reglab/statecodes huggingface dataset:
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter B - PLAN MANAGEMENT › Section 284-43-0203 - Use of subcontracted networks

Current through Register Vol. 24-14, July 15, 2024
(1) The primary contractor with each provider
				and facility in an issuer's network must be specifically identified in network
				report filings with the commissioner. An issuer may use subcontracted networks
				as part of a provider network for a service area, subject to the following
				requirements:
(a) An issuer must not elect to
				use less than one hundred percent of the subcontracted network or networks in
				its service area.
(b) An issuer may
				use a combination of directly contracting with providers and use of a
				subcontracted network in the same service area.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter B - PLAN MANAGEMENT › Section 284-43-0204 - Provider directories

Current through Register Vol. 24-14, July 15, 2024
(1)
				Provider directories must be updated at least monthly, and must be offered to
				accommodate individuals with limited-English proficiency or disabilities. An
				issuer must post the current provider directory for each health plan online,
				and must make a printed copy of the current directory available to an enrollee
				upon request as required under
				RCW
				 48.43.510(1)(g).
(2) For each health plan, the associated
				provider directory must include the following information for each provider:
(a) The specialty area or areas for which the
				provider is licensed to practice and included in the network;
(b) Any in-network institutional affiliation
				of the provider, such as hospitals where the provider has admitting privileges
				or provider groups with which a provider is a member;
(c) Whether the provider may be accessed
				without referral;
(d) Any
				languages, other than English, spoken by the provider.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter B - PLAN MANAGEMENT › Section 284-43-0220 - Network reports - Format

Current through Register Vol. 24-14, July 15, 2024
(1) An
				issuer must submit its provider network materials to the commissioner for
				approval prior to or at the time it files a newly offered health plan.
(a) For individual and small groups, the
				submission must occur when the issuer submits its plan under WAC
				284-170-870. For groups other
				than individual and small, the submission must occur when the issuer submits a
				new health plan and as required in this section.
(b) The commissioner may extend the time for
				filing for good cause shown.
(c)
				For plan year 2015 only, the commissioner will permit a safe harbor standard.
				An issuer who can not meet the submission requirements in (e) and (f) of this
				subsection will be determined to meet the requirements of those subsections
				even if the submissions are incomplete, provided that the issuer:
(i) Identifies specifically each map required
				under subsection (3)(e)(i) of this section, or Access Plan component required
				under subsection (3)(f) of this section, which has not been included in whole
				or part;
(ii) Explains the specific
				reason each map or component has not been included; and
(iii) Sets forth the issuer's plan to
				complete the submission, including the date(s) by which each incomplete map and
				component will be completed and submitted.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter B - PLAN MANAGEMENT › Section 284-43-0221 - Essential community providers for exchange plans-Definition

Current through Register Vol. 24-14, July 15, 2024
"Essential community provider" means providers listed on the
				  Centers for Medicare and Medicaid Services Non-Exhaustive List of Essential
				  Community Providers. This list includes providers and facilities that have
				  demonstrated service to medicaid, low-income, and medically underserved
				  populations in addition to those that meet the federal minimum standard, which
				  includes:
(1) Hospitals and providers
				who participate in the federal 340B Drug Pricing Program;
(2) Disproportionate share hospitals, as
				designated annually;
(3) Those
				eligible for Section 1927 Nominal Drug Pricing;
(4) Those whose patient mix is at least
				thirty percent medicaid or medicaid expansion patients who have approved
				applications for the Electronic Medical Record Incentive Program;
(5) State licensed community clinics or
				health centers or community clinics exempt from licensure;
(6) Indian health care providers as defined
				in WAC 284-43-130(16);
(7) Long-term care facilities in which the
				average residency rate is fifty percent or more eligible for medicaid during
				the preceding calendar year;
(8)
				School-based health centers as referenced for funding in Sec. 4101 of Title IV
				of ACA;
(9) Providers identified as
				essential community providers by the U.S. Department of Health and Human
				Services through subregulatory guidance or bulletins;
(10) Facilities or providers who waive
				charges or charge for services on a sliding scale based on income and that do
				not restrict access or services because of a client's financial
				limitations;
(11) Title X Family
				Planning Clinics and Title X look-alike Family Planning Clinics;
(12) Rural based or free health centers as
				identified on the Rural Health Clinic and the Washington Free Clinic
				Association web sites; and
(13)
				Federal qualified health centers (FQHC) or FQHC look-alikes.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter B - PLAN MANAGEMENT › Section 284-43-0225 - Issuer recordkeeping-Provider networks

Current through Register Vol. 24-14, July 15, 2024
(1) An issuer must make available to the
				commissioner upon request its records, contracts, and agreements related to its
				provider networks.
(a) Records to support
				proof of good faith contracting efforts must be retained for seven
				years.
(b) Signed contracts,
				reimbursement agreements, and associated accounting records must be retained
				for ten years after the contract is terminated.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter B - PLAN MANAGEMENT › Section 284-43-0229 - Tiered provider networks

Current through Register Vol. 24-14, July 15, 2024
(1) "Tiered provider network" means a network
				that identifies and groups providers and facilities into specific groups to
				which different provider reimbursement, enrollee cost-sharing, or provider
				access requirements, or any combination thereof, apply as a means to manage
				cost, utilization, quality, or to otherwise incentivize enrollee or provider
				behavior.
(a) An issuer may use a term other
				than tiered network as long as the term is not misleading or susceptible to
				confusion with a specific licensee designation, such as accountable care
				organization.
(b) An issuer must
				not use tiered networks to limit access to certain categories of providers or
				facilities.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter B - PLAN MANAGEMENT › Section 284-43-0230 - Risk adjustment program

Current through Register Vol. 24-14, July 15, 2024
(1) An issuer of a nongrandfathered
				individual or small group health plan in Washington state must participate in
				the permanent risk adjustment program, established pursuant to RCW  48.43.720.
(2) U.S. Department of Health and
				Human Services (HHS) will administer the risk adjustment program for 2014-2015.
				Issuers must comply with HHS requirements for the risk adjustment
				program.
(3) Beginning September 1,
				2015, or on the date established by the HHS, the commissioner will annually
				publish a notice of benefit and payment parameters, and include a statement of
				intent regarding whether the state or HHS will administer the risk adjustment
				program for the ensuring benefit year.
The commissioner will determine the form of the notice, which
				  will be consistent with the form required by HHS.
(4) The commissioner will establish an
				advisory group to provide advice regarding whether the state should operate the
				risk adjustment program for a future period of benefit year or years.
(a) The advisory group consists of
				representatives from issuers who participate in the risk adjustment program,
				the health benefit exchange, and if under contract or otherwise established by
				the legislature, the designated administrative entity for the state risk
				adjustment program. If an issuer wishes to participate in the advisory group,
				it must notify the commissioner in writing of its designated participant not
				later than May 1st of each year.
(b) The advisory group will meet at the
				commissioner's discretion.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter B - PLAN MANAGEMENT › Section 284-43-0251 - Enrollee's access to providers

Current through Register Vol. 24-14, July 15, 2024
(1) Each issuer must allow an enrollee to
				choose a primary care provider who is accepting new patients from a list of
				participating providers.
(a) Enrollees also
				must be permitted to change primary care providers at any time with the change
				becoming effective not later than the beginning of the month following the
				enrollee's request for the change.
(b) The issuer must ensure at all times that
				there are a sufficient number of primary care providers in the service area
				accepting new patients to accommodate new enrollees if the plan is open to new
				enrollment, and to ensure that existing enrollees have the ability to change
				primary care providers.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter B - PLAN MANAGEMENT › Section 284-43-0252 - Hospital emergency service departments and practice groups

Current through Register Vol. 24-14, July 15, 2024
Enrollees must have access to emergency services twenty-four
				  hours per day, seven days per week. An issuer must make good faith attempts to
				  contract with provider groups offering services within hospital emergency
				  departments, if the hospital is included in its network. Such evidence of good
				  faith efforts to contract will include documentation about the efforts to
				  contract but not the substantive contract terms offered by either the issuer or
				  the provider groups. If the issuer is unsuccessful in contracting with provider
				  groups offering services within contracted hospital emergency departments, the
				  issuer's provider directory must prominently note that while the hospital's
				  emergency department is contracted, the providers within the department are
				  not.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter B - PLAN MANAGEMENT › Section 284-43-0260 - Standards for temporary substitution of contracted network providers - "Locum tenens" providers

Current through Register Vol. 24-14, July 15, 2024
It is a longstanding and widespread practice for contracted
				  network providers to retain substitute providers to take over their
				  professional practices when the contracted network providers are absent for
				  reasons such as illness, pregnancy, vacation, or continuing medical education,
				  and for contracted network providers to bill and receive payment for the
				  substitute providers' services as though they were provided by the contracted
				  network provider. The contracted network provider generally pays the substitute
				  provider based on an agreement between the contracted network provider and the
				  substitute provider, and the substitute provider has the status of an
				  independent contractor rather than an employee of the contracted network
				  provider. These substitute providers are commonly called "locum tenens"
				  providers.
In order to protect patients and ensure that they benefit
				  from seamless quality care when contractual network providers are away from
				  their practices, and that patients receive quality care from qualified
				  substitute providers, carriers may require substitute providers to provide the
				  information required in subsection (1) of this section.
The following are minimum standards for temporary provider
				  substitution and do not prevent a carrier from entering into other agreed
				  arrangements with its contracted network providers for terms that are less
				  restrictive or more favorable to providers.
Carriers must permit the following categories of contracted
				  network provider to arrange for temporary substitution by a substitute
				  provider: Doctor of medicine, doctor of osteopathic medicine, doctor of dental
				  surgery or dental medicine, doctor of chiropractic, podiatric physician and
				  surgeon, doctor of optometry, doctor of naturopathic medicine and advanced
				  registered nurse practitioner.
(1) At
				the time of substitution, the substitute provider:
(a) Must have a current Washington license
				and be legally authorized to practice in this state;
(b) Must provide services under the same
				scope of practice as the contracted network provider;
(c) Must not be suspended or excluded from
				any state or federal health care program;
(d) Must have professional liability
				insurance coverage; and
(e) Must
				have a current drug enforcement certificate, if applicable.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter B - PLAN MANAGEMENT › Section 284-43-0262 - Rule concerning contracted network providers called to active duty military service

Current through Register Vol. 24-14, July 15, 2024
In lieu of substitution of a provider during a period of
				  active duty military service longer than sixty continuous days, carriers must
				  provide contracted network providers with the opportunity to return to the
				  carrier's network after the provider's active duty military service is
				  completed.
(1)
(a) A carrier must allow the provider a
				period of at least one hundred twenty days to request a return to contracted
				network provider status after the provider returns to civilian
				status.
(b) The one hundred
				twenty-day period must begin no earlier than the date the provider's period of
				active duty ends.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter B - PLAN MANAGEMENT › Section 284-43-0270 - Market conduct requirements related to grandfathered status

Current through Register Vol. 24-14, July 15, 2024
(1) An issuer may
				allow a group covered by grandfathered health insurance coverage to add new
				employees to its health benefit plan, and move employees between benefit
				options at open enrollment without affecting grandfathered status, as long as
				the group's plan does not change in any way that triggers the loss of
				grandfathered status as set forth in
				45 C.F.R.
				147.140 and WAC
				284-43-0250.
(2) An issuer must provide a statement in the
				plan materials provided to participants or beneficiaries describing the
				benefits provided under the plan, explaining that the group health plan
				believes it is a grandfathered health plan within the meaning of Section 1251
				of the Affordable Care Act, and include contact information for questions and
				complaints that conforms to the model notice language found in
				45 C.F.R.
				147.140.
(3) An issuer must not restrict group
				eligibility to purchase a nongrandfathered plan offered through an association
				or member-governed group because the group is not affiliated with or does not
				participate in the association or member-governed group, unless the association
				or member-governed group meets the requirements of WAC
				284-43-0330(1).
(4) WAC
				284-43-0250 through
				284-43-0330 does not prohibit an
				issuer from discontinuing a grandfathered plan design and replacing it with a
				nongrandfathered plan.
(5) An
				issuer must not limit eligibility based on health status for either
				grandfathered or nongrandfathered health plans.
Statutory Authority: RCW  48.02.060, 48.43.700, 48.43.715,
					 48.44.050, 48.46.200, and  45 C.F.R. 150.101(2). WSR 14-01-039 (Matter No. R
					 2013-13), §
											284-170-952, filed 12/11/13, effective
					 1/11/14.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter B - PLAN MANAGEMENT › Section 284-43-0290 - Small group coverage market transition requirements

Current through Register Vol. 24-14, July 15, 2024
(1) For all nongrandfathered small group
				plans issued and in effect prior to January 1, 2014, in 2014 issuers must
				replace issued nongrandfathered small group health benefit plans with health
				benefit plans approved by the commissioner as follows:
(a) An issuer may elect to withdraw a product
				pursuant to
				RCW
				 48.43.035, and discontinue each health
				benefit plan in force under that product on the same date, requiring groups to
				select a replacement plan to be effective on the date of discontinuation;
				or
(b) An issuer may discontinue a
				small group's coverage at renewal and offer the full range of plans the issuer
				offers in the small group market as replacement options, to take effect on the
				small group's renewal date. For small groups covered by nongrandfathered health
				benefit plans purchased based on an association or member-governed group
				affiliation or membership, the requirements of WAC
				284-43-0310 and
				284-43-0330 apply;
(c) If an issuer does not have a replacement
				plan approved by the commissioner to offer in place of the discontinued plan,
				the issuer must assist each enrollee in identifying a replacement option
				offered by another issuer.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter B - PLAN MANAGEMENT › Section 284-43-0300 - Provider and facility contracts with issuers-Generally

Current through Register Vol. 24-14, July 15, 2024
(1) An issuer contracting with providers or
				facilities for health care service delivery to enrollees must satisfy all the
				requirements contained in this subchapter.
(2) An issuer must ensure that subcontractors
				of its contracted providers and facilities comply with the requirements of this
				subchapter. An issuer's obligation to comply with these requirements is
				nondelegable; the issuer is not exempt from these requirements because it
				relied upon a third-party vendor or subcontracting arrangement.
Statutory Authority:
					 RCW
					  48.02.060,
					 48.20.450,
					 48.20.460,
					 48.30.010,
					 48.44.020,
					 48.44.050,
					 48.44.080,
					 48.46.030,
					 48.46.060(2),
					 48.46.200 and
					 48.46.243. 98-04-005 (Matter No. R
					 97-3), §
											284-43-300, filed 1/22/98,
					 effective 2/22/98.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter B - PLAN MANAGEMENT › Section 284-43-0310 - Association health plan compliance with statutory or regulatory changes (Recodified)

Current through Register Vol. 24-14, July 15, 2024
Statutory Authority: RCW  48.02.060, 48.43.700, 48.43.715,
					 48.44.050, 48.46.200, and  45 C.F.R. 150.101(2). WSR 14-01-039 (Matter No. R
					 2013-13), §
											284-170-955, filed 12/11/13, effective
					 1/11/14.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter B - PLAN MANAGEMENT › Section 284-43-0325 - Pharmacy claims - Rejections, notifications and disclosures

Current through Register Vol. 24-14, July 15, 2024
Issuers must provide to billing pharmacies sufficient
				  information about transactions initiated by the pharmacy so that pharmacy
				  claims can be processed in a timely manner.
(1) For purposes of this section "claim
				rejection" is an administrative step in the claim process where a claim is
				neither paid nor denied, but is held awaiting a defined action from the
				pharmacist, prescriber, or member.
(2) An issuer must notify the billing
				pharmacy of a claim rejection electronically and make available to the
				pharmacy, utilizing the National Council for Prescription Drug Programs (NCPDP)
				Telecommunications Standard transaction, all required data elements, as well as
				the following information, to the extent supported by the transaction:
(a) Rejection reasons such as prior
				authorization, quantity level limit, and exclusion;
(b) Other medications to consider that would
				not require a preauthorization (if applicable);
(c) Other medications to consider that would
				require a preauthorization (if applicable);
(d) Instructions for further processing of
				claim or for more specific contact information which may include a reference to
				a specific location on a web site;
(e) Contact phone number of a person or
				department to contact who can provide additional information.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter B - PLAN MANAGEMENT › Section 284-43-0330 - Transition of plans purchased by association members (Recodified)

Current through Register Vol. 24-14, July 15, 2024
Statutory Authority: RCW  48.02.060, 48.43.700, 48.43.715,
					 48.44.050, 48.46.200, and  45 C.F.R. 150.101(2). WSR 14-01-039 (Matter No. R
					 2013-13), §
											284-170-958, filed 12/11/13, effective
					 1/11/14.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter B - PLAN MANAGEMENT › Section 284-43-0350 - Individual coverage market transition requirements

Current through Register Vol. 24-14, July 15, 2024
(1) For all nongrandfathered individual
				health benefit plans issued and in effect prior to January 1, 2014, during 2014
				issuers must replace the plans with health benefit plans approved by the
				commissioner as follows:
(a) An issuer may
				elect to withdraw a product, pursuant to RCW  48.43.038, and discontinue each
				health benefit plan in force under that product on the same date, requiring
				selection of a replacement plan to be effective on the date of discontinuation;
				or
(b) An issuer may discontinue an
				individual's coverage and offer the full range of plans the issuer offers in
				the individual market as replacement options. The replacement coverage must
				take effect on the individual's renewal date.
(c) If an issuer does not have a replacement
				plan approved by the commissioner to offer in place of the discontinued plan,
				the issuer must assist each enrollee in identifying a replacement option
				offered by another issuer.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter B - PLAN MANAGEMENT › Section 284-43-0400 - 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 health
				carriers and to create minimum standards for carriers to adopt policies and
				procedures that conform administrative, business, and operational practices to
				protect an enrollee's right to privacy and right to confidential health care
				services granted under state or federal laws.
(2) This subchapter applies to all health
				carriers 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
				administration of health care benefits. 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, health care benefit manager, 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.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter B - PLAN MANAGEMENT › Section 284-43-0410 - Definitions

Current through Register Vol. 24-14, July 15, 2024
(1) "Communications
				subject to confidentiality" means written, verbal, or electronic communication
				regarding sensitive health care services, and all health care services if a
				protected individual has requested to limited disclosure including:
(a) Bills and attempts to collect payment,
				except for premium billing that does not contain any health
				information;
(b) A notice of
				adverse benefit determination;
(c)
				An explanation of benefits notice;
(d) A carrier's request for additional
				information regarding a claim;
(e)
				A notice of contested claim;
(f)
				The name and address of a provider, a description of services provided, and
				other visit information; and
(g)
				Any written, oral, or electronic communication from a carrier that contains
				protected health information.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter B - PLAN MANAGEMENT › Section 284-43-0420 - Sensitive health care services

Current through Register Vol. 24-14, July 15, 2024
(1) A health carrier must direct all
				communication regarding sensitive health care services, including
				communications subject to confidentiality, directly to the protected
				individual. To facilitate communication of these services, a carrier must allow
				the protected individual to select their preferred communication format unless
				the format is otherwise specified by law or regulation and may provide
				sensitive health services communications to the protected individual by:
(a) Health care portal that is only
				accessible to the protected individual;
(b) Email address, if provided by the
				protected individual;
(c) Telephone
				of the protected individual; or
(d)
				Mail to the address requested by a protected individual, and if no address has
				been requested, then mail to the known address if the communication and
				envelope are addressed only to the protected individual.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter B - PLAN MANAGEMENT › Section 284-43-0430 - Requests regarding confidentiality and to limit disclosure

Current through Register Vol. 24-14, July 15, 2024
(1) When requested
				by an enrollee, a health carrier must limit disclosure of that enrollee's
				information, including personal health information and communications subjected
				to confidentiality. Once limited, a health carrier must communicate directly
				with the enrollee through the identified physical address, email, telephone
				number, or carrier portal.
(2)
				Health carriers must establish a process for informing enrollees, including
				protected individuals, of the ability to request confidentiality, limit
				disclosure, and update their contact information. Enrollees must be able to
				provide a request telephonically, or submit it by email or online, such as
				through a portal or on the carrier's webpage.
(a) Health carriers must post a
				confidentiality request form clearly and conspicuously on their website for
				individuals limit disclosure or to change their limits regarding communication
				preferences, such as updating their address, or selecting another means of
				communication. When carriers post the form on their website, or make the form
				available through other means, carriers must ensure that the form is
				accompanied by clear instructions about how a protected individual or enrollee
				may submit the form and the process, including other means available to change
				the enrollee's contact information. If carriers utilize their own
				confidentiality request form, then carriers must also provide a link to the
				form specified for use and made available on the office of the insurance
				commissioner's website. Carriers must accept the form specified by the
				commissioner when submitted by an enrollee, authorized representative, or
				provider acting on behalf of the enrollee.
(b) Carriers must implement the request and
				any subsequent request for changes within three business days from receipt of
				the request. If a request is incomplete or missing information, the carrier
				must implement as much of the request as possible, and contact the enrollee to
				obtain a complete request within three business days.
(c) The request must remain in effect until
				the enrollee revokes or modifies the request in writing.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter B - PLAN MANAGEMENT › Section 284-43-0818 - Formulary changes

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 substitution 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 web site 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 thirty 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 B - PLAN MANAGEMENT › Section 284-43-0920 - When a carrier is required to file (Repealed)

Current through Register Vol. 24-14, July 15, 2024
Statutory Authority:
					 RCW
					  48.02.060,
					 48.44.050, and
					 48.46.200. 05-07-006 (Matter No. R
					 2004-05), §
											284-43-920, 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. 98-04-011 (Matter No. R
					 97-2), §
											284-43-920, 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 B - PLAN MANAGEMENT › Section 284-43-0927 - 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 B - PLAN MANAGEMENT › Section 284-43-0950 - Summary for group contract filings other than small group contract filings (Repealed)

Current through Register Vol. 24-14, July 15, 2024
Statutory Authority:
					 RCW
					  48.02.060,
					 48.44.050, and
					 48.46.200. 05-07-006 (Matter No. R
					 2004-05), §
											284-43-950, 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. 98-04-011 (Matter No. R
					 97-2), §
											284-43-950, 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 C - OPEN AND SPECIAL ENROLLMENT REQUIREMENTS › Section 284-43-1020 - Special enrollment requirements for small group plans

Current through Register Vol. 24-14, July 15, 2024
(1) A "special enrollment period" means a
				period of time outside the initial or annual group renewal period during which
				an individual applicant may enroll if the individual has experienced a
				qualifying event. An issuer must make periods for special enrollment in its
				small group plans available to an otherwise eligible applicant if the applicant
				has experienced one of the qualifying events identified in this
				section.
(2) A qualifying event for
				special enrollment in small group plans offered on or off the health benefit
				exchange is one of the following:
(a) The
				loss of minimum essential benefits, including loss of employer sponsored
				insurance coverage, or of the coverage of a person under whose policy they were
				enrolled, unless the loss is based on the individual's voluntary termination of
				employer sponsored coverage, the misrepresentation of a material fact affecting
				coverage or for fraud related to the terminated health coverage;
(b) The loss of eligibility for medicaid or a
				public program providing health benefits;
(c) The loss of coverage as the result of
				dissolution of marriage or termination of a domestic partnership;
(d) A permanent change in residence, work, or
				living situation, whether or not within the choice of the individual, where the
				health plan under which they were covered does not provide coverage in that
				person's new service area;
(e) The
				birth, placement for adoption or adoption of the applicant for whom coverage is
				sought;
(f) A situation in which a
				plan no longer offers benefits to the class of similarly situated individuals
				that includes the applicant;
(g)Loss of individual or group coverage
				purchased on the health benefit exchange due to an error on the part of the
				exchange, the issuer or the U.S. Department of Health and Human
				Services;
(h) Marriage or entering
				into a domestic partnership, including eligibility as a dependent of an
				individual marrying or entering into a domestic partnership.
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 284-43-1040 - Special enrollment periods for small group qualified health plans

Current through Register Vol. 24-14, July 15, 2024
(1) Issuers of
				small group qualified health plans must comply with the additional special
				enrollment period requirements set forth in
				45 C.F.R.
				155.420(b)(2) and
				45 C.F.R.
				155.725.
(2) In addition to meeting the requirements
				set forth in WAC
				284-43-1020, issuers must include
				in qualified health plan contract forms and required disclosure documents an
				explanation of special enrollment rights if one of the following triggering
				events occurs:
(a) In addition to the
				requirements for adopted, placed for adoption, and newborn children, the same
				special enrollment right accrues for foster children and children placed in
				foster care;
(b) The individual
				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)
				An individual's enrollment in or nonenrollment in a qualified health plan is
				unintentional, inadvertent or erroneous, and is the result of the error,
				misinterpretation or inaction of an officer, employee or agent of the health
				benefit exchange of the U.S. Department of Health and Human Services, as
				determined by the health benefit exchange upon evaluation;
(d) In addition to the special enrollment
				event in WAC
				284-43-1020(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;
(e) 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.
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 284-43-1060 - Duration and effective dates of small group special enrollment periods

Current through Register Vol. 24-14, July 15, 2024
(1) This section
				applies to nongrandfathered small group plans offered on or off the health
				benefit exchange.
(2) Special
				enrollment periods must not be shorter than sixty days from the date of the
				qualifying event.
(3) The effective
				date of coverage for those enrolling in a small group plan through a special
				enrollment period is the first date of the next month after the application for
				coverage is received, unless one of the following exceptions applies:
(a) For special enrollment of newborn,
				adopted or placed for adoption children, the date of birth, date of adoption or
				date of placement for adoption becomes the first effective date of
				coverage;
(b) For applicants
				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, unless the applicant is enrolling due to marriage or the commencement
				of a domestic partnership. An issuer may establish an earlier effective date at
				their discretion. An issuer may establish an earlier effective date at their
				discretion;
(c) For applicants
				enrolling because of marriage or the commencement of a domestic partnership,
				when notice of the marriage or domestic partnership is received within sixty
				days of the marriage or commencement of the domestic partnership, either as
				spouse, domestic partner or as a dependent child, coverage must begin no later
				than the first date of the month immediately following the date of marriage or
				domestic partnership.
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 284-43-1080 - Individual market open enrollment requirements

Current through Register Vol. 24-14, July 15, 2024
(1) For purposes of this section, "open
				enrollment" means a specific period of time each year during which enrollment
				in a health benefit plan is permitted. This section applies to plans offered in
				the individual market.
(2) An
				issuer must limit the dates for enrollment in plans offered on the individual
				market off the health benefit exchange to the same time period for open
				enrollment established by the health benefit exchange.
(3) An issuer must prominently display
				information on its web site about open enrollment periods and special
				enrollment periods applicable to its plans offered either on or off the health
				benefit exchange.
(a) The web site
				information about enrollment periods must provide a consumer with the ability
				to access or request and receive an application packet for enrollment at any
				time.
(b) The displayed information
				must include details written in plain language explaining what constitutes a
				qualifying event for special enrollment.
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 284-43-1100 - Individual market special enrollment requirements

Current through Register Vol. 24-14, July 15, 2024
(1) For a nongrandfathered individual health
				plan offered on or off the health benefit exchange, an issuer must make a
				special enrollment period of not less than sixty days available to any person
				who experiences a qualifying event, permitting enrollment in an individual
				health benefit plan outside the open enrollment period. This requirement
				applies to plans offered on the health benefit exchange that cover pediatric
				oral benefits offered as essential health benefits necessary to satisfy minimum
				essential coverage requirements.
(2) A qualifying event means the occurrence
				of one of the following:
(a) The loss of
				minimum essential coverage, including employer sponsored insurance coverage due
				to action by either the employer or the issuer or due to the individual's loss
				of eligibility for the employer sponsored coverage, or the loss of the
				individual or group coverage of a person under whose policy they were enrolled,
				unless the loss is based on the individual's misrepresentation of a material
				fact affecting coverage or for fraud related to the discontinued health
				coverage;
(b) The loss of
				eligibility for medicaid or a public program providing health
				benefits;
(c) The loss of coverage
				as the result of dissolution of marriage or termination of a domestic
				partnership;
(d) A permanent change
				in residence, work, or living situation, whether or not within the choice of
				the individual, where the health plan under which they were covered does not
				provide coverage in that person's new service area;
(e) The birth, placement for or adoption of
				the person for whom coverage is sought. For newborns, coverage must be
				effective from the moment of birth; for those adopted or placed for adoption,
				coverage must be effective from the date of adoption or placement for adoption,
				whichever occurs first;
(f) A
				situation in which a plan no longer offers any benefits to the class of
				similarly situated individuals that includes the individual;
(g) Coverage is discontinued in a qualified
				health plan by the health benefit exchange pursuant to  45 C.F.R. 155.430  and
				the three month grace period for continuation of coverage has
				expired;
(h) Exhaustion of COBRA
				coverage due to failure of the employer to remit premium;
(i) Loss of COBRA coverage where the
				individual has exceeded the lifetime limit in the plan and no other COBRA
				coverage is available;
(j) If the
				person discontinues coverage under a health plan offered pursuant to chapter
				48.41 RCW;
(k) Loss of coverage as
				a dependent on a group plan due to age;
(l) Marriage or entering into a domestic
				partnership, including eligibility as a dependent of an individual marrying or
				entering into a domestic partnership.