Chapter 284-43 WAC

Last Update: 10/17/18

HEALTH CARRIERS AND HEALTH PLANS

WAC Sections

SUBCHAPTER A
GENERAL PROVISIONS
284-43-0110Purpose.
284-43-0120Applicability and scope.
284-43-0140Compliance with state and federal laws.
284-43-0160Definitions.
SUBCHAPTER B
PLAN MANAGEMENT
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.
284-43-0310Association health plan compliance with statutory or regulatory changes.
284-43-0330Transition of plans purchased by association members.
284-43-0350Individual coverage market transition requirements.
SUBCHAPTER C
OPEN AND SPECIAL ENROLLMENT REQUIREMENTS
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.
SUBCHAPTER D
PRIOR AUTHORIZATION AND UTILIZATION REVIEW
284-43-2000Health care services utilization review—Generally.
284-43-2020Drug utilization review—Generally.
284-43-2050Prior authorization processes.
284-43-2060Extenuating circumstances in prior authorization.
SUBCHAPTER E
ADVERSE BENEFIT DETERMINATION PROCESS REQUIREMENTS FOR NONGRANDFATHERED PLANS
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.
SUBCHAPTER F
GRANDFATHERED HEALTH PLAN APPEAL PROCEDURES
284-43-4000Application of subchapter F.
284-43-4020Grievance and complaint procedures—Generally.
284-43-4040Procedures for review and appeal of adverse determinations.
SUBCHAPTER G
GRIEVANCES
284-43-4500Definition.
284-43-4520Grievance process—Generally.
SUBCHAPTER H
HEALTH PLAN BENEFITS
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.
284-43-5170Prescription drug benefit disclosures.
284-43-5200Anticancer medication.
284-43-5400Purpose and scope.
284-43-5410Definitions.
284-43-5420Clinical trials.
284-43-5440Medical necessity determination.
284-43-5600Essential health benefits package benchmark reference plan.
284-43-5602Essential health benefits package benchmark reference plan.
284-43-5620Plan design.
284-43-5622Plan design.
284-43-5640Essential health benefit categories.
284-43-5642Essential health benefit categories.
284-43-5700Essential health benefit category—Pediatric oral services.
284-43-5702Essential 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.
284-43-5780Pediatric vision services.
284-43-5782Pediatric vision services.
284-43-5800Plan cost-sharing and benefit substitutions and limitations.
284-43-5820Representations regarding coverage.
284-43-5900Effective date.
SUBCHAPTER I
HEALTH PLAN RATES
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.
SUBCHAPTER J
HEALTH PLANS, STAND-ALONE DENTAL PLANS AND STAND-ALONE VISION PLANSFILING REQUIREMENTS
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.
284-43-6600Issuer 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.
SUBCHAPTER K
MENTAL HEALTH AND SUBSTANCE USE DISORDER
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 health plan benefits—Financial requirements and quantitative treatment limitations.
284-43-7060Measuring health plan benefits—Nonquantitative treatment limitations.
284-43-7080Prohibited exclusions.
284-43-7100Required disclosures.
284-43-7120Compliance and reporting of quantitative parity analysis.
SUBCHAPTER L
SHORT-TERM LIMITED DURATION MEDICAL PLANS
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.
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