48.43.0125  <<  48.43.0126 >>   48.43.0127

Summary of benefits and explanation of coverageStandards and requirementsNotice of modificationFinesStandards for definitions of health insurance termsRules.

(1) The commissioner shall develop standards for use by a health carrier offering individual or group coverage, in compiling and providing to applicants and enrollees a summary of benefits and coverage explanation that accurately describes the benefits and coverage under the applicable plan. In developing the standards, the commissioner must use the standards developed under 42 U.S.C. Sec. 300gg-15 in use on April 17, 2019.
(2) The standards must provide for the following:
(a) The standards must ensure that the summary of benefits and coverage is presented in a uniform format that does not exceed four pages in length and does not include print smaller than twelve-point font.
(b) The standards must ensure that the summary is presented in a culturally and linguistically appropriate manner and utilizes terminology understandable by the average plan enrollee.
(c) The standards must ensure that the summary of benefits and coverage includes:
(i) Uniform definitions of standard insurance and medical terms, consistent with the standard definitions developed under this section, so that consumers may compare health insurance coverage and understand the terms of coverage, or exceptions to such coverage;
(ii) A description of the coverage, including cost sharing for:
(A) The essential health benefits; and
(B) Other benefits identified by the commissioner;
(iii) The exceptions, reductions, and limitations on coverage;
(iv) The cost-sharing provisions, including deductible, coinsurance, and copayment obligations;
(v) The renewability and continuation of coverage provisions;
(vi) A coverage facts label that includes examples to illustrate common benefits scenarios, including pregnancy and serious or chronic medical conditions and related cost sharing. The scenarios must be based on recognized clinical practice guidelines;
(vii) A statement of whether the plan:
(A) Provides minimum essential coverage under 26 U.S.C. Sec. 5000A(f); and
(B) Ensures that the plan share of the total allowed costs of benefits provided under the plan is no less than sixty percent of the costs;
(viii) A statement that the outline is a summary of the policy or certificate and that the coverage document itself should be consulted to determine the governing contractual provisions; and
(ix) A contact number for the consumer to call with additional questions and a website where a copy of the actual individual coverage policy or group certificate of coverage may be reviewed and obtained.
(3) The commissioner shall periodically review and update the standards developed under this section.
(4) A health carrier must provide a summary of benefits and coverage explanation to:
(a) An applicant at the time of application;
(b) An enrollee prior to the time of enrollment or reenrollment, as applicable; and
(c) A policyholder or certificate holder at the time of issuance of the policy or delivery of the certificate.
(5) A health carrier may provide the summary of benefits and coverage either in paper or electronically.
(6) If a health carrier makes any material modification in any of the terms of the plan that is not reflected in the most recently provided summary of benefits and coverage, the carrier shall provide notice of the modification to enrollees no later than sixty days prior to the date on which the modification will become effective.
(7) A health carrier that fails to provide the information required under this section is subject to a fine of no more than one thousand dollars for each failure. A failure with respect to each enrollee constitutes a separate offense for purposes of this subsection.
(8) The commissioner shall, by rule, provide for the development of standards for the definitions of terms used in health insurance coverage, including the following:
(a) Insurance-related terms, including premium; deductible; coinsurance; copayment; out-of-pocket limit; preferred provider; nonpreferred provider; out-of-network copayments; usual, customary, and reasonable fees; excluded services; grievance; appeals; and any other terms the commissioner determines are important to define so that consumers may compare health insurance coverage and understand the terms of their coverage; and
(b) Medical terms, including hospitalization, hospital outpatient care, emergency room care, physician services, prescription drug coverage, durable medical equipment, home health care, skilled nursing care, rehabilitation services, hospice services, emergency medical transportation, and any other terms the commissioner determines are important to define so that consumers may compare the medical benefits offered by health insurance and understand the extent of those medical benefits or exceptions to those benefits.
(9) Unless preempted by federal law, the commissioner shall adopt any rules necessary to implement this section, consistent with federal rules and guidance in effect on January 1, 2017, implementing the patient protection and affordable care act.


Effective date2019 c 33: See note following RCW 48.43.005.
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