reglab/statecodes huggingface dataset:
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter H - HEALTH PLAN BENEFITS › Section 284-43-5975 - Designation of responsible employee and adoption of grievance procedures

Current through Register Vol. 24-14, July 15, 2024
(1) Each issuer
				shall designate at least one employee to coordinate its efforts to comply with
				and carry out its responsibilities under
				RCW
				 48.43.0128 and WAC 284-43-5935 through
				284-43-5980, including the investigation of any grievance communicated to it
				alleging noncompliance with
				RCW
				 48.43.0128 or WAC 284-43-5935 through
				284-43-5980 or alleging any action that would be prohibited by
				RCW
				 48.43.0128 or WAC 284-43-5935 through
				284-43-5980.
(2) Each issuer shall
				adopt grievance procedures that incorporate appropriate due process standards
				and that provide for the prompt and equitable resolution of grievances alleging
				any action that would be prohibited by RCW 48.43.-0128 or WAC 284-43-5935
				through 284-43-5980. An issuer whose grievance procedures comply with
				45
				C.F.R. 92.7 as in effect on January 1, 2017,
				will be deemed compliant with this subsection.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter H - HEALTH PLAN BENEFITS › Section 284-43-5980 - Notice requirement

Current through Register Vol. 24-14, July 15, 2024
(1) An
				issuer offering a plan shall take appropriate initial and continuing steps to
				notify enrollees, applicants, and members of the public of the following:
(a) The issuer does not discriminate on the
				basis of race, color, national origin, disability, age, sex, gender identity,
				or sexual orientation in its benefits and services;
(b) The issuer provides appropriate auxiliary
				aids and services, including qualified interpreters for individuals with
				disabilities and information in alternate formats, free of charge and in a
				timely manner, when such aids and services are necessary to ensure an equal
				opportunity to participate to individuals with disabilities;
(c) The issuer provides language assistance
				services, including translated documents and oral interpretation, free of
				charge and in a timely manner, when such services are necessary to provide
				meaningful access to individuals with limited-English proficiency;
(d) How to obtain the aids and services in
				(b) and (c) of this subsection;
(e)
				An identification of, and contact information for, the employee responsible for
				compliance with
				RCW
				 48.43.0128 and WAC 284-43-5935 through
				284-43-5980;
(f) How to file a
				grievance with the issuer related to the issuer's compliance with
				RCW
				 48.43.0128 and WAC 284-43-5935 through
				284-43-5980; and
(g) How to file a
				complaint with the commissioner related to the issuer's compliance with
				RCW
				 48.43.0128 and WAC 284-43-5935 through this
				section or with the federal Department of Health and Human Services, Office of
				Civil Rights related to the issuer's compliance with  42 U.S.C. Sec. 18119  (Sec.
				1557 of the Affordable Care Act).
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter I - HEALTH PLAN RATES › Section 284-43-6000 - Authority and purpose

Current through Register Vol. 24-14, July 15, 2024
This subchapter is adopted under the general authority of
				  RCW
				   48.02.060,
				  48.44.017,
				  48.44.020,
				  48.44.050,
				  48.46.060,
				  48.46.062,
				  48.46.200, and
				  48.43.733. Its purpose is to
				  provide guidelines for the implementation of RCW 48.44.-017(2), 48.44.020(3),
				  48.44.022, 48.44.023, 48.44.040, 48.46.060 (4) and (6), 48.46.062(2),
				  48.46.064, 48.46.066, 48.18.110, 48.18.480, and 48.43.733 as to the filing of
				  grandfathered individual and small group health plans applicable under
				  RCW
				   48.44.017,
				  48.44.022, and
				  48.44.023 by health care service
				  contractors, grandfathered individual and small group health plans applicable
				  under RCW
				   48.46.062,
				  48.46.064, and
				  48.46.066 by health maintenance
				  organizations, stand-alone dental plans and stand-alone vision plans offered by
				  health care service contractors, health maintenance organizations, and
				  disability carriers to individuals and small groups, and the calculations and
				  evaluations of premium rates for these contracts.
Statutory Authority: RCW  48.02.060, 48.18.110, 48.44.020,
					 48.44.050, 48.46.060, 48.46.200. WSR 08-20-071 (Matter No. R 2008-08), §
					 284-43-901, filed 9/25/08, effective
					 10/26/08.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter I - HEALTH PLAN RATES › Section 284-43-6010 - Applicability and scope

Current through Register Vol. 24-14, July 15, 2024
This subchapter applies to grandfathered individual and
				  small group health benefit plans offered by health care service contractors and
				  health maintenance organizations transacting business in this state under
				  chapter 48.44 or 48.46 RCW, stand-alone dental plans and stand-alone vision
				  plans. This subchapter applies to such plans purchased directly by individuals
				  and small employers.
Statutory Authority: RCW  48.02.060, 48.44.050, and
					 48.46.200. WSR 05-07-006 (Matter No. R 2004-05), § 284-43-905, filed
					 3/3/05, effective 4/3/05. 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 and 48.46.066. WSR 98-04-011 (Matter No. R 97-2), § 284-43-905,
					 filed 1/23/98, effective 3/1/98.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter I - HEALTH PLAN RATES › Section 284-43-6040 - Demonstration that benefits provided are not reasonable in relation to the amount charged for a contract per RCW 48.44.020 and 48.46.060

Current through Register Vol. 24-14, July 15, 2024
(1) The provisions of this section are in
				addition to the requirements set forth in RCW  48.44.022, 48.44.023, 48.46.064,
				and 48.46.066.
(2) Benefits will be
				found not to be unreasonable if the projected earned premium for the rate
				renewal period is equal to the following:
(a)
				An actuarially sound estimate of incurred claims associated with the filing for
				the rate renewal period, where the actuarial estimate of claims recognizes, as
				applicable, the savings and costs associated with managed care provisions of
				the plans included in the filing; plus
(b) An actuarially sound estimate of
				prudently incurred expenses associated with the plans included in the filing
				for the rate renewal period, where the estimate is based on an equitable and
				consistent expense allocation or assignment methodology; plus
(c) An actuarially sound provision for
				contribution to surplus, contingency charges, or risk charges, where the
				justification recognizes the carrier's investment earnings on assets other than
				those related to claim reserves or other similar liabilities; minus
(d) An actuarially sound estimate of the
				forecasted investment earnings on assets related to claim reserves or other
				similar liabilities for the plans included in the filing for the rate renewal
				period.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter I - HEALTH PLAN RATES › Section 284-43-6060 - General contents of all filings (Recodified)

Current through Register Vol. 24-14, July 15, 2024
Statutory Authority: RCW  48.02.060, 48.18.110, 48.44.020,
					 48.44.050, 48.46.060, 48.46.200. WSR 08-20-071 (Matter No. R 2008-08), §
					 284-43-925, filed 9/25/08, effective 10/26/08. Statutory Authority: RCW
					  48.02.060, 48.44.050, and 48.46.200. WSR 05-07-006 (Matter No. R 2004-05),
					 § 284-43-925, filed 3/3/05, effective 4/3/05. 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 and 48.46.066. WSR 98-04-011 (Matter No. R
					 97-2), § 284-43-925, filed 1/23/98, effective
					 3/1/98.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter I - HEALTH PLAN RATES › Section 284-43-6080 - Issuer filing of attestation form, transparency tools (Recodified)

Current through Register Vol. 24-14, July 15, 2024
Statutory Authority: RCW  48.02.060, 48.43.340, and
					 48.44.050. WSR 15-21-095 (Matter No. R 2015-03), § 284-43-927, filed
					 10/21/15, effective 1/1/16.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter I - HEALTH PLAN RATES › Section 284-43-6100 - Contents of individual and small group filings

Current through Register Vol. 24-14, July 15, 2024
Under RCW  48.44.022 and 48.46.064 the experience of all
				  individual plans must be pooled. Under RCW  48.44.023 and 48.46.066 the
				  experience of all small group plans must be pooled. Filings for individual
				  plans must include each individual plan rate schedule. Filings for small group
				  plans must include base rates and annual base rate changes in dollar and
				  percentage amounts for each small group plan. Each individual and small group
				  filing must include the following information and documents:
(1) An actuarially sound estimate of incurred
				claims. Experience data, assumptions, and justifications of the carrier's
				projected incurred claims must be provided in a manner consistent with the
				carrier's rate-making methodology and incorporate the following elements:
(a) A brief description of the carrier's
				rate-making methodology, including identification of the data used and the
				kinds of assumptions and projections made.
(b) The number of subscribers by family size,
				or covered persons for the plans included in the filing. These figures must be
				shown for each month or quarter of the experience period and the prior two
				periods if not included in previous filings. This data must be presented in
				aggregate for the plans included in the filing and in aggregate for all of the
				carrier's plans.
(c) Earned premium
				for each month or quarter of the experience period and the prior two periods if
				not included in previous filings, for the plans included in the
				filing.
(d) An estimate of the
				adjusted earned premium for each month or quarter of the experience period and
				prior two periods for the plans included in the filing.
(e) Claims data for each month or quarter of
				the experience period and the prior two periods. Examples of claims data are
				incurred claims, capitation payments, utilization data, unit cost data, and
				staffing data. The specific data elements included in the filing must be
				consistent with the carrier's rate-making methodology.
(f) Documentation and justification of any
				adjustments made to the experience data.
(g) Documentation and justification of the
				factors and methods used to forecast incurred claims.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter I - HEALTH PLAN RATES › Section 284-43-6120 - Experience records (Recodified)

Current through Register Vol. 24-14, July 15, 2024
Statutory Authority: RCW  48.02.060, 48.44.050, and
					 48.46.200. WSR 05-07-006 (Matter No. R 2004-05), § 284-43-935, filed
					 3/3/05, effective 4/3/05. 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 and 48.46.066. WSR 98-04-011 (Matter No. R 97-2), § 284-43-935,
					 filed 1/23/98, effective 3/1/98.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter I - HEALTH PLAN RATES › Section 284-43-6140 - Evaluating experience data (Recodified)

Current through Register Vol. 24-14, July 15, 2024
Statutory Authority: RCW  48.02.060, 48.44.050, and
					 48.46.200. WSR 05-07-006 (Matter No. R 2004-05), § 284-43-940, filed
					 3/3/05, effective 4/3/05. 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 and 48.46.066. WSR 98-04-011 (Matter No. R 97-2), § 284-43-940,
					 filed 1/23/98, effective 3/1/98.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter I - HEALTH PLAN RATES › Section 284-43-6160 - Summary for individual and small group contract filings (Recodified)

Current through Register Vol. 24-14, July 15, 2024
Statutory Authority: RCW  48.02.060, 48.18.110, 48.44.020,
					 48.44.050, 48.46.060, 48.46.200. WSR 08-20-071 (Matter No. R 2008-08), §
					 284-43-945, filed 9/25/08, effective 10/26/08. Statutory Authority: RCW
					  48.02.060, 48.44.050, and 48.46.200. WSR 05-07-006 (Matter No. R 2004-05),
					 § 284-43-945, filed 3/3/05, effective 4/3/05. 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 and 48.46.066. WSR 98-04-011 (Matter No. R
					 97-2), § 284-43-945, filed 1/23/98, effective
					 3/1/98.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter I - HEALTH PLAN RATES › Section 284-43-6200 - Geographic rating area factor development (Recodified)

Current through Register Vol. 24-14, July 15, 2024
Statutory Authority: RCW  48.02.060, 48.44.050, 48.46.200,
					 and  45 C.F.R. 147.102. WSR 13-11-003 (Matter No. R 2013-01), §
											284-170-250, filed 5/1/13, effective
					 6/1/13.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter I - HEALTH PLAN RATES › Section 284-43-6220 - Geographic rating area designation (Recodified)

Current through Register Vol. 24-14, July 15, 2024
Statutory Authority: RCW  48.02.060, 48.44.050, 48.46.200,
					 and  45 C.F.R. 147.102. WSR 13-11-003 (Matter No. R 2013-01), §
											284-170-252, filed 5/1/13, effective
					 6/1/13.
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 284-43-6500 - Applicability and scope

Current through Register Vol. 24-14, July 15, 2024
This sub-chapter is adopted under the general authority of
				  RCW
				   48.02.060. This subchapter 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, standalone dental plans and
				  stand-alone vision plans. This sub-chapter also applies to plans offered by
				  carriers under the requirements of
				  RCW
				   48.43.733.
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.
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 284-43-6540 - Summary for group contract filings other than small group contract filings

Current through Register Vol. 24-14, July 15, 2024
Groups Other Than Small Groups Filing
				  Summary
Carrier Name
___________________________
Address
___________________________
___________________________
___________________________
Contract Holder/Pool Category and Name (Check One
							 Box)
[] Single Employer Group:
Employer Name:
[] Multiemployer other than Association/Trust
							 Groups
Group Pool Name:
[] Association/Trust Groups
Association/Trust Group Name:
Contract Form Number
____________________
Rate Form Number (if different from Contract Form
							 Number)
____________________
Product Name
____________________
If additional space is required to list the contract/rate
				  form number and product name, attach a separate sheet.
Rate Renewal Period:
From: ________
To: _________
Date Submitted:
_____
Type of Filing (Check One Box)
[] New Group Contract
[] Revision of Existing Group Contract
Proposed Rate Schedules:
Attach a separate sheet
				  to list all proposed tier rates.
Rate Summary
Current Rate (Composite per employee or per
							 member)
$
per member per month
Percentage Rate Change
%
New Rate
$
per member per month
Average Number of Enrollees Each Month During the
							 Experience Period (If the average number of enrollees is equal to or less than
							 fifty, explain why this is not a small group, as defined in RCW
							  48.43.005.)
_____________
Anticipated Loss Ratio
%
Portion of carrier's total enrollment affected
%
Portion of carrier's total premium revenue
							 affected
%
Summary of Contract Experience
Experience Period
First Prior Period
Second Prior Period
From To
From To
From To
Member Months
Billed Premium
Incurred Claims
Expenses
Gain/Loss
Experience Refund/Credit or Recoupment
Earned Premium (Billed Premium -/+ Refund/Credit or
						  Recoupment)
Loss Ratio Percentage
Attach comments or additional
							 information.
Preparer's Information
Name:
________________
Title:
________________
Telephone Number:
________________
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.
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 284-43-6560 - When a carrier is required to file

Current through Register Vol. 24-14, July 15, 2024
(1) All rates and forms of group health
				benefit plans other than small group plans and all stand-alone dental and
				stand-alone vision plans offered by a health carrier or limited health care
				service contractor as defined in RCW  48.44.035 and modification of a contract
				form or rate must be filed before the contract form is offered for sale to the
				public and before the rate schedule is used.
(2) Filings of negotiated contract forms for
				groups other than small groups, and applicable rate schedules, that are placed
				into effect at time of negotiation or that have a retroactive effective date
				are not required to be filed in accordance with subsection (1) of this section,
				but must be filed within thirty working days after the earlier of:
(a) The date group contract negotiations are
				completed; or
(b) The date renewal
				premiums are implemented.
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 284-43-6580 - General contents of all filings

Current through Register Vol. 24-14, July 15, 2024
Each filing required by WAC 284-43-6560 must be submitted
				  with the filing transmittal form prescribed by and available from the
				  commissioner. The form must include the name of the filing entity, its address,
				  identification number, the type of filing being submitted, the form name or
				  group name and number, and other relevant information. Filings also must
				  include the information required on the filing summary set forth in WAC
				  284-43-6660 for individual and small group plans and rate schedules or as set
				  forth in WAC 284-43-6540 for group plans and rate schedules other than those
				  for small groups.
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 284-43-6590 - Requirements for mitigating inequity in the health insurance market

Current through Register Vol. 24-14, July 15, 2024
For the purposes of mitigating inequity in the health
				  insurance market, unless waived by the commissioner pursuant to RCW  48.43.725 and subsection (3) of this section, the commissioner must assess a fee on any
				  health carrier offering a health plan or student health plan that excludes,
				  under state or federal law, any benefit mandated or required by Title 48 RCW or
				  rules adopted by the commissioner. Such health carrier must:
(1) Notify each enrollee in writing of the
				following:
(a) Which benefits the health plan
				or student health plan does not cover; and
(b) Alternate ways in which the enrollees may
				access excluded benefits in a timely manner.
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 284-43-6600 - Issuer filing of attestation form, transparency tools

Current through Register Vol. 24-14, July 15, 2024
Every issuer offering or renewing a health benefit plan on or
				  after January 1, 2016, must attest to the insurance commissioner that the
				  transparency tools available to their members meet the requirements of
				  RCW
				   48.43.007.
(1) Annually, each health plan issuer must
				file an attestation form with the insurance commissioner for each line of
				business written by the issuer. For purposes of this section, line of business
				is defined as individual, small group and large group health plans.
(2) The form must be signed by an officer of
				the issuer that is responsible for ensuring compliance with
				RCW
				 48.43.007.
(3) The form must be submitted to the
				insurance commissioner no later than February 1st of each calendar year.
				Instructions for filing of the form will be available on the insurance
				commissioner's web site no later than sixty days prior to the filing
				deadline.
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 284-43-6620 - Experience records

Current through Register Vol. 24-14, July 15, 2024
(1) For each
				plan, carriers must maintain the following records for five years:
(a) Incurred claims;
(b) Earned premiums; and
(c) Expenses.
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 284-43-6640 - Evaluating experience data

Current through Register Vol. 24-14, July 15, 2024
In determining the credibility and appropriateness of
				  experience data, consideration will be given to all relevant factors,
				  including:
(1) Statistical credibility
				of the amount charged and services and benefits paid, such as low exposure, low
				loss frequency, and recoupment;
(2)
				Actual and projected trends relative to changes in medical costs and changes in
				utilization;
(3) The mix of
				business by risk classification; and
(4) Adverse selection or lapse factors
				reasonably expected in connection with revisions to plan provisions, services,
				benefits, and amount charged.
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 284-43-6660 - Summary for individual and small group contract filings

Current through Register Vol. 24-14, July 15, 2024
INDIVIDUAL AND SMALL GROUP FILING SUMMARY
Carrier Name _____________
Address _____________
_____________
_____________
Carrier
Identification
Number
Rate
Renewal
Period:
From
___
To
___
Date
Submitted:
						  _________________
Proposed Rate Summary
Current community rate
per month
Proposed community rate
per month
Percentage change
%
Portion of carrier's total
enrollment affected
%
Portion of carrier's total premium revenue
						  affected
%
Components of Proposed Community Rate
Dollars Per Month
% of Total
a) Claims
b) Expenses
c) Contribution to surplus, contingency
						  charges, or risk charges
d) Investment earnings
e) Total (a + b + c - d)
Summary of Pooled Experience
Experience Period
First Prior Period
Second Prior Period
From To
From To
From To
Member Months
Earned Premium
Paid Claims
Beginning Claim Reserve
Ending Claim Reserve
Incurred Claims
Expenses
Gain/Loss
Loss Ratio Percentage
General Information
1. Trend Factor Summary
Type of Service
Annual Trend Assumed
Portion of Claim Dollars
Hospital
%
%
Professional
%
%
Prescription Drugs
%
%
Dental
%
%
Other
%
%
2. List the effective date and the rate of
						  increase for all rate changes in the past three rate periods.
1)
____________
2)
____________
3)
____________
Date
%
Date
%
Date
%
3. Since the previous filing, have any
						  changes been made to the factors or methodology for adjusting base rates?
Geographic Area
[] Yes
[] No
Family Size
[] Yes
[] No
Age
[] Yes
[] No
Wellness Activities
[] Yes
[] No
Other (specify)
[] Yes
[] No
4. Attach a table showing the base rate for
						  each plan affected by this filing.
5. Attach comments or additional
						  information.
6. Preparer's Information
Name: _________________
Title: _________________
Telephone Number: _________________
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 284-43-6680 - Geographic rating area factor development

Current through Register Vol. 24-14, July 15, 2024
(1) For nongrandfathered individual or small
				group health plans offered, issued or renewed on or after January 1, 2014, and
				on or before December 31, 2018, if an issuer elects to adjust its premium rates
				based on geographic area, the issuer must use the geographic rating areas
				designated in WAC
				284-43-6700.
(2) The premium ratio for the highest cost
				geographic rating area, when compared to the lowest cost geographic rating
				area, must not be more than 1.15.
(a) King
				County is the index geographic rating area for purposes of calculating the
				premium ratio. The geographic rating area factor for the index area must be set
				at 1.00.
(b) A health-status
				related factor may not be used to establish a rating factor for a geographic
				rating area. Health factor means any of the following:
(i) Health status of enrollees or the
				population in an area;
(ii) Medical
				condition of enrollees or the population in an area, including both physical
				and mental illnesses;
(iii) Claims
				experience;
(iv) Health services
				utilization in the area;
(v)
				Medical history of enrollees or the population in an area;
(vi) Genetic information of enrollees or the
				population in an area;
(vii)
				Disability status of enrollees or the population in an area;
(viii) Other evidence of insurability
				applicable in the area.
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 284-43-6681 - Geographic rating area factor development on or after January 1, 2019

Current through Register Vol. 24-14, July 15, 2024
(1) For
				non-grandfathered individual or small group health plans offered, issued or
				renewed on or after January 1, 2019, if an issuer elects to adjust its premium
				rates based on geographic area, the issuer must use the geographic rating areas
				designated in WAC 284-43-6701.
(2)
(a) Except as provided in (b) and (c) of this
				subsection the premium ratio for the highest cost geographic rating area, when
				compared to the lowest cost geographic rating area, must not be more than
				1.15.
(b) An issuer that offers
				qualified health plans as described in
				RCW
				 43.71.065 in every county in six or more
				rating areas designated in WAC 284-43-6701 may utilize a premium ratio for the
				highest cost geographic rating area, when compared to the lowest cost
				geographic area of up to 1.22, if the development of rating factors is
				actuarially justified and meets all applicable requirements.
(c) An issuer that offers qualified health
				plans as described in
				RCW
				 43.71.065 in every county in every rating
				area designated in WAC 284-43-6701 may utilize a premium ratio for the highest
				cost geographic rating area, when compared to the lowest cost geographic area
				of up to 1.40, if the development of rating factors is actuarially justified
				and meets all applicable requirements.
(d)
(i) The
				area factor for the index geographic rating area must be set at 1.00. Except to
				the extent provided otherwise in (d) of this subsection, King County is the
				index geographic rating area for purposes of calculating the premium
				ratio.
(ii) If King County (area 1)
				is not in an issuer's service area, the geographic rating area of the county
				with the largest enrollment in the issuer's service area must be set at
				1.00.
(iii) If the issuer offers
				both individual and small group health plans and either the individual or small
				group health plans are not offered in King County (area 1), the index
				geographic rating area may be different for individual and small group health
				plans. The index geographic rating area for each market must be established
				consistent with (d)(i) or (ii) of this subsection as applicable.
(iv) If the issuer is new to the Washington
				state market, the geographic rating area within the issuer's service area that
				has the greatest number of counties must be set at 1.00.
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 284-43-6700 - Geographic rating area designation

Current through Register Vol. 24-14, July 15, 2024
(1) The following geographic rating areas are
				designated for Washington state for nongrandfathered individual and small group
				plans offered, issued, or renewed on or after January 1, 2014, and on or before
				December 31, 2018:
Area 1: Index geographic rating area: King County.
Area 2: Clallam, Cowlitz, Grays Harbor, Island, Jefferson,
				  Mason, Lewis, Kitsap, Pacific, Pierce, San Juan, Skagit, Snohomish, Thurston,
				  Wahkiakum, and Whatcom counties.
Area 3: Clark, Klickitat, and Skamania counties.
Area 4: Ferry, Lincoln, Pend Oreille, Spokane, and Stevens
				  counties.
Area 5: Adams, Asotin, Benton, Chelan, Columbia, Douglas,
				  Franklin, Garfield, Grant, Kittitas, Okanogan, Walla Walla, Whitman, and Yakima
				  counties.
(2) The
				commissioner will review the geographic rating area designation in this section
				not more frequently than every three years, beginning January 31, 2016. The
				commissioner will publish changes in the geographic rating area designation
				within sixty days of the review date.
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 284-43-6701 - Geographic rating area designation on or after January 1, 2019

Current through Register Vol. 24-14, July 15, 2024
(1) The following
				geographic rating areas are designated for Washington state for
				nongrandfathered individual and small group plans issued or renewed on or after
				January 1, 2019:
Area 1: King County.
Area 2/West: Clallam, Cowlitz, Grays Harbor, Jefferson,
				  Kitsap, Lewis, Pacific, and Wahkiakum counties.
Area 3/South: Clark, Klickitat, and Skamania counties.
Area 4/Northeast: Ferry, Lincoln, Pend Oreille, Spokane, and
				  Stevens counties.
Area 5/South Sound: Mason, Pierce, and Thurston
				  counties.
Area 6/South Central: Benton, Franklin, Kittitas, and Yakima
				  counties.
Area 7/North Central: Adams, Chelan, Douglas, Grant, and
				  Okanogan counties.
Area 8/Northwest: Island, San Juan, Skagit, Snohomish, and
				  Whatcom counties.
Area 9/Southeast: Asotin, Columbia, Garfield, Walla Walla,
				  and Whitman counties.
(2)
				The commissioner will review the geographic rating area designation in this
				section not more frequently than every three years, beginning January 31,
				2021.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter K - MENTAL HEALTH AND SUBSTANCE USE DISORDER › Section 284-43-7000 - Scope and intent-Parity in mental health and substance use disorder benefits

Current through Register Vol. 24-14, July 15, 2024
This sub-chapter applies to:
(1) Health plans;
(2) Plans deemed by the commissioner to have
				a short-term limited purpose or duration;
(3) Plans deemed by the commissioner to be
				student-only health plans that are guaranteed renewable while the covered
				person is enrolled as a regular, full-time undergraduate student at an
				accredited higher education institution; and
(4) Issuers.
The purpose of this subchapter is to consolidate existing
				  state mental health and substance use disorder regulation with federal mental
				  health and substance use disorder parity requirements into state regulation.
				  This rule also provides health plans, plans deemed by the commissioner to have
				  a short-term limited purpose or duration, or to be student-only health plans
				  that are guaranteed renewable while the covered person is enrolled as a
				  regular, full-time undergraduate student at an accredited higher education
				  institution and issuers with the method of demonstrating compliance with these
				  requirements. A plan or issuer's obligation to comply with these requirements
				  is non-delegable; a plan or issuer is obligated to ensure compliance with WAC
				  284-43-7000 through
				  284-43-7120,
				  even if they use a third-party vendor or subcontracting arrangement. A plan or
				  issuer is not exempt from any of these requirements because it relied upon a
				  third-party vendor or subcontracting arrangement for administration of any
				  aspect of its mental health or substance use disorder benefits or
				  services.
Statutory Authority: RCW  48.02.060, 48.43.715, 48.44.050,
					 48.46.200 and Paul Wellstone and Pete Domenici Mental Health Parity and
					 Addiction Equity Act of 2008,  Pub. L. 110-343. WSR 14-23-057 (Matter No. R
					 2012-29), § 284-43-990, filed 11/17/14, effective
					 12/18/14.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter K - MENTAL HEALTH AND SUBSTANCE USE DISORDER › Section 284-43-7020 - Classification of benefits

Current through Register Vol. 24-14, July 15, 2024
(1) A
				plan providing mental health or substance use disorder benefits, must provide
				mental health or substance use disorder benefits in every classification in
				which medical/surgical benefits are provided.
(2) Parity requirements must be applied to
				the following six classifications of benefits: Inpatient, in-network;
				inpa-tient, out-of-network; outpatient, in-network; outpatient, out-of-network;
				emergency care; and prescription drugs. These are the only classifications of
				benefits that can be used.
(a)
Inpatient, in-network.
Benefits furnished on an inpatient basis
				and within a network of providers established or recognized under a plan or
				health insurance coverage.
(b)
Inpatient, out-of-network.
Benefits furnished on an inpatient
				basis and outside any network of providers established or recognized under a
				plan or health insurance coverage. This classification includes inpatient
				benefits under a plan (or health insurance coverage) that has no network of
				providers.
(c)
Outpatient,
				in-network.
Benefits furnished on an outpatient basis and within a
				network of providers established or recognized under a plan or health insurance
				coverage.
(d)
Outpatient,
				out-of-network.
Benefits furnished on an outpatient basis and outside
				any network of providers established or recognized under a plan or health
				insurance coverage. This classification includes outpatient benefits under a
				plan (or health insurance coverage) that has no network of providers.
(e)
Emergency care.
Benefits for
				treatment of an emergency condition related to a mental health or substance use
				disorder. Such benefits must comply with the requirements for emergency medical
				services in
				RCW
				 48.43.093. Medically necessary detoxification
				must be covered as an emergency medical condition according to
				RCW
				 48.43.093, and may be provided in hospitals
				licensed under chapter 70.41 RCW. Medically necessary detoxification services
				must not require prenotification.
(f)
Prescription drugs.
Benefits
				for prescription drugs.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter K - MENTAL HEALTH AND SUBSTANCE USE DISORDER › Section 284-43-7040 - Measuring plan benefits-Financial requirements and quantitative treatment limitations

Current through Register Vol. 24-14, July 15, 2024
(1)
				Classification of benefits must be measured as follows:
(a) By type and level of financial
				requirement or treatment limitation.
(i) A
				financial requirement or treatment limitation type includes deductibles,
				copayments, coinsurance, and out-of-pocket maximums. Types of quantitative
				treatment limitations include annual, episode, and lifetime day and visit
				limits.
(ii) A financial
				requirement or treatment limitation level includes the amount of the financial
				requirement or treatment limitation type. For example, different levels of
				coinsurance include twenty percent and thirty percent; different levels of a
				copayment include fifteen dollars and twenty dollars; different levels of a
				deductible include two hundred fifty dollars and five hundred dollars; and
				different levels of an episode limit include twenty-one inpatient days per
				episode and thirty inpatient days per episode.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter K - MENTAL HEALTH AND SUBSTANCE USE DISORDER › Section 284-43-7060 - Measuring plan bene-fits-Nonquantitative treatment limitations

Current through Register Vol. 24-14, July 15, 2024
(1) A plan or
				issuer may not impose an NQTL with respect to mental health or substance use
				disorder in any classification unless, under the terms of the plan as written
				and in operation, any processes, strategies, evidentiary standards or other
				factors used in applying the NQTL to mental health or substance use disorder
				benefits in the classification are comparable to, and are applied no more
				stringently than, the processes, strategies, evidentiary standards, or other
				factors used in applying the limitation with respect to medical/surgical
				benefits in the same classification.
(2) All plan standards, such as
				in-and-out-of-network geographic limitations, limitations on inpatient services
				for situations where the enrollee is a threat to self or others, exclusions for
				court-ordered and involuntary holds, experimental treatment limitations,
				service coding, exclusions for services provided by clinical social workers,
				and network adequacy, while not specifically enumerated in the illustrative
				list of NQTLs must be applied in a manner that complies with this
				subsection.
Statutory Authority: RCW  48.02.060, 48.43.715, 48.44.050,
					 48.46.200 and Paul Wellstone and Pete Domenici Mental Health Parity and
					 Addiction Equity Act of 2008,  Pub. L. 110-343. WSR 14-23-057 (Matter No. R
					 2012-29), § 284-43-994, filed 11/17/14, effective
					 12/18/14.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter K - MENTAL HEALTH AND SUBSTANCE USE DISORDER › Section 284-43-7080 - Prohibited exclusions

Current through Register Vol. 24-14, July 15, 2024
(1)
				Benefits for actual treatment and services rendered may not be denied solely
				because a course of treatment was interrupted or was not completed.
(2) If a service is prescribed for a mental
				health condition and is medically necessary, it may not be denied solely on the
				basis that it is part of a category of services or benefits that is excluded by
				the terms of the contract.
(3)
				Benefits for mental health services and substance use disorder may not be
				limited or denied based solely on age or condition.
(4) When a treatment or service is gender
				affirming treatment, as defined in
				RCW
				 48.43.0128, a health carrier may not:
(a) Deny or limit coverage, deny or limit
				coverage of a claim, issue automatic denials of coverage or impose additional
				cost sharing or other limitations or restrictions on coverage if that treatment
				is:
(i) 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;
(ii) Medically necessary; and
(iii) Prescribed in accordance with accepted
				standards of care; or
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter K - MENTAL HEALTH AND SUBSTANCE USE DISORDER › Section 284-43-7100 - Required disclosures

Current through Register Vol. 24-14, July 15, 2024
(1)
				Plans and issuers must provide reasonable access to and copies of all
				documents, records, and other information relevant to an individual's claim.
(a) Plans and issuers must provide
				disclosures consistent with WAC
				284-43-4040,
				284-43-3170,
				284-43-3110,
				and
				284-43-2000.
				For any other disclosures related to an individual's claim, the plan or issuer
				must provide disclosures within thirty days.
(b) When a claim relates to a protected
				individual, as defined in
				RCW
				 48.43.005, the health carrier must comply
				with
				RCW
				 48.43.505.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter K - MENTAL HEALTH AND SUBSTANCE USE DISORDER › Section 284-43-7120 - Compliance and reporting of quantitative parity analysis

Current through Register Vol. 24-14, July 15, 2024
(1) Plans and issuers must file a
				justification demonstrating the analysis of each plan's financial requirements
				and quantitative treatment limitations as required under WAC
				284-43-7040.
(2) Filing of this justification is subject
				to the requirements of chapters 284-44A, 284-46A, and 284-58 WAC and may be
				rejected and closed if it does not comply.
Statutory Authority: RCW  48.02.060, 48.43.715, 48.44.050,
					 48.46.200 and Paul Wellstone and Pete Domenici Mental Health Parity and
					 Addiction Equity Act of 2008,  Pub. L. 110-343. WSR 14-23-057 (Matter No. R
					 2012-29), § 284-43-997, filed 11/17/14, effective
					 12/18/14.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter L - REPRODUCTIVE HEALTH CARE AND CONTRACEPTION › Section 284-43-7200 - Purpose and scope

Current through Register Vol. 24-14, July 15, 2024
(1) The purpose of
				this subchapter is to establish uniform regulatory standards for required
				coverage of contraceptive services and other reproductive health services and
				supplies, voluntary sterilization, and abortion under
				RCW
				 48.43.072 and
				48.43.073.
(2) This subchapter applies to all health
				plans, except as otherwise expressly provided in this subchapter. Health
				carriers are responsible for compliance with the provisions of this subchapter
				and are responsible for the compliance of any person or organization acting on
				behalf of or at the direction of the carrier, or acting pursuant to carrier
				standards or requirements concerning the coverage of, payment for, or provision
				of contraceptive services and supplies, voluntary sterilization, and abortion.
				A carrier may not offer as a defense to a violation of any provision of this
				subchapter that the violation arose from the act or omission of a participating
				provider or facility, network administrator, claims administrator, or other
				person acting on behalf of or at the direction of the carrier, or acting
				pursuant to carrier standards or requirements under a contract with the carrier
				rather than from the direct act or omission of the carrier.
(3) Effective January 1, 2021, except as
				otherwise provided, this subchapter applies to all student health plans deemed
				by the insurance commissioner to have a short-term limited purpose or duration,
				including short-term limited purpose student health plans and guaranteed
				renewable plans while the covered person is an enrolled student as a regular
				full-time undergraduate or graduate student at an accredited higher education
				institution.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter L - REPRODUCTIVE HEALTH CARE AND CONTRACEPTION › Section 284-43-7210 - Definitions

Current through Register Vol. 24-14, July 15, 2024
(1) "Contraceptive
				services" means consultations, examinations, procedures, and other health care
				services to obtain contraceptive supplies or voluntary sterilization. This
				includes prescribing, dispensing, inserting, delivering, distributing,
				administering, or removing contraceptive supplies and voluntary sterilization
				procedures.
(2) "Contraceptive
				supplies" means all contraceptive drugs, devices, and other products approved
				by the Federal Food and Drug Administration. This includes over-the-counter
				contraceptive drugs, devices, and products approved by the Federal Food and
				Drug Administration.
(3)
				"Cost-sharing" means any expenditure required of a covered person for covered
				services or supplies, including applicable taxes. Cost-sharing includes
				deductibles, coinsurance, copayments, or similar charges. Cost-sharing does not
				include premiums, balance billing amounts for nonnetwork providers, or spending
				for noncovered services or supplies.
(4) "Covered person" or "enrollee" has the
				same meaning as defined in RCW  48.43.005.
(5) "Gender expression" has the same meaning
				as defined in
				RCW
				 48.43.072.
(6) "Gender identity" has the same meaning as
				defined in
				RCW
				 48.43.072.
(7) "Medical management" or "medical
				management techniques" has the same meaning as defined in RCW
				 48.165.010.
(8) "Reproductive
				health care services" has the same meaning as defined in
				RCW
				 48.43.072.
(9) "Reproductive system" has the same
				meaning as defined in
				RCW
				 48.43.072.
(10) "Well-person preventative visits" has
				the same meaning as defined in
				RCW
				 48.43.072.