Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter M - SHORT-TERM LIMITED DURATION MEDICAL PLANS › Section 284-43-8010 - Standard disclosure form for short-term limited duration medical plans

Current through Register Vol. 24-14, July 15, 2024
(1) All carriers
				offering or issuing a short-term limited duration medical plan with an
				effective date on or after January 1, 2019, must issue a standard disclosure
				form for each short-term limited duration medical plan in the same format and
				with the same content as the disclosure form included in this section. The
				standard disclosure form must be displayed prominently in the medical plan
				contract and in any application materials provided in connection with
				enrollment in such coverage, and must be provided as a distinct, separate
				document to the person upon initial receipt of the medical plan
				application.
(2) Every carrier must
				have a mechanism in place to verify delivery of the standard disclosure form to
				the applicant and obtain the applicant's acknowledgment of receipt of the form.
				The carrier must retain each acknowledged disclosure form for five years. The
				forms must be available for review by the commissioner upon request.
(3) The type size and font of the standard
				disclosure form must be easily read and be no smaller than fourteen
				point.
(4) The standard disclosure
				form must not be used until it has been filed with and approved by the
				commissioner.
(5) The standard
				disclosure form must include, at a minimum, the following information and must
				be presented in the following format:
(Carrier's name and address)
IMPORTANT INFORMATION ABOUT THE LIMITS OF THE COVERAGE
				  YOU ARE BEING OFFERED
Save this document! It may be important to you in the
				  future.
CAUTION:
This plan may not cover pre-existing
							 conditions, including any medical or mental health condition you've been
							 treated for in the past.
It provides limited benefits and does
not
include benefits required by the Affordable Care
							 Act.
It's temporary and may not cover your costs for
							 most hospital or other medical services, or some essential health
							 benefits.
Read carefully what the plan does and doesn't
							 cover before you sign up.
Before enrolling, check to see if you can buy a health plan
				  through Washington State's Exchange, at
www.wahealthplanfinder.org
or
				  1-855-923-4633. If so, you may get help lowering your premium. Health plans
				  sold through the Exchange provide more coverage and protections. If you missed
				  the annual open enrollment period, see if you qualify for a special enrollment
				  period here:
www.insurance.wa.gov/when-can-i-buy-individual-health-plan
This medical plan is not a Medicare supplement plan.
This medical plan is not required to comply with certain
				  federal market requirements for health insurance, principally those contained
				  in the Affordable Care Act. Be sure to check your medical plan carefully to
				  make sure you are aware of any exclusions or limitations regarding coverage of
				  preexisting conditions or health benefits (such as hospitalization, emergency
				  services, maternity care, preventive care, prescription drugs, and mental
				  health and substance use disorder services). Your medical plan might also have
				  lifetime and/or annual dollar limits on health benefits.
This disclosure form is not a complete description of this
				  medical plan. To understand what is and isn't covered, please read your plan.
				  The plan will include information about your rights and the company's
				  responsibilities.
Short-Term Limited Duration Medical Plan
				  Disclosure
Below is a summary of the key benefits provided by this
				  short-term limited duration medical plan:
Type of coverage:
Short-term limited duration
				  medical plan
How long does coverage last?
(Provide
				  the number of days or months of coverage)
Does this policy cover pre-existing conditions?
("Yes" or "No, it limits/excludes coverage for medical or behavioral
				  health conditions for which medical advice, diagnosis, care or treatment was
				  received by or recommended to you, including taking prescription medication, in
				  the 24 months prior to the date you apply for coverage under the plan. See
				  policy for details.").
Who is NOT eligible for coverage?
(List
				  all excluded categories, e.g. over a certain age, Medicare/Medicaid eligible,
				  pregnant women, those with certain preexisting conditions,
				  etc.)
Can the policy be renewed?
No
What benefits are covered and what is the financial
				  responsibility of the member?
(For each benefit listed below, if
				  not covered, list "Not covered". If covered, list applicable cost-sharing,
				  including whether or not the deductible applies, the member's percentage of
				  coinsurance, copay-ment, any quantitative treatment limitations and any cap on
				  the amount the policy will pay for the service.
Examples include: "Covered after deductible, $45
				  copay plus 20% coinsurance, limited to only $1,000 of coverage"; "Covered
				  without deductible, $50 copay, limited to 30 visits total or per year";
				  "Covered after deductible, limited to treatment of involuntary complications of
				  pregnancy")
*
Deductible:
$ ______
(If there is more
				  than one deductible, list each deductible with a description of the services to
				  which it applies.)
*
Plan coinsurance (amount member must pay per
				  service)____%
(Must be expressed in terms of the percenta be
				  paid by the member. If coinsurance applies up to a maximum amount, provide that
				  information here. Example: "This policy has a 50% coinsurance up to $10,000,
				  after which benefits are paid at 100%")
*
The maximum amount a member will pay out-of-pocket
				  for cost-sharing for the term of the plan:
$ _____
(If there is no out-of-pocket maximum, clearly
				  state that there is no limit on the amount a member will have to pay for
				  out-of-pocket cost-sharing. If there is an out of pocket maximum, clearly state
				  which member payments are applied to this maximum, such as deductibles,
				  copayments and coinsurance.)
"
The maximum dollar amount this plan
				  will pay:
$_____
(Also include lifetime limit, if applicable.
				  Example: "$1 Million under this plan; lifetime limit of $2
				  Million")
*
Emergency Room Services:
*
Ambulance Services:
*
Inpatient Hospital Services:
*
Outpatient Hospital Services:
*
Services at an Urgent Care Facility:
*
Primary Care Visit to Treat an Injury or
				  Illness:
*
Specialist Visit:
*
Physical therapy, speech therapy, occupational
				  therapy:
*
Mental Health Outpatient Services
*
Mental Health Inpatient Services
*
Substance Use Disorder Outpatient
				  Services:
*
Substance Use Disorder Inpatient
				  Services;
*
Imaging (CT/PET Scans, MRIs):
*
Laboratory testing and services:
*
Durable medical equipment:
*
Preventive Care/Screening/Immunization:
*
Prescription drugs:
*
Skilled Nursing Facility:
*
Services in an Ambulatory Surgical
				  Center:
Does the policy exclude, eliminate, restrict, reduce,
				  limit, or delay coverage for any benefits NOT listed above?
("No" or if "Yes" include details)
Does the policy require that the member use a specific
				  network of health care providers or pharmacies?
("No" or if
				  "Yes", include details)
Can a member be charged additional costs for covered
				  services, in addition to their coinsurance or copays?
(If
				  members can be balance billed for any covered service, answer "Yes" and explain
				  when this would occur. You must answer "Yes" for plan designs that do not use a
				  provider network, or that use in-network facilities where not all services may
				  be provided by in-network providers. If other situations apply, include any
				  further explanation about when balance billing is possible.)
If this coverage expires or you lose eligibility for this
				  coverage, you might have to wait until an open enrollment period to get other
				  health insurance coverage. This coverage is
not
considered
				  comprehensive and would not qualify you for a special enrollment period.
Open enrollment for individual health plans begins November 1
				  each year for coverage that begins January 1 of the upcoming year.
You will need to complete and confirm all medical information
				  you provide when applying for this plan. Your producer (also referred to as
				  insurance agent) is not allowed to fill out any of this information for
				  you.
Consumer acknowledgment:
I confirm that I have reviewed the content of this disclosure
				  form and that I understand the limitations of this short-term limited-duration
				  medical plan.
Consumer signature/name: __________________________
Date: ___________________________________________
This notice has important information about this short-term
				  limited duration medical plan. If you, or someone you're helping, has questions
				  about this document or complaints about this medical plan and how it was sold
				  to you, call the Washington State Office of the Insurance Commissioner at
				  1-800-562-6900. If you need help speaking to us in your preferred language, we
				  will find an interpreter for you at no cost.