Wash. Admin. Code ch. 284-43 – Health Carriers and Health Plans | Midpage

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Washington Administrative Code (WAC)

Chapter 43

Wash. Admin. Code ch. 284-43

Health Carriers and Health Plans

INSURANCE COMMISSIONER, OFFICE OF THE

284-43-0110Purpose 284-43-0120Applicability and scope 284-43-0140Compliance with state and federal laws 284-43-0160Definitions 284-43-0200Deadline for filing individual health plans, small group health plans, and stand-alone dental plans 284-43-0210Transitional reinsurance program 284-43-0230Risk adjustment program 284-43-0250Grandfathered health plan status 284-43-0270Market conduct requirements related to grandfathered status 284-43-0290Small group coverage market transition requirements 284-43-0350Individual coverage market transition requirements 284-43-0400Purpose and scope 284-43-0410Definitions 284-43-0420Sensitive health care services 284-43-0430Requests regarding confidentiality and to limit disclosure 284-43-1020Special enrollment requirements for small group plans 284-43-1040Special enrollment periods for small group qualified health plans 284-43-1060Duration and effective dates of small group special enrollment periods 284-43-1080Individual market open enrollment requirements 284-43-1100Individual market special enrollment requirements 284-43-1120Individual market special enrollment period requirements for qualified health plans 284-43-1140Duration, notice requirements and effective dates of coverage for individual market special enrollment periods 284-43-2000Health care services utilization review—Generally 284-43-2020Drug utilization review—Generally 284-43-2021Prescription drug utilization management exception and substitution process 284-43-2022Time frame for exception and substitution request determinations 284-43-2050Prior authorization processes 284-43-2060Extenuating circumstances in prior authorization 284-43-2070Forms for authorization of inpatient or residential substance use disorder treatment 284-43-3000Scope and intent 284-43-3010Definitions 284-43-3030Review of adverse benefit determinations—Generally 284-43-3050Explanation of right to review 284-43-3070Notice and explanation of adverse benefit determination—General requirements 284-43-3090Electronic disclosure and communication by carriers 284-43-3110Internal review of adverse benefit determinations 284-43-3130Exhaustion of internal review remedies 284-43-3150Notice of internal review determination 284-43-3170Expedited review 284-43-3190Concurrent expedited review of adverse benefit determinations 284-43-4000Application of subchapter F 284-43-4020Grievance and complaint procedures—Generally 284-43-4040Procedures for review and appeal of adverse determinations 284-43-4500Definition 284-43-4520Grievance process—Generally 284-43-5000Preexisting condition limitations 284-43-5020Recognizing the exercise of conscience by purchasers of basic health plan services and ensuring access for all enrollees to such services 284-43-5060General prescription drug benefit requirements 284-43-5080Prescription drug benefit design 284-43-5100Formulary changes 284-43-5110Cost-sharing for prescription drugs 284-43-5130Health plan disclosure requirements 284-43-5150Unfair practice relating to health coverage 284-43-5151Unfair practice relating to gender affirming treatment and services 284-43-5170Prescription drug benefit disclosures 284-43-5200Anticancer medication 284-43-5400Purpose and scope 284-43-5410Definitions 284-43-5420Clinical trials 284-43-5440Medical necessity determination 284-43-5602Essential health benefits package benchmark reference plan 284-43-5604Essential health benefits package benchmark plan 284-43-5622Plan design 284-43-5624Plan design 284-43-5642Essential health benefit categories 284-43-5644Essential health benefit categories 284-43-5702Essential health benefit category—Pediatric oral services 284-43-5704Essential health benefit category—Pediatric oral services 284-43-5720Purpose and scope—Pediatric dental benefits for health benefit plans sold outside of the health benefit exchange 284-43-5740Definitions 284-43-5760Pediatric dental benefits design—Methods of satisfying requirements 284-43-5782Pediatric vision services 284-43-5784Pediatric vision services 284-43-5800Plan cost-sharing and benefit substitutions and limitations 284-43-5820Representations regarding coverage 284-43-5900Effective date 284-43-5910Prohibition on organ transplant waiting periods 284-43-5920Health plan rescission 284-43-5930Qualified health plan marketing and benefit design 284-43-5935Definitions 284-43-5937Hearing instrument coverage 284-43-5939Hearing instrument coverage 284-43-5940Nondiscrimination in health plans, short-term limited duration medical plans and student-only health plans 284-43-5950Access for individuals with limited-English proficiency and individuals with disabilities 284-43-5960Meaningful access for individuals with limited-English proficiency 284-43-5965Effective communication for people with disabilities 284-43-5970Equal program access on the basis of sex 284-43-5975Designation of responsible employee and adoption of grievance procedures 284-43-5980Notice requirement 284-43-6000Authority and purpose 284-43-6010Applicability and scope 284-43-6020Definitions 284-43-6040Demonstration that benefits provided are not reasonable in relation to the amount charged for a contract per RCW 48.44.020 and 48.46.060 284-43-6100Contents of individual and small group filings 284-43-6500Applicability and scope 284-43-6520Definitions 284-43-6540Summary for group contract filings other than small group contract filings 284-43-6560When a carrier is required to file 284-43-6580General contents of all filings 284-43-6590Requirements for mitigating inequity in the health insurance market 284-43-6600Issuer filing of attestation form, transparency tools 284-43-6620Experience records 284-43-6640Evaluating experience data 284-43-6660Summary for individual and small group contract filings 284-43-6680Geographic rating area factor development 284-43-6681Geographic rating area factor development on or after January 1, 2019 284-43-6700Geographic rating area designation 284-43-6701Geographic rating area designation on or after January 1, 2019 284-43-6800Definitions 284-43-6810Standardized induced demand factors and AV pricing value guardrails 284-43-6820Uniform cost-sharing reduction silver load adjustment factor 284-43-7000Scope and intent—Parity in mental health and substance use disorder benefits 284-43-7010Definitions 284-43-7020Classification of benefits 284-43-7040Measuring plan benefits—Financial requirements and quantitative treatment limitations 284-43-7060Measuring plan benefits—Nonquantitative treatment limitations 284-43-7080Prohibited exclusions 284-43-7100Required disclosures 284-43-7120Compliance and reporting of quantitative parity analysis 284-43-7200Purpose and scope 284-43-7210Definitions 284-43-7220Coverage required 284-43-7230Services provided without discrimination, prohibited limitations, and confidentiality 284-43-7240Access to contraceptive services and supplies 284-43-7250Filing requirements 284-43-7260Deductibles for over-the-counter contraceptives and voluntary male sterilization in HSA qualifying plans 284-43-7270Access to prenatal vitamins and breast pumps 284-43-8000Definition of short-term limited duration medical plan 284-43-8010Standard disclosure form for short-term limited duration medical plans 284-43-8020Commissioner's approval required 284-43-8030Short-term limited duration medical plan cancellation and rescission 284-43-8100Definitions 284-43-8110Requirements for Pathway 1 Association Health Plan form filings related to the bona fide status of Pathway 1 Associations 284-43-8120Requirements for governmental plans 284-43-8130Association health plan compliance with statutory or regulatory changes 284-43-8140Transition of plans purchased by association members 284-43-8210Definitions 284-43-8220Prompt reply to the commissioner required 284-43-8230Continuously sharing medical expenses