Chapter 284-43 WAC: HEALTH CARRIERS AND HEALTH PLANS

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WACs > Title 284 > Chapter 284-43

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Chapter 284-43 WAC	Last Update: 1/9/13
HEALTH CARRIERS AND HEALTH PLANS

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WAC Sections

SUBCHAPTER A GENERAL PROVISIONS
284-43-110	Purpose.
284-43-120	Applicability and scope.
284-43-125	Compliance with state and federal laws.
284-43-130	Definitions.
SUBCHAPTER B HEALTH CARE NETWORKS
284-43-200	Network adequacy.
284-43-205	Every category of health care providers.
284-43-220	Network reports -- Format.
284-43-250	Health carrier standards for women's right to directly access certain health care practitioners for women's health care services.
284-43-251	Covered person's access to providers.
284-43-260	Standards for temporary substitution of contracted network providers -- "Locum tenens" providers.
284-43-262	Rule concerning contracted network providers called to active duty military service.
SUBCHAPTER C PROVIDER CONTRACTS AND PAYMENT
284-43-300	Provider and facility contracts with health carriers -- Generally.
284-43-310	Selection of participating providers -- Credentialing and unfair discrimination.
284-43-320	Provider contracts -- Standards -- Hold harmless provisions.
284-43-321	Provider contracts -- Terms and conditions of payment.
284-43-322	Provider contracts -- Dispute resolution process.
284-43-323	Pharmacy identification cards.
284-43-324	Provider contracts -- Audit guidelines.
284-43-330	Participating provider -- Filing and approval.
284-43-331	Effective date.
284-43-340	Effective date.
SUBCHAPTER D UTILIZATION REVIEW
284-43-410	Utilization review -- Generally.
SUBCHAPTER E ADVERSE BENEFIT DETERMINATION PROCESS REQUIREMENTS FOR NONGRANDFATHERED PLANS
284-43-500	Scope and intent.
284-43-505	Definitions.
284-43-510	Review of adverse benefit determinations -- Generally.
284-43-511	Explanation of right to review.
284-43-515	Notice and explanation of adverse benefit determination -- General requirements.
284-43-520	Electronic disclosure and communication by carriers.
284-43-525	Internal review of adverse benefit determinations.
284-43-530	Exhaustion of internal review remedies.
284-43-535	Notice of internal review determination.
284-43-540	Expedited review.
284-43-545	Concurrent expedited review of adverse benefit determinations.
284-43-550	External review of adverse benefit determinations.
SUBCHAPTER F GRANDFATHERED HEALTH PLAN APPEAL PROCEDURES
284-43-611	Application of subchapter F.
284-43-615	Grievance and complaint procedures -- Generally.
284-43-620	Procedures for review and appeal of adverse determinations.
284-43-630	Independent review of adverse determinations.
SUBCHAPTER G GRIEVANCES
284-43-711	Definition.
284-43-721	Grievance process -- Generally.
SUBCHAPTER H HEALTH PLAN BENEFITS
284-43-800	Recognizing the exercise of conscience by purchasers of basic health plan services and ensuring access for all enrollees to such services.
284-43-815	Coverage for pharmacy services.
284-43-816	General prescription drug benefit requirements.
284-43-817	Prescription drug benefit design.
284-43-818	Formulary changes.
284-43-819	Cost-sharing for prescription drugs.
284-43-820	Health plan disclosure requirements.
284-43-822	Unfair practice relating to health coverage.
284-43-825	Prescription drug benefit disclosures.
284-43-840	Anticancer medication.
284-43-850	Clinical trials.
284-43-865	Essential health benefits package benchmark reference plan.
284-43-899	Effective date.
SUBCHAPTER I -- HEALTH PLAN RATES
284-43-901	Authority and purpose.
284-43-905	Applicability and scope.
284-43-910	Definitions.
284-43-915	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.
284-43-920	When a carrier is required to file.
284-43-925	General contents of all filings.
284-43-930	Contents of individual and small group filings.
284-43-935	Experience records.
284-43-940	Evaluating experience data.
284-43-945	Summary for individual and small group contract filings.
284-43-950	Summary for group contract filings other than small group contract filings.
SUBCHAPTER J HEALTH PLAN ENROLLMENT AND COVERAGE REQUIREMENTS
284-43-970	Purpose and scope.
284-43-975	Definitions.
284-43-980	Preexisting conditions.
284-43-985	Enrollment of persons under age nineteen.

DISPOSITIONS OF SECTIONS FORMERLY CODIFIED IN THIS CHAPTER

284-43-040	Review and approval of certified health plan provider selection, termination, and dispute resolution provisions. [Statutory Authority: RCW 48.01.030, 48.02.060 (3)(a), 48.43.140, 43.72.100(4) and 43.72.100(6). 94-23-056, § 284-43-040, filed 11/14/94, effective 12/15/94.] Repealed by 98-04-005 (Matter No. R 97-3), filed 1/22/98, effective 2/22/98. 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.
284-43-100	Health carrier standards for women's right to directly access certain health care practitioners for women's health care services. [Statutory Authority: RCW 48.02.060, 48.18.120, 48.20.450, 48.20.460, 48.44.020, 48.44.050, 48.44.070, 48.46.200 and 48.46.243. 96-16-050 (Matter No. R 95-10), § 284-43-100, filed 8/1/96, effective 9/1/96.] Repealed by 98-04-005 (Matter No. R 97-3), filed 1/22/98, effective 2/22/98. 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.
284-43-210	Access plan. [Statutory Authority: RCW 48.02.060, 48.18.120, 48.20.450, 48.20.460, 48.30.010, 48.44.050, 48.46.030, 48.46.200. 00-04-034 (Matter No. R 99-2), § 284-43-210, filed 1/24/00, effective 1/1/01. 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), § 284-43-210, filed 1/22/98, effective 2/22/98.] Repealed by 08-17-037 (Matter No. R 2008-17), filed 8/13/08, effective 9/13/08. Statutory Authority: RCW 48.02.060.
284-43-610	Definitions. [Statutory Authority: RCW 48.02.060, 48.18.120, 48.20.450, 48.20.460, 48.30.010, 48.43.055, 48.44.050, 48.46.100 and 48.46.200. 99-24-075 (Matter No. R 98-17), § 284-43-610, filed 11/29/99, effective 12/30/99.] Repealed by 01-03-033 (Matter No. R 2000-02), filed 1/9/01, effective 7/1/01. Statutory Authority: RCW 48.02.060, 48.18.120, 48.20.450, 48.20.460, 48.30.010, 48.44.050, 48.46.100, 48.46.200, 48.43.505, 48.43.510, 48.43.515, 48.43.520, 48.43.525, 48.43.530, 48.43.535.
284-43-700	Purpose. [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), § 284-43-700, filed 1/22/98, effective 2/22/98.] Repealed by 08-09-022 (Matter No. R 2008-01), filed 4/7/08, effective 5/8/08. Statutory Authority: RCW 48.02.060, 48.20.450, 48.20.460, 48.44.050, 48.46.030, 48.46.200.
284-43-710	Portability of health insurance benefits. [Statutory Authority: RCW 48.02.060, 48.18.120, 48.20.450, 48.20.460, 48.30.010, 48.44.050, 48.46.030, 48.46.200. 00-04-034 (Matter No. R 99-2), § 284-43-710, filed 1/24/00, effective 2/24/00. 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), § 284-43-710, filed 1/22/98, effective 2/22/98.] Repealed by 08-09-022 (Matter No. R 2008-01), filed 4/7/08, effective 5/8/08. Statutory Authority: RCW 48.02.060, 48.20.450, 48.20.460, 48.44.050, 48.46.030, 48.46.200.
284-43-720	Guaranteed issue and restrictions on the denial, exclusion, or limitation of health benefits for preexisting conditions. [Statutory Authority: RCW 48.02.060, 48.18.120, 48.20.450, 48.20.460, 48.30.010, 48.44.050, 48.46.030, 48.46.200. 00-04-034 (Matter No. R 99-2), § 284-43-720, filed 1/24/00, effective 2/24/00. 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), § 284-43-720, filed 1/22/98, effective 2/22/98.] Repealed by 08-09-022 (Matter No. R 2008-01), filed 4/7/08, effective 5/8/08. Statutory Authority: RCW 48.02.060, 48.20.450, 48.20.460, 48.44.050, 48.46.030, 48.46.200.
284-43-730	Guaranteed renewability -- Health insurance. [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), § 284-43-730, filed 1/22/98, effective 2/22/98.] Repealed by 08-09-022 (Matter No. R 2008-01), filed 4/7/08, effective 5/8/08. Statutory Authority: RCW 48.02.060, 48.20.450, 48.20.460, 48.44.050, 48.46.030, 48.46.200.
284-43-810	Coverage for mental health services. [Statutory Authority: RCW 48.02.060, 48.30.010, 48.44.050, 48.46.200, 48.30.040, 48.44.110 and 48.46.400. 99-19-032 (Matter No. R 98-7), § 284-43-810, filed 9/8/99, effective 10/9/99.] Repealed by 08-09-021 (Matter No. R 2008-02), filed 4/7/08, effective 5/8/08. Statutory Authority: RCW 48.02.060, 48.18.120(2), 48.20.450, 48.20.460, 48.44.050, 48.46.200. Later promulgation, see RCW 48.20.580, 48.21.240, 48.44.341 and 48.46.291.
284-43-821	Maternity and pregnancy-related exclusions, limitations and conditions in individual plans. [Statutory Authority: 2000 c 79 and RCW 48.43.041, 48.44.020, and 48.46.060. 01-03-035 (Matter No. R 2000-03), § 284-43-821, filed 1/9/01, effective 7/1/01.] Repealed by 01-19-001 (Matter No. R 2001-02), filed 9/5/01, effective 10/6/01. Statutory Authority: RCW 48.02.060, 48.18.480, 48.20.450, 48.20.460, 48.21.045, 48.30.010, 48.30.300, 48.41.110, 48.41.170, 48.42.010, 48.42.040, 48.42.100, 48.43.012, 48.43.025, 48.43.035, 48.43.041, 48.43.115, 48.43.520, 48.44.020, 48.44.023, 48.44.050, 48.44.220, 48.46.060, 48.46.066, 48.46.110, 48.46.200, 49.60.010, 49.60.030, 49.60.120, 49.60.178, 49.60.220.
284-43-823	Maternity and pregnancy-related exclusions, limitations and conditions in group plans. [Statutory Authority: 2000 c 79 and RCW 48.43.041, 48.44.020, and 48.46.060. 01-03-035 (Matter No. R 2000-03), § 284-43-823, filed 1/9/01, effective 7/1/01.] Repealed by 01-19-001 (Matter No. R 2001-02), filed 9/5/01, effective 10/6/01. Statutory Authority: RCW 48.02.060, 48.18.480, 48.20.450, 48.20.460, 48.21.045, 48.30.010, 48.30.300, 48.41.110, 48.41.170, 48.42.010, 48.42.040, 48.42.100, 48.43.012, 48.43.025, 48.43.035, 48.43.041, 48.43.115, 48.43.520, 48.44.020, 48.44.023, 48.44.050, 48.44.220, 48.46.060, 48.46.066, 48.46.110, 48.46.200, 49.60.010, 49.60.030, 49.60.120, 49.60.178, 49.60.220.
284-43-824	Effective date. [Statutory Authority: 2000 c 79 and RCW 48.43.041, 48.44.020, and 48.46.060. 01-03-035 (Matter No. R 2000-03), § 284-43-824, filed 1/9/01, effective 2/9/01.] Repealed by 01-19-001 (Matter No. R 2001-02), filed 9/5/01, effective 10/6/01. Statutory Authority: RCW 48.02.060, 48.18.480, 48.20.450, 48.20.460, 48.21.045, 48.30.010, 48.30.300, 48.41.110, 48.41.170, 48.42.010, 48.42.040, 48.42.100, 48.43.012, 48.43.025, 48.43.035, 48.43.041, 48.43.115, 48.43.520, 48.44.020, 48.44.023, 48.44.050, 48.44.220, 48.46.060, 48.46.066, 48.46.110, 48.46.200, 49.60.010, 49.60.030, 49.60.120, 49.60.178, 49.60.220.
284-43-900	Authority and purpose. [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), § 284-43-900, filed 1/23/98, effective 3/1/98.] Repealed by 05-07-006 (Matter No. R 2004-05), filed 3/3/05, effective 4/3/05. Statutory Authority: RCW 48.02.060, 48.44.050, and 48.46.200.
284-43-955	Effective date. [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), § 284-43-955, filed 1/23/98, effective 3/1/98.] Repealed by 05-07-006 (Matter No. R 2004-05), filed 3/3/05, effective 4/3/05. Statutory Authority: RCW 48.02.060, 48.44.050, and 48.46.200.