Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-44 - Health care services contractors-Agents-Contract formats-Standards › Section 284-44-040 - Contract standards required

Current through Register Vol. 24-14, July 15, 2024
Every health care service contract issued or renewed after
				December 31, 1974, shall conform to the following standards:
(1) A contract shall not unreasonably limit
			 benefits to a specified period of time. For example, a provision that services
			 for a particular condition will be covered only for one year without regard to
			 the amount of the benefits paid or provided, is not acceptable. Contracts may,
			 however, limit major medical benefits, supplemental accident benefits, and
			 diagnostic X-ray and laboratory benefits to a reasonable period of time.
			 Benefits may also be limited to a reasonable maximum dollar amount, and, in the
			 case of doctor calls, to a reasonable number of calls over a stated period of
			 time.
(2) A contract must provide
			 that reasonable benefits will be restored upon each renewal of the contract or
			 upon a calendar year basis or that such benefits be reasonably continuous. It
			 is not required that a major medical contract with a lifetime maximum benefit
			 be renewed or restored.
(3) A
			 contract shall not contain any provision which gives or purports to give the
			 contractor, its agent, officer, employee, or designee the authority to make a
			 decision relative to the contract, or coverage or claims thereunder, which is
			 final and binding on the subscriber or beneficiary. That is, in the case of
			 controversy arising out of the contract, a subscriber shall not be denied the
			 right to have the controversy determined by legal or arbitration
			 proceedings.
(4) A contract shall
			 not contain any provision which requires a subscriber to purchase a "monthly
			 treatment order." This prohibits provisions that require a subscriber to pay a
			 special charge, distinct from the pre-payment fees required of all subscribers
			 and coinsurance deductible amounts, in order to obtain advance authorization
			 for treatment or services.
(5) If a
			 contract restricts treatment to services by the contractor's participants or
			 agents, a reasonable provision shall be included to allow emergency treatment
			 consistent with the scope of the benefits regularly provided by the
			 contract.
(6) If a contract
			 provides maternity benefits, there shall be no waiting period for maternity
			 benefits in advance of a conception occurring while the contract is in
			 force.
(7) No contract shall
			 contain any provision that unreasonably restricts or delays the payment of
			 benefits payable under the contract. Delays are not justified because the
			 expenses incurred, or the services received, resulted from an act or omission
			 of a third party.
(8) Every
			 contract shall provide for a grace period of not less than ten days following
			 the due date for the payment of the subscriber's dues, fees, or premium, during
			 which grace period the contract shall continue in force. If payment is not made
			 within the grace period, the contract may be terminated as of the due date of
			 payment rather than at the end of the grace period.
(9) No contract other than a conversion
			 contract issued pursuant to chapter 284-52 WAC shall contain any provision
			 having the effect of coordinating benefits with other health care service
			 contracts, health maintenance agreements, or disability insurance policies,
			 except that group contracts may provide for coordination of benefits pursuant
			 to chapter 284-51 WAC, and except that any contract may provide for
			 coordination with respect to governmental programs.
Statutory Authority:
				  RCW
				  48.02.060,
				  48.44.050 and
				  48.46.200. 84-19-055 (Order R
				  84-4), §
										284-44-040, filed 9/19/84; Order
				  R-74-1, §
										284-44-040, filed 6/4/74,
				  effective 8/1/74.