Last Update: 12/14/15

Chapter 284-43 WAC

HEALTH CARRIERS AND HEALTH PLANS

WAC Sections

SUBCHAPTER A
GENERAL PROVISIONS
Purpose.
Applicability and scope.
Compliance with state and federal laws.
Definitions.
SUBCHAPTER B
PLAN MANAGEMENT
Deadline for filing individual health plans, small group health plans, and stand-alone dental plans.
Transitional reinsurance program.
Risk adjustment program.
Grandfathered health plan status.
Market conduct requirements related to grandfathered status.
Small group coverage market transition requirements.
Association health plan compliance with statutory or regulatory changes.
Transition of plans purchased by association members.
Individual coverage market transition requirements.
SUBCHAPTER C
OPEN AND SPECIAL ENROLLMENT REQUIREMENTS
Special enrollment requirements for small group plans.
Special enrollment periods for small group qualified health plans.
Duration and effective dates of small group special enrollment periods.
Individual market open enrollment requirements.
Individual market special enrollment requirements.
Individual market special enrollment period requirements for qualified health plans.
Duration, notice requirements and effective dates of coverage for individual market special enrollment periods.
SUBCHAPTER D
UTILIZATION REVIEW
Health care services utilization reviewGenerally.
Drug utilization reviewGenerally.
SUBCHAPTER E
ADVERSE BENEFIT DETERMINATION PROCESS REQUIREMENTS FOR NONGRANDFATHERED PLANS
Scope and intent.
Definitions.
Review of adverse benefit determinationsGenerally.
Explanation of right to review.
Notice and explanation of adverse benefit determinationGeneral requirements.
Electronic disclosure and communication by carriers.
Internal review of adverse benefit determinations.
Exhaustion of internal review remedies.
Notice of internal review determination.
Expedited review.
Concurrent expedited review of adverse benefit determinations.
External review of adverse benefit determinations.
SUBCHAPTER F
GRANDFATHERED HEALTH PLAN APPEAL PROCEDURES
Application of subchapter F.
Grievance and complaint proceduresGenerally.
Procedures for review and appeal of adverse determinations.
Independent review of adverse determinations.
SUBCHAPTER G
GRIEVANCES
Definition.
Grievance processGenerally.
SUBCHAPTER H
HEALTH PLAN BENEFITS
Preexisting condition limitations.
Recognizing the exercise of conscience by purchasers of basic health plan services and ensuring access for all enrollees to such services.
Coverage for pharmacy services.
General prescription drug benefit requirements.
Prescription drug benefit design.
Formulary changes.
Cost-sharing for prescription drugs.
Health plan disclosure requirements.
Unfair practice relating to health coverage.
Prescription drug benefit disclosures.
Anticancer medication.
Purpose and scope.
Definitions.
Clinical trials.
Medical necessity determination.
Essential health benefits package benchmark reference plan.
Essential health benefits package benchmark reference plan.
Plan design.
Plan design.
Essential health benefit categories.
Essential health benefit categories.
Essential health benefit categoryPediatric oral services.
Essential health benefit categoryPediatric oral services.
Purpose and scope—Pediatric dental benefits for health benefit plans sold outside of the health benefit exchange.
Definitions.
Pediatric dental benefits design—Methods of satisfying requirements.
Pediatric vision services.
Pediatric vision services.
Plan cost-sharing and benefit substitutions and limitations.
Representations regarding coverage.
Effective date.
SUBCHAPTER IHEALTH PLAN RATES
Authority and purpose.
Applicability and scope.
Definitions.
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.
General contents of all filings.
Issuer filing of attestation form, transparency tools.
Contents of individual and small group filings.
Experience records.
Evaluating experience data.
Summary for individual and small group contract filings.
Geographic rating area factor development.
Geographic rating area designation.
SUBCHAPTER K
MENTAL HEALTH AND SUBSTANCE USE DISORDER
Scope and intentParity in mental health and substance use disorder benefits.
Definitions.
Classification of benefits.
Measuring health plan benefitsFinancial requirements and quantitative treatment limitations.
Measuring health plan benefitsNonquantitative treatment limitations.
Prohibited exclusions.
Required disclosures.
Compliance and reporting of quantitative parity analysis.
SUBCHAPTER Y
HEALTH CARE NETWORKS
When a carrier is required to file.
Summary for group contract filings other than small group contract filings.
Network accessGeneral standards.
Alternate access delivery request.
Maintenance of sufficient provider networks.
Use of subcontracted networks.
Provider directories.
Every category of health care providers.
Network reportsFormat.
Essential community providers for exchange plansDefinition.
Essential community providers for exchange plansNetwork access.
Issuer recordkeepingProvider networks.
Tiered provider networks.
Assessment of access.
Issuer standards for women's right to directly access certain health care practitioners for women's health care services.
Enrollee's access to providers.
Hospital emergency service departments and practice groups.
Standards for temporary substitution of contracted network providers"Locum tenens" providers.
Rule concerning contracted network providers called to active duty military service.
SUBCHAPTER Z
PROVIDER CONTRACTS AND PAYMENT
Provider and facility contracts with issuersGenerally.
Selection of participating providersCredentialing and unfair discrimination.
Provider contractsStandardsHold harmless provisions.
Provider contractsTerms and conditions of payment.
Provider contractsDispute resolution process.
Pharmacy identification cards.
Provider contractsAudit guidelines.
Pharmacy claimsRejections, notifications and disclosures.
Participating providerFiling and approval.
Effective date.