the new policy, whereas a similar claim
			 might have been payable under your present policy.
Drafting note. This subsection may be modified if preexisting
				conditions are covered under the new policy.
(2) You may wish to secure the advice of your
			 present insurer or its agent regarding the proposed replacement of your present
			 policy. This is not only your right, but it is also in your best interest to
			 make sure you understand all the relevant factors involved in replacing your
			 present coverage.
(3) If, after due
			 consideration, you still wish to terminate your present policy and replace it
			 with new coverage, be certain to truthfully and completely answer all questions
			 on the application concerning your medical/health history. Failure to include
			 all material medical information on an application may provide a basis for the
			 company to deny any future claims and to refund your premium as though your
			 policy had never been in force. After the application has been completed and
			 before you sign it, reread it carefully to be certain that all information has
			 been properly recorded.
The above "Notice to Applicant" was delivered to me on:
. . . . . . . . . . . . . . . . . . . ..
(Date)
. . . . . . . . . . . . . . . . . . . ..
(Applicant's Signature)
Statutory Authority:
				  RCW
				  48.02.060(3)(a) and
				  48.30.010(2).
				  88-22-061 (Order R 88-9), §
										284-55-080, filed 11/1/88.
				  Statutory Authority:
				  RCW
				   48.02.060,
				  48.44.050 and
				  48.46.200. 82-01-016 (Order R
				  81-6), §
										284-55-080, filed
				  12/9/81.