Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter J - HEALTH PLANS, STAND-ALONE DENTAL PLANS AND STAND-ALONE VISION PLANS-FILING REQUIREMENTS › Section 284-43-6520 - Definitions

Current through Register Vol. 24-14, July 15, 2024
For the purpose of this subchapter:
(1) "Contract" means an agreement to provide
				health care services or pay health care costs for or on behalf of a
				"subscriber" or group of "subscribers" and such eligible dependents as may be
				included therein.
(2) "Contract
				form" means the prototype of a "contract" and any associated riders and
				endorsements filed with the commissioner by a carrier.
(3) "Covered person" or "enrollee" has the
				same meaning as that contained in RCW  48.43.005.
(4) "Dependent" has the same meaning as that
				contained in RCW  48.43.005.
(5)
				"Health carrier" or "carrier" means an insurer that issues disability insurance
				regulated under chapter 48.20 or 48.21 RCW, a health care service contractor as
				defined in RCW  48.44.010, or a health maintenance organization as defined in
				RCW  48.46.020, and includes "issuers" as that term is used in the federal
				Patient Protection and Affordable Care Act (Public Law 111-148).
(6) "Large group contracts" or "large group
				plans" include group health benefit plans and stand-alone dental plans or
				stand-alone vision plans that are not small group plans and are not individual
				plans.
(7) "Limited health care
				service contractor" means a health care service contractor that offers one and
				only one limited health care service.
(8) "Negotiated contract" form means a health
				benefit plan or stand-alone dental plan or stand-alone vision plan where
				benefits and other terms and conditions, including the applicable rate
				schedules, are negotiated and agreed to by the carrier or limited health care
				service contractor and the policy or contract holder. The only plans that
				carriers can negotiate are large group plans. The negotiated policy form and
				associated rate schedule must otherwise comply with state and federal laws
				governing the content and schedule of rates for the negotiated plans.
(9) "Premium" means all sums charged,
				received, or deposited as consideration for a contract or the continuance of a
				contract. Any assessment, or any "membership," "policy," "survey,"
				"inspection," "service," or similar fee or charge made by the carrier in
				consideration for a contract is part of the premium. Premium does not include
				amounts paid as enrollee point-of-service cost-sharing.
(10) "Rate" or "rates" means all
				classification manuals, rate manuals, rating schedules, class rates, and rating
				rules.
(11) "Rate schedule" means
				the schedule of rates that includes the description of methodology used to
				obtain the premium rate for a specific individual or group, if given the
				necessary information such as the demographic data and plan design of the
				individual or group. For a single negotiated contract form, the rate schedule
				also includes the premium for the employer.
(12) "Small employer" means an employer that
				fits within the definition of small employer as that term is used in the
				federal Patient Protection and Affordable Care Act (Public Law 111-148).
(13) "Small group plans"
				means the class of "group contracts" issued to "small employers." For the
				purposes of this section, "small group contracts" and "small group plans" also
				apply to stand-alone dental plans or stand-alone vision plans.
(14) "Stand-alone dental plan" means coverage
				for a set of benefits limited to oral care including, but not necessarily
				limited to, pediatric oral care.
(15) "Stand-alone vision plan" means coverage
				for a set of benefits limited to vision care including, but not necessarily
				limited to, materials.
(16)
				"Subscriber" means a person on whose behalf a "contract" or "certificate" is
				issued.
Statutory Authority: RCW  48.02.060, 48.44.050, 48.46.200,
					 48.44.020 (2)(d), 48.44.022, 48.44.023, 48.46.060 (3)(d) and (5), 48.46.064,
					 48.46.066, and   2015 c  19.