Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter B - PLAN MANAGEMENT › Section 284-43-0250 - Grandfathered health plan status

Current through Register Vol. 24-14, July 15, 2024
(1) An issuer must retain in its files all
				necessary documentation to support its determination that a purchaser's plan is
				grandfathered. The information must be sufficient to demonstrate that the
				issuer's determination of grandfathered status is credible. For purposes of
				this section, "grandfathered plan" means a health plan that meets the
				requirements of this section and as defined in RCW  48.43.005.
(2) An issuer's documentation supporting
				grandfathered plan designation must be made available to the commissioner or
				the U.S. Department of Health and Human Services for review and examination
				upon request. Beginning with the effective date of this section, for fully
				insured health plans designated as grandfathered, an issuer must retain the
				records for a period of not less than ten years. For each plan, the records
				supporting the issuer's determination must also be made available to
				participants and beneficiaries upon request.
(3) An issuer's documentation must establish
				for each grandfathered plan that since March 23, 2010:
(a) The plan was not amended to eliminate all
				or substantially all the benefits to diagnose or treat a particular condition.
				A list of all plan benefit amendments that eliminate benefits and the date of
				the amendment is the minimum level of acceptable documentation that must be
				available to support this criteria;
(b) The percentage of fixed amount
				cost-sharing percentage requirements, if applicable, for the plan were not
				increased when measured from March 23, 2010. A list of each cost-sharing
				percentage that has been in place for a grandfathered group's plan, beginning
				with the cost-sharing percentage on March 23, 2010, is the minimum level of
				acceptable documentation that must be available to support this
				criteria;
(c) The fixed
				cost-sharing requirements other than copayments did not increase by a total
				percentage measured from March 23, 2010, to the date of change that is more
				than the sum of medical inflation plus fifteen percent. A list of the fixed
				cost-sharing requirements other than copayments that apply to a grandfathered
				group's plan beginning on March 23, 2010, and a record of any increase, the
				date and the amount of the increase, is the minimum level of documentation that
				must be available to support this criteria;
(d) Copayments did not increase by an amount
				that exceeds the greater of:
(i) A total
				percentage measured from March 23, 2010, to the date of change that is more
				than the sum of medical inflation plus fifteen percent; or
(ii) Five dollars, adjusted annually for
				medical inflation measured from March 23, 2010. A record of all copayments
				beginning on March 23, 2010, applicable to a grandfathered group plan, and any
				changes in the copayment since that date is the minimum level of documentation
				that must be available to support this criterion.
(e) The employer's contribution rate toward
				any tier of coverage for any class of similarly situated individuals did not
				decrease by more than five percent below the contribution rate in place on
				March 23, 2010, expressed as a percentage of the total cost of coverage. The
				total cost of coverage must be determined using the methodology for determining
				applicable COBRA premiums. If the employer's contribution rate is based on a
				formula such as hours worked, a decrease of more than five percent in the
				employer's contributions under the formula will cause the plan to lose
				grandfathered status. The issuer must retain a record of the employer's
				contribution rate for each tier of coverage, and any changes in that
				contribution rate, beginning March 23, 2010, as the minimum level of
				documentation that must be available to support this criteria;
(f) On or after March 23, 2010, the plan was
				not amended to impose an overall annual limit on the dollar value of benefits
				that was not in the applicable plan documents on March 23, 2010;
(g) On or after March 23, 2010, the plan was
				not amended to adopt an overall annual limit at a dollar value that is lower
				than the dollar value of the lifetime limit for all benefits that was in effect
				on March 23, 2010; and
(h) The plan
				was not amended to decrease the dollar value of the annual limit, regardless of
				whether the plan or health insurance coverage also imposes an overall lifetime
				limit on the dollar value of all benefits.