reglab/statecodes huggingface dataset:
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter C - OPEN AND SPECIAL ENROLLMENT REQUIREMENTS › Section 284-43-1120 - Individual market special enrollment period requirements for qualified health plans

Current through Register Vol. 24-14, July 15, 2024
(1) An issuer
				offering individual qualified health plans on the health benefit exchange must
				make special enrollment opportunities, subject to the same terms and conditions
				specified in WAC
				284-43-1100, available to
				applicants who experience a qualifying event.
(2) In addition to the special enrollment
				qualifying events set forth in WAC
				284-43-1100, the following
				special enrollment opportunities must be made available for individual plans
				offered on the health benefit exchange:
(a)
				For qualified individuals who are an Indian, as defined by Section 4 of the
				Indian Health Care Improvement Act, enrollment in a qualified health plan or
				change from one qualified health plan to another must be permitted one time per
				month, without requiring an additional special enrollment triggering
				event;
(b) The applicant
				demonstrates to the health benefit exchange that the qualified health plan in
				which they are enrolled violated a material provision of the coverage contract
				in relation to the individual;
(c)
				If applicant lost prior coverage due to errors by the health benefit exchange
				staff or the U.S. Department of Health and Human Services;
(d) The applicant, or his or her dependent,
				not previously a citizen, national or lawfully present individual, gains such
				status. For purposes of this subsection, "dependent" means a dependent as
				defined in
				RCW
				 48.43.005;
(e) The individual becomes newly eligible or
				newly ineligible for advance payment of premium tax credits, has a change in
				eligibility for cost-sharing reductions, or the individual's dependent becomes
				newly eligible. For purposes of (e) and (f) of this subsection, "dependent"
				means dependent as defined in
				26 C.F.R.
				54.9801-2;
(f) The individual or their dependent who is
				currently enrolled in employer sponsored coverage is determined newly eligible
				for advance payment of premium tax credit pursuant to the criteria established
				in 45 C.F.R.
				155.420(d)(6)(iii);
(g) In addition to the special enrollment
				event in WAC
				284-43-1100(2)(d),
				a change in the individual's residence as the result of a permanent move
				results in new eligibility for previously unavailable qualified health
				plans.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter C - OPEN AND SPECIAL ENROLLMENT REQUIREMENTS › Section 284-43-1140 - Duration, notice requirements and effective dates of coverage for individual market special enrollment periods

Current through Register Vol. 24-14, July 15, 2024
(1) Special enrollment periods must not be
				shorter than sixty days from the date of the qualifying event.
(2) The effective date of coverage for those
				enrolling in an individual health plan through a special enrollment period is
				the first date of the next month after the premium is received by the issuer,
				unless one of the following exceptions applies:
(a) For those enrolling after the fifteenth
				of the month, the issuer must begin coverage not later than the first date of
				the second month after the application is received. Issuers may establish an
				earlier effective date at their discretion;
(b) For special enrollment of newborn,
				adopted or placed for adoption children, the date of birth, date of adoption or
				date of placement for adoption, as applicable, becomes the first effective date
				of coverage. The same requirement applies to foster children or children placed
				for foster care on qualified health plans;
(c) For special enrollment based on marriage
				or the beginning of a domestic partnership, and for special enrollment based on
				loss of minimum essential coverage, coverage must begin on the first day of the
				next month.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter D - PRIOR AUTHORIZATION AND UTILIZATION REVIEW › Section 284-43-2000 - Health care services utilization review-Generally

Current through Register Vol. 24-14, July 15, 2024
(1) Unless provided otherwise in this chapter
				or chapter 284-170 WAC with respect to utilization review of prescription drug
				services, this section governs issuer utilization review programs.
(2) These definitions apply to this section:
(a) "Concurrent care review request" means:
(i) Any request for an extension of a
				previously authorized inpatient stay or a previously authorized ongoing
				outpatient service, e.g., physical therapy, home health, etc.; and
(ii) Any request for authorization of
				continued withdrawal management or extension of inpatient or residential
				substance use disorder treatment services, including during the period of time
				that a behavioral health agency is arranging a transfer to an appropriate
				facility or lower level of care following an initial period of treatment under
				RCW  48.43.761.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter D - PRIOR AUTHORIZATION AND UTILIZATION REVIEW › Section 284-43-2020 - Drug utilization review-Generally

Current through Register Vol. 24-14, July 15, 2024
(1) These definitions apply to this section
				only:
(a) "Nonurgent review request" means
				any request for approval of care or treatment where the request is made in
				advance of the patient obtaining medical care or services, or a renewal of a
				previously approved request, and is not an urgent care request.
(b) "Urgent care review request" means any
				request for approval of care or treatment where the passage of time could
				seriously jeopardize the life or health of the patient, seriously jeopardize
				the patient's ability to regain maximum function or, in the opinion of a
				provider with knowledge of the patient's medical condition, would subject the
				patient to severe pain that cannot be adequately managed without the care or
				treatment that is the subject of the request.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter D - PRIOR AUTHORIZATION AND UTILIZATION REVIEW › Section 284-43-2021 - Prescription drug utilization management exception and substitution process

Current through Register Vol. 24-14, July 15, 2024
(1) For purposes of
				this section and WAC 284-43-2022:
(a)
				"Emergency fill" means a limited dispensed amount of medication that allows
				time for the processing of prescription drug utilization management.
(b) "Medically appropriate" means
				prescription drugs that under the applicable standard of care are appropriate:
(i) To improve or preserve an enrollee's
				health, life, or function;
(ii) To
				slow the deterioration of an enrollee's health, life, or function; or
(iii) For the early screening, prevention,
				evaluation, diagnosis, or treatment of a disease, condition, illness, or
				injury.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter D - PRIOR AUTHORIZATION AND UTILIZATION REVIEW › Section 284-43-2060 - Extenuating circumstances in prior authorization

Current through Register Vol. 24-14, July 15, 2024
(1) This section applies to health benefit
				plans as defined in
				RCW
				 48.43.005, contracts for limited health care
				services as defined in
				RCW
				 48.44.035, and standalone dental and
				stand-alone vision plans. This section applies to plans issued or renewed on or
				after January 1, 2018.
(2)A carrier
				or its designated or contracted representative must have an extenuating
				circumstances policy which eliminates the administrative requirement for a
				prior authorization of services when an extenuating circumstance prevents a
				participating provider or facility from obtaining a required prior
				authorization before a service is delivered.
(3)For purposes of this section, an
				extenuating circumstance means an unforeseen event or set of circumstances
				which adversely affects the ability of a participating provider or facility to
				request prior authorization prior to service delivery.
(4)When a carrier or its designated
				contracted representative is notified of the occurrence of an extenuating
				circumstance by a participating provider or facility, either before a claim is
				submitted or at the initiation of an appeal, the carrier or its designated or
				contracted representative must process the claim or appeal without any
				administrative requirement for a prior authorization.
(5) The following situations are extenuating
				circumstances and must be included in the extenuating circumstances policy:
(a)A participating provider or facility is
				unable to identify from which carrier or its designated or contracted
				representative to request a prior authorization;
(b)A participating provider or facility is
				unable to anticipate the need for a prior authorization before or while
				performing a service; and
(c)An
				enrollee is discharged from a facility and insufficient time exists for
				institutional or home health care services to receive approval prior to
				delivery of the service.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter E - ADVERSE BENEFIT DETERMINATION PROCESS REQUIREMENTS FOR NONGRANDFATHERED PLANS › Section 284-43-3000 - Scope and intent

Current through Register Vol. 24-14, July 15, 2024
Carriers and not grandfathered plans must follow the rules in
				  this subchapter in order to comply with the adverse benefit determination
				  process required by RCW  48.43.530 and 48.43.535. These rules apply to any
				  request for a review of an adverse benefit determination made by a carrier or
				  its designee on or after January 1, 2012.
Statutory Authority: RCW  48.02.060, 48.43.525, 48.43.530,
					 48.43.535, and The Patient Protection and Affordable Care Act,  P.L. 111-148, as
					 amended (2010). WSR 12-23-005 (Matter No. R 2011-11), § 284-43-500, filed
					 11/7/12, effective 11/20/12.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter E - ADVERSE BENEFIT DETERMINATION PROCESS REQUIREMENTS FOR NONGRANDFATHERED PLANS › Section 284-43-3010 - Definitions

Current through Register Vol. 24-14, July 15, 2024
These definitions apply to the sections in this subchapter,
				  WAC 284-43-3030 through
				  284-43-3190 and
				  284-43A-140:
"Adverse benefit determination" has the same meaning as
				  defined in
				  RCW
				   48.43.005 and WAC
				  284-43-0160.
"Appellant" means an applicant or a person covered as an
				  enrollee, subscriber, policy holder, participant, or beneficiary of an
				  individual or group health plan, and when designated, their representative.
				  Consistent with the requirements of WAC
				  284-43-2000, providers seeking
				  expedited review of an adverse benefit determination on behalf of an appellant
				  may act as the appellant's representative even if the appellant has not
				  formally notified the health plan or carrier of the designation.
"External appeal or review" means the request by an appellant
				  for an independent review organization to determine whether the carrier or
				  health plan's internal appeal decisions are correct.
"Internal appeal or review" means an appellant's request for
				  a carrier or health plan to review and reconsider an adverse benefit
				  determination.
Statutory Authority: RCW  48.02.060, 48.43.525, 48.43.530,
					 48.43.535, and The Patient Protection and Affordable Care Act,  P.L. 111-148, as
					 amended (2010). WSR 12-23-005 (Matter No. R 2011-11), § 284-43-505, filed
					 11/7/12, effective 11/20/12.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter E - ADVERSE BENEFIT DETERMINATION PROCESS REQUIREMENTS FOR NONGRANDFATHERED PLANS › Section 284-43-3030 - Review of adverse benefit determinations-Generally

Current through Register Vol. 24-14, July 15, 2024
(1) Each carrier must establish and implement
				a comprehensive process for the review of adverse benefit determinations. The
				process must offer an appellant the opportunity for both internal review and
				external review of an adverse benefit determination. The process must meet
				accepted national certification standards such as those used by the National
				Committee for Quality Assurance, except as otherwise required by this
				chapter.
(2) Neither a carrier nor
				a health plan may take or threaten to take any punitive action against a
				provider acting on behalf of or in support of an appellant.
(3) When the appeal is related to services
				the appellant is currently receiving as an inpatient, or for which a continuous
				course of treatment is medically necessary, coverage for those services must be
				continued while an adverse benefit determination is reviewed. Appellants must
				be notified that they may be responsible for the cost of services if the
				adverse benefit determination is upheld.
(4) A carrier must accept a request for
				internal review of an adverse benefit determination if the request is received
				within one hundred eighty days of the appellant's receipt of a determination
				under the plan. A carrier must notify an appellant of its receipt of the
				request within seventy-two hours of receiving the request.
(5) Each carrier and health plan must
				maintain a log of each adverse benefit determination review, its resolution,
				and the dates of receipt, notification, and determination.
(a) The carrier must make its review log
				available to the commissioner upon request in a form accessible by the
				commissioner. The log must be maintained by the carrier for a six-year
				period.
(b) Each carrier must
				identify, evaluate, and make available to the commissioner data and reports on
				trends in reviews for at least a six-year time frame, including the data on the
				number of adverse benefit determination reviews, the subject matter of the
				reviews and their outcome.
(c) When
				a carrier resolves issues related to an adverse benefit determination over the
				phone, without receiving a formal request for review, the carrier must include
				in these resolutions in its review log. A carrier's actions that are not in
				response to a member's call regarding an adverse benefit determination do not
				need to be included in the adverse benefit determination review log.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter E - ADVERSE BENEFIT DETERMINATION PROCESS REQUIREMENTS FOR NONGRANDFATHERED PLANS › Section 284-43-3050 - Explanation of right to review

Current through Register Vol. 24-14, July 15, 2024
A carrier must clearly communicate in writing the right to
				  request a review of an adverse benefit determination.
(1) At a minimum, the notice must be sent at
				the following times:
(a) Upon
				request;
(b) As part of the notice
				of adverse benefit determination;
(c) To new enrollees at the time of
				enrollment; and
(d) Annually
				thereafter to enrollees, group administrators, and subcontractors of the
				carrier.
(e) The notice requirement
				is satisfied if the description of the internal and external review process is
				included in or attached to the summary health plan descriptions, policy,
				certificate, membership booklet, outline of coverage or other evidence of
				coverage provided to participants, beneficiaries, or enrollees.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter E - ADVERSE BENEFIT DETERMINATION PROCESS REQUIREMENTS FOR NONGRANDFATHERED PLANS › Section 284-43-3070 - Notice and explanation of adverse benefit determination-General requirements

Current through Register Vol. 24-14, July 15, 2024
(1) A carrier must
				notify enrollees of an adverse benefit determination either electronically or
				by U.S. mail. The notification must be provided:
(a) To an appellant or their authorized
				representative;
(b) To the provider
				if the adverse benefit determination involves the preservice denial of
				treatment or procedure prescribed by the provider; and
(c) Whenever an adverse benefit determination
				relates to a protected individual, as defined in
				RCW
				 48.43.005, the health carrier must follow
				RCW
				 48.43.505.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter E - ADVERSE BENEFIT DETERMINATION PROCESS REQUIREMENTS FOR NONGRANDFATHERED PLANS › Section 284-43-3090 - Electronic disclosure and communication by carriers

Current through Register Vol. 24-14, July 15, 2024
(1) Except as otherwise provided by
				applicable law, rule, or regulation, a carrier furnishing documents through
				electronic media is deemed to satisfy the notice and disclosure requirements
				regarding adverse benefit determinations with respect to applicants, covered
				persons, and appellants or their representative, if the carrier takes
				appropriate and necessary measures reasonably calculated to ensure that the
				system for furnishing documents, including ensuring that its measures:
(a) Result in actual receipt of transmitted
				information (e.g., using return-receipt or notice of undelivered electronic
				mail features, conducting periodic reviews or surveys to confirm receipt of the
				transmitted information);
(b)
				Protect the confidentiality of personal information relating to the
				individual's accounts and benefits (e.g., incorporating into the system
				measures designed to preclude unauthorized receipt of or access to such
				information by individuals other than the individual for whom the information
				is intended);
(c) Provide notice in
				electronic or nonelectronic form, at the time a document is furnished
				electronically, that apprises the recipient of the significance of the document
				when it is not otherwise reasonably evident as transmitted (e.g., the attached
				document describes the internal review process used by your plan) and of the
				right to request and obtain a paper version of such document; and
(d) Furnish the appellant or their
				representative with a paper version of the electronically furnished documents
				if requested.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter E - ADVERSE BENEFIT DETERMINATION PROCESS REQUIREMENTS FOR NONGRANDFATHERED PLANS › Section 284-43-3130 - Exhaustion of internal review remedies

Current through Register Vol. 24-14, July 15, 2024
(1) If a carrier fails to strictly adhere to
				its requirements with respect to the internal review, the internal review
				process is deemed exhausted, and the appellant may request external review
				without receiving an internal review determination from the carrier or the
				health plan.
(2) A carrier may
				challenge external review requested under this section on the basis that its
				violations are de minimis, and do not cause and are not likely to cause,
				prejudice or harm to the appellant. The carrier or health plan may challenge
				external review on this basis either in court or to the independent review
				organization.
(a) This exception applies only
				if the external reviewer or court determines that the carrier has demonstrated
				that the violation was for good cause or was due to matters beyond the control
				of the carrier, and that the violation occurred in the context of an ongoing,
				good faith exchange of information between the carrier or health plan and the
				appellant.
(b) This exception is
				not available, and the challenge may not be sustained, if the violation is part
				of a pattern or practice of violations by the carrier or health plan.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter E - ADVERSE BENEFIT DETERMINATION PROCESS REQUIREMENTS FOR NONGRANDFATHERED PLANS › Section 284-43-3150 - Notice of internal review determination

Current through Register Vol. 24-14, July 15, 2024
Each carrier's review process must require delivery of
				  written notification of the internal review determination to the appellant. In
				  addition to the requirements of WAC
				  284-43-3070, the written
				  determination must include:
(1) The
				actual reasons for the determination;
(2) If applicable, instructions for obtaining
				further review of the determination, either through a second level of internal
				review, if applicable, or using the external review process;
(3) The clinical rationale for the decision,
				which may be in summary form; and
(4) Instructions on obtaining the clinical
				review criteria used to make the determination;
(5) A statement that the appellant has up to
				one hundred eighty days to file a request for external review, and that if
				review is not requested, the internal review decision is final and
				binding.
Statutory Authority: RCW  48.02.060, 48.43.525, 48.43.530,
					 48.43.535, and The Patient Protection and Affordable Care Act,  P.L. 111-148, as
					 amended (2010). WSR 12-23-005 (Matter No. R 2011-11), § 284-43-535, filed
					 11/7/12, effective 11/20/12.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter E - ADVERSE BENEFIT DETERMINATION PROCESS REQUIREMENTS FOR NONGRANDFATHERED PLANS › Section 284-43-3170 - Expedited review

Current through Register Vol. 24-14, July 15, 2024
(1) A carrier's
				internal and external review processes must permit an expedited review of an
				adverse benefit determination at any time in the review process, if:
(a) The appellant is currently receiving or
				is prescribed treatment or benefits that would end because of the adverse
				benefit determination; or
(b) The
				ordering provider for the appellant, regardless of their affiliation with the
				carrier or health plan, believes that a delay in treatment based on the
				standard review time may seriously jeopardize the appellant's life, overall
				health or ability to regain maximum function, or would subject the appellant to
				severe and intolerable pain; or
(c)
				The determination is related to an issue related to admission, availability of
				care, continued stay, or emergency health care services where the appellant has
				not been discharged from the emergency room or transport service.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter E - ADVERSE BENEFIT DETERMINATION PROCESS REQUIREMENTS FOR NONGRANDFATHERED PLANS › Section 284-43-3190 - Concurrent expedited review of adverse benefit determinations

Current through Register Vol. 24-14, July 15, 2024
(1) "Concurrent
				expedited review" means initiation of both the internal and external expedited
				review simultaneously to:
(a) Review of a
				decision made under WAC
				284-43-2000; or
(b) Review conducted during a patient's stay
				or course of treatment in a facility, the office of a health care professional
				or other inpatient or outpatient health care setting so that the final adverse
				benefit determination is reached as expeditiously as possible.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter E - ADVERSE BENEFIT DETERMINATION PROCESS REQUIREMENTS FOR NONGRANDFATHERED PLANS › Section 284-43-3210

Current through Register Vol. 24-14, July 15, 2024
Statutory Authority: RCW  48.02.060 and 48.43.530. WSR
					 15-24-072 (Matter No. R 2015-12), § 284-43-550, filed 11/25/15, effective
					 12/26/15. Statutory Authority: RCW  48.02.060, 48.43.525, 48.43.530, 48.43.535,
					 and The Patient Protection and Affordable Care Act,  P.L. 111-148, as amended
					 (2010). WSR 12-23-005 (Matter No. R 2011-11), § 284-43-550, filed 11/7/12,
					 effective 11/20/12.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter F - GRANDFATHERED HEALTH PLAN APPEAL PROCEDURES › Section 284-43-4000 - Application of subchapter F

Current through Register Vol. 24-14, July 15, 2024
Subchapter F applies to grandfathered health plans. For any
				  grandfathered health plan as defined in
				  RCW
				   48.43.005, a carrier may comply with
				  RCW
				   48.43.530 and
				  48.43.535 by using an appeal
				  process that conforms to the procedures and standards set forth in WAC
				  284-43-4020 through
				  284-43-4040 and
				  284-43A-150.
Statutory Authority: RCW  48.02.060, 48.43.525, 48.43.530,
					 48.43.535, and The Patient Protection and Affordable Care Act,  P.L. 111-148, as
					 amended (2010). WSR 12-23-005 (Matter No. R 2011-11), § 284-43-611, filed
					 11/7/12, effective 11/20/12.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter F - GRANDFATHERED HEALTH PLAN APPEAL PROCEDURES › Section 284-43-4020 - Grievance and complaint procedures-Generally

Current through Register Vol. 24-14, July 15, 2024
(1) Each carrier must adopt and implement a
				comprehensive process for the resolution of appeals of adverse determinations.
				This process shall meet accepted national certification standards such as those
				used by the National Committee for Quality Assurance except as otherwise
				required by this chapter.
(2) This
				process must conform to the provisions of this chapter and each carrier must:
(a) Provide a clear explanation of the appeal
				process upon request, upon enrollment to new enrollees, and annually to
				enrollees and subcontractors of the carrier.
(b) Ensure that the appeal process is
				accessible to enrollees who are limited-English speakers, who have literacy
				problems, or who have physical or mental disabilities that impede their ability
				to file an appeal.
(c) Implement
				procedures for registering and responding to oral and written appeals in a
				timely and thorough manner including the notification of an enrollee that an
				appeal has been received.
(d)
				Assist the enrollee with all appeal processes.
(e) Cooperate with any representative
				authorized in writing by the enrollee.
(f) Consider all information submitted by the
				enrollee or representative.
(g)
				Investigate and resolve all appeals.
(h) Provide information on the enrollee's
				right to obtain second opinions.
(i) Track each appeal until final resolution;
				maintain, and make accessible to the commissioner for a period of three years,
				a written log of all appeals; and identify and evaluate trends in appeals. The
				written log may be maintained electronically.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter F - GRANDFATHERED HEALTH PLAN APPEAL PROCEDURES › Section 284-43-4060

Current through Register Vol. 24-14, July 15, 2024
Statutory Authority: RCW  48.02.060 and 48.43.530. WSR
					 15-24-072 (Matter No. R 2015-12), § 284-43-630, filed 11/25/15, effective
					 12/26/15. Statutory Authority: RCW  48.02.060 and 48.53.535(10). WSR 08-07-101
					 (Matter R 2006-11), § 284-43-630, filed 3/19/08, effective 4/19/08.
					 Statutory Authority: RCW  48.02.060, 48.18.120, 48.20.450, 48.20.460, 48.30.010,
					 48.44.050, 48.46.100, 48.46.200, 48.43.505, 48.43.510, 48.43.515, 48.43.520,
					 48.43.525, 48.43.530, 48.43.535. WSR 01-03-033 (Matter No. R 2000-02), §
					 284-43-630, filed 1/9/01, effective
					 7/1/01.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter G - GRIEVANCES › Section 284-43-4500 - Definition

Current through Register Vol. 24-14, July 15, 2024
This definition applies to subchapter G. "Grievant" means a
				  person filing a grievance as defined in WAC
				  284-43-0160, and who is not an
				  appellant under either subchapter E or F of this chapter.
Statutory Authority: RCW  48.02.060, 48.43.525, 48.43.530,
					 48.43.535, and The Patient Protection and Affordable Care Act,  P.L. 111-148, as
					 amended (2010). WSR 12-23-005 (Matter No. R 2011-11), § 284-43-711, filed
					 11/7/12, effective 11/20/12.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter G - GRIEVANCES › Section 284-43-4520 - Grievance process-Generally

Current through Register Vol. 24-14, July 15, 2024
This section applies to a health benefit plan regardless of
				  its status as grandfathered or nongrandfathered.
(1) Each carrier and health plan must offer
				applicants, covered persons, and providers a way to resolve
				grievances.
(2) Each carrier must
				maintain a log or otherwise register grievances, and retain the log or record
				for three years. It must be available for review by the commissioner upon
				request. The log must provide sufficient detail to permit the commissioner to
				determine whether the carrier is administering its grievance process in
				accordance with the law, and in good faith, and to identify whether and in what
				manner the carrier adjusted practices or requirements in response to a
				grievance.
(3) Grievances are not
				adverse benefit determinations and do not establish the right to internal or
				external review of a carrier or health plan's resolution of the
				grievance.
(4) Nothing in this
				section prohibits a carrier from creating or using its own system to categorize
				the nature of grievances in order to collect data, if the system permits
				reporting of the data specified in subsection (2) of this section.
Statutory Authority: RCW  48.02.060, 48.43.525, 48.43.530,
					 48.43.535, and The Patient Protection and Affordable Care Act,  P.L. 111-148, as
					 amended (2010). WSR 12-23-005 (Matter No. R 2011-11), § 284-43-721, filed
					 11/7/12, effective 11/20/12.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter H - HEALTH PLAN BENEFITS › Section 284-43-5000 - Preexisting condition limitations

Current through Register Vol. 24-14, July 15, 2024
For health plans offered, issued or renewed on or after
				  January 1, 2014, issuers must not condition or otherwise limit enrollment based
				  on preexisting health conditions.
Statutory Authority: RCW  48.02.060, 48.18.120(2),
					 48.20.450, 48.43.0211, 48.43.720(3), 48.44.050, 48.46.200,  45 C.F.R. §§
												147.104, 147.106, 155.420, and 155.725. WSR 14-01-042 (Matter No.
					 R 2013-02), §
											284-170-400, filed 12/11/13, effective
					 1/1/14.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter H - HEALTH PLAN BENEFITS › Section 284-43-5020 - Recognizing the exercise of conscience by purchasers of basic health plan services and ensuring access for all enrollees to such services

Current through Register Vol. 24-14, July 15, 2024
(1) All carriers
				required pursuant to law to offer and file with the commissioner a plan
				providing benefits identical to the basic health plan services (the model plan)
				shall file for such plan a full description of the process it will use to
				recognize an organization or individual's exercise of conscience based on a
				religious belief or conscientious objection to the purchase of coverage for a
				specific service. This process may not affect a nonobjecting enrollee's access
				to coverage for those services.
(2)
				A religiously sponsored carrier who elects, for reasons of religious belief,
				not to participate in the provision of certain services otherwise included in
				the model plan, shall file for such plan a description of the process by which
				enrollees will have timely access to all services in the model plan.
(3) The commissioner will not disapprove
				processes that meet the following criteria:
(a) Enrollee access to all basic health plan
				services is not impaired in any way;
(b) The process meets notification
				requirements specified in RCW  48.43.065; and
(c) The process relies on sound actuarial
				principles to distribute risk.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter H - HEALTH PLAN BENEFITS › Section 284-43-5040

Current through Register Vol. 24-14, July 15, 2024
Statutory Authority: RCW  48.02.060, 48.20.450, 48.20.460,
					 48.30.010, 48.44.050, 48.46.200, 2000 c 79 § 26, and RCW  48.30.040,
					 48.44.110, 48.46.400. WSR 01-03-032 (Matter No. R 2000-04), § 284-43-815,
					 filed 1/9/01, effective 2/9/01.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter H - HEALTH PLAN BENEFITS › Section 284-43-5060 - General prescription drug benefit requirements

Current through Register Vol. 24-14, July 15, 2024
A health carrier must not offer, renew, or issue a health
				  benefit plan providing a prescription drug benefit, which the commissioner
				  determines results or can reasonably be expected to result in an unreasonable
				  restriction on the treatment of patients. A carrier may restrict prescription
				  drug coverage based on contract or plan terms and conditions that otherwise
				  limit coverage, such as a preexisting condition waiting period, or medical
				  necessity.
(1) A carrier must ensure
				that a prescription drug benefit covers Federal Drug Administration approved
				prescribed drugs, medications or drug therapies that are the sole prescription
				drug available for a covered medical condition.
(2) A prescription drug benefit that only
				covers generic drugs constitutes an unreasonable restriction on the treatment
				of patients.
(3) A prescription
				drug benefit or formulary must not exclude coverage for a nonformulary drug or
				medication if the only formulary drug available for an enrollee's covered
				condition is one that the enrollee cannot tolerate or that is not clinically
				efficacious for the enrollee.
(4)
				Nothing in this chapter is intended to limit or deter the use of "Dispense as
				Written" prescriptions, subject to the terms and conditions of the health
				plan.
Statutory Authority: RCW  48.02.060, 48.02.062, 48.18.140,
					 48.43.525, 48.44.050, 48.44.440(2), 48.44.460(2), 48.46.200, and 48.46.510. WSR
					 12-21-019 (Matter No. R 2012-03), § 284-43-816, filed 10/8/12, effective
					 11/8/12.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter H - HEALTH PLAN BENEFITS › Section 284-43-5100 - Formulary change

Current through Register Vol. 24-14, July 15, 2024
An issuer is not required to use a formulary as part of its
				  prescription drug benefit design. If a formulary is used, an issuer must, at a
				  minimum, comply with these requirements when a formulary change occurs.
(1) In addition to the requirements set forth
				in WAC
				284-30-450,
				an issuer must not exclude or remove a medication from its formulary if the
				medication is the sole prescription medication option available to treat a
				disease or condition for which the health benefit plan, policy or agreement
				otherwise provides coverage, unless the medication or drug is removed because
				the drug or medication becomes available over-the-counter, is proven to be
				medically inefficacious, or for documented medical risk to patient
				health.
(2) If a drug is removed
				from an issuer's formulary for a reason other than withdrawal of the drug from
				the market, availability of the drug over-the-counter, or the issue of black
				box warnings by the Federal Drug Administration, an issuer must continue to
				cover a drug that is removed from the issuer's formulary for the time period
				required for an enrollee who is taking the medication at the time of the
				formulary change to use an issuer's exception request process to request
				continuation of coverage for the removed medication, and receive a decision
				through that process, unless patient safety requires swifter
				replacement.
(3) Formularies and
				related preauthorization information must be posted on an issuer or issuer's
				contracted pharmacy benefit manager website and must be current. Unless the
				removal is done on an immediate or emergency basis or because a generic
				equivalent becomes available without prior notice, formulary changes must be
				posted sixty days before the effective date of the change. In the case of an
				emergency removal, the change must be posted as soon as practicable, without
				unreasonable delay.
(4) An issuer
				must make current formulary information electronically available for loading
				into e-prescribing applications/electronic health records utilizing the
				National Council for Prescription Drug Programs (NCPDP) formulary and benefit
				standard transaction. Issuers must include all required data elements as well
				as the following information, to the extent supported by the transaction:
(a) Tier level;
(b) Contract exclusions;
(c) Quantity limits;
(d) Preauthorization required;
(e) Preferred/step therapy.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter H - HEALTH PLAN BENEFITS › Section 284-43-5130 - Health plan disclosure requirements

Current through Register Vol. 24-14, July 15, 2024
(1) Health plan disclosure information must
				comply with and include each requirement listed in RCW  48.43.510.
(2) Health plan disclosures must be current
				and:
(a) Provided by paper copy upon
				request;
(b) Provided by electronic
				communication upon request;
(c)
				Clearly identified as health plan disclosures; and
(d) Prominently displayed and accessible on
				the carrier's web site.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter H - HEALTH PLAN BENEFITS › Section 284-43-5150 - Unfair practice relating to health coverage

Current through Register Vol. 24-14, July 15, 2024
(1) It is an unfair practice for any health
				carrier to restrict, exclude, or reduce coverage or benefits under any health
				plan on the basis of sex. By way of example, a health plan providing generally
				comprehensive coverage of prescription drugs and prescription devices
				restricts, excludes, or reduces coverage or benefits on the basis of sex if it
				fails to provide prescription contraceptive coverage that complies with this
				regulation.
An example of a plan that provides generally comprehensive
				  coverage of prescription drugs is a plan that covers prescription drugs but
				  excludes some categories such as weight reduction or smoking cessation.
(2)
(a) Health plans providing generally
				comprehensive coverage of prescription drugs and/or prescription devices shall
				not exclude prescription contraceptives or cover prescription contraceptives on
				a less favorable basis than other covered prescription drugs and prescription
				devices. Coverage of prescription contraceptives includes coverage for medical
				services associated with the prescribing, dispensing, delivery, distribution,
				administration and removal of a prescription contraceptive to the same extent,
				and on the same terms, as other outpatient services.
(b) Health plans may not impose benefit
				waiting periods, limitations, or restrictions on prescription contraceptives
				that are not required or imposed on other covered prescription drugs and
				prescription devices.
(c) Health
				plans may not require cost sharing, such as copayments or deductibles, for
				prescription contraceptives and for services associated with the prescribing,
				dispensing, delivery, distribution, administration, and removal of the
				prescription contraceptives.
(d)
				Health carriers may use, and health plans may limit coverage to, a closed
				formulary for prescription contraceptives if they otherwise use a closed
				formulary, but the formulary shall cover each of the types of prescription
				contraception as defined in (e) of this subsection.
(e) For purposes of subsections (1) and (2)
				of this section, "prescription contraceptives" include United States Food and
				Drug Administration (FDA) approved contraceptive drugs, devices, and
				prescription barrier methods, including contraceptive products declared safe
				and effective for use as emergency contraception by the FDA.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter H - HEALTH PLAN BENEFITS › Section 284-43-5151 - Unfair practice relating to gender affirming treatment and services

Current through Register Vol. 24-14, July 15, 2024
When a treatment or service is gender affirming treatment, as
				  defined in
				  RCW
				   48.43.0128, it is an unfair practice for any
				  health carrier to:
(1) Deny or limit
				coverage, issue automatic denials of coverage, impose additional cost sharing
				or other limitations or restrictions on coverage, or deny or limit coverage of
				a claim, if gender affirming treatment is:
(a) Prescribed to an individual because of,
				related to, or consistent with a person's gender expression or identity, as
				defined in
				RCW
				 49.60.040;
(b) Medically necessary; and
(c) Prescribed in accordance with accepted
				standards of care;
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter H - HEALTH PLAN BENEFITS › Section 284-43-5170 - Prescription drug benefit disclosures

Current through Register Vol. 24-14, July 15, 2024
(1) A carrier must include the following
				information in the certificate of coverage issued for a health benefit plan,
				policy or agreement that includes a prescription drug benefit in addition to
				those required elsewhere in Titles 48 RCW and 284 WAC. The commissioner may
				disapprove any contract issued on or after January 1, 2018, if the requirements
				of this subsection are not met.
(a) A clear
				statement explaining that the health benefit plan uses the following in its
				coverage of drugs (as applicable):
(i)
				Exclusion of certain brand name or other medications from its
				formulary;
(ii) Therapeutic drug
				substitution;
(iii) Incentives for
				use of generic drugs (such as step-therapy protocols);
(iv) Prior authorization
				requirements;
(v) Mid-plan year
				formulary changes; or
(vi) Other
				limits of its prescription drug benefit.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter H - HEALTH PLAN BENEFITS › Section 284-43-5200 - Anticancer medication

Current through Register Vol. 24-14, July 15, 2024
A carrier and health plan must cover prescribed,
				  self-administered anticancer medication that is used to kill or slow the growth
				  of cancerous cells on at least a comparable basis to the plan's coverage for
				  the delivery of cancer chemotherapy medications administered in a clinical or
				  medical setting.
(1) A carrier may not
				impose dollar limits, copayments, deductibles or coinsurance requirements on
				coverage for orally administered anticancer drugs or chemotherapy that are less
				favorable to an insured or enrollee than the dollar limits, copayments,
				deductibles or coinsurance requirements that apply to coverage for anticancer
				medication or chemotherapy that is administered intravenously or by
				injection.
(2) A carrier may not
				reclassify an anticancer medication or increase an enrollee's out-of-pocket
				costs as a method of compliance with the requirements of this
				section.
Statutory Authority: RCW  48.02.060, 48.02.062, 48.18.140,
					 48.43.525, 48.44.050, 48.44.440(2), 48.44.460(2), 48.46.200, and 48.46.510. WSR
					 12-21-019 (Matter No. R 2012-03), § 284-43-840, filed 10/8/12, effective
					 11/8/12.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter H - HEALTH PLAN BENEFITS › Section 284-43-5400 - Purpose and scope

Current through Register Vol. 24-14, July 15, 2024
For plan years beginning on or after January 1, 2014, each
				  nongrandfathered health benefit plan offered, issued, or renewed to small
				  employers or individuals, both inside and outside the Washington health benefit
				  exchange, must provide coverage for a package of essential health benefits,
				  pursuant to RCW 48.43.-715. WAC 284-43-5400 through
				  284-43-5820
				  explains the regulatory standards defining this coverage, and establishes
				  supplementation of the base-benchmark plan consistent with
				  RCW
				   48.43.715, and the parameters of the state
				  EHB-benchmark plan.
(1) WAC
				284-43-5400 through
				284-43-5820
				do not apply to a health benefit plan that provides excepted benefits as
				described in section 2722 of the federal Public Health Service Act (42 U.S.C. Sec. 300gg-21), to a health benefit plan that qualifies as a grandfathered
				health plan as defined in
				RCW
				 48.43.005, nor to a health plan excluded from
				the definition of "health plan" as defined in
				RCW
				 48.43.005.
(2) WAC 284-43-5400 through
				284-43-5820
				do not require provider reimbursement at the same levels negotiated by the
				base-benchmark plan's issuer for their plan.
(3) WAC 284-43-5400 through
				284-43-5820
				do not require a health benefit plan to exclude the services or treatments from
				coverage that are excluded in the base-benchmark plan.
Statutory Authority: RCW  48.02.060, 48.21.241, 48.21.320,
					 48.44.050, 48.44.341, 48.44.460, 48.46.200, 48.46.291, 48.46.530, 48.43.715,
					 and  Pub. L. No. 111-148, 124 Stat. 119 (Mar. 23, 2010) (PPACA), as amended by
					 the Health Care and Education Reconciliation Act (HCERA),  Pub. L. No. 111-152,
					 124 Stat. 1029 (Mar. 30, 2010), in particular § 1302 of PPACA, §
					 10104 (b)(1) (HCERA). WSR 13-15-025 (Matter No. R 2012-17), § 284-43-849,
					 filed 7/9/13, effective 7/10/13.