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Chapter 284-43 WAC

|Show DispositionsLast Update: 11/30/23

HEALTH CARRIERS AND HEALTH PLANS

WAC Sections

SUBCHAPTER A
GENERAL PROVISIONS
HTMLPDF284-43-0110Purpose.
HTMLPDF284-43-0120Applicability and scope.
HTMLPDF284-43-0140Compliance with state and federal laws.
HTMLPDF284-43-0160Definitions.
SUBCHAPTER B1
PLAN MANAGEMENT
HTMLPDF284-43-0200Deadline for filing individual health plans, small group health plans, and stand-alone dental plans.
HTMLPDF284-43-0210Transitional reinsurance program.
HTMLPDF284-43-0230Risk adjustment program.
HTMLPDF284-43-0250Grandfathered health plan status.
HTMLPDF284-43-0270Market conduct requirements related to grandfathered status.
HTMLPDF284-43-0290Small group coverage market transition requirements.
HTMLPDF284-43-0350Individual coverage market transition requirements.
SUBCHAPTER B2
CONFIDENTIALITY OF INSURANCE COMMUNICATIONS
HTMLPDF284-43-0400Purpose and scope.
HTMLPDF284-43-0410Definitions.
HTMLPDF284-43-0420Sensitive health care services.
HTMLPDF284-43-0430Requests regarding confidentiality and to limit disclosure.
SUBCHAPTER C
OPEN AND SPECIAL ENROLLMENT REQUIREMENTS
HTMLPDF284-43-1020Special enrollment requirements for small group plans.
HTMLPDF284-43-1040Special enrollment periods for small group qualified health plans.
HTMLPDF284-43-1060Duration and effective dates of small group special enrollment periods.
HTMLPDF284-43-1080Individual market open enrollment requirements.
HTMLPDF284-43-1100Individual market special enrollment requirements.
HTMLPDF284-43-1120Individual market special enrollment period requirements for qualified health plans.
HTMLPDF284-43-1140Duration, notice requirements and effective dates of coverage for individual market special enrollment periods.
SUBCHAPTER D
PRIOR AUTHORIZATION AND UTILIZATION REVIEW
HTMLPDF284-43-2000Health care services utilization review—Generally.
HTMLPDF284-43-2020Drug utilization review—Generally.
HTMLPDF284-43-2021Prescription drug utilization management exception and substitution process.
HTMLPDF284-43-2022Time frame for exception and substitution request determinations.
HTMLPDF284-43-2050Prior authorization processes.
HTMLPDF284-43-2060Extenuating circumstances in prior authorization.
SUBCHAPTER E
ADVERSE BENEFIT DETERMINATION PROCESS REQUIREMENTS FOR NONGRANDFATHERED PLANS
HTMLPDF284-43-3000Scope and intent.
HTMLPDF284-43-3010Definitions.
HTMLPDF284-43-3030Review of adverse benefit determinations—Generally.
HTMLPDF284-43-3050Explanation of right to review.
HTMLPDF284-43-3070Notice and explanation of adverse benefit determination—General requirements.
HTMLPDF284-43-3090Electronic disclosure and communication by carriers.
HTMLPDF284-43-3110Internal review of adverse benefit determinations.
HTMLPDF284-43-3130Exhaustion of internal review remedies.
HTMLPDF284-43-3150Notice of internal review determination.
HTMLPDF284-43-3170Expedited review.
HTMLPDF284-43-3190Concurrent expedited review of adverse benefit determinations.
SUBCHAPTER F
GRANDFATHERED HEALTH PLAN APPEAL PROCEDURES
HTMLPDF284-43-4000Application of subchapter F.
HTMLPDF284-43-4020Grievance and complaint procedures—Generally.
HTMLPDF284-43-4040Procedures for review and appeal of adverse determinations.
SUBCHAPTER G
GRIEVANCES
HTMLPDF284-43-4500Definition.
HTMLPDF284-43-4520Grievance process—Generally.
SUBCHAPTER H
HEALTH PLAN BENEFITS
HTMLPDF284-43-5000Preexisting condition limitations.
HTMLPDF284-43-5020Recognizing the exercise of conscience by purchasers of basic health plan services and ensuring access for all enrollees to such services.
HTMLPDF284-43-5060General prescription drug benefit requirements.
HTMLPDF284-43-5080Prescription drug benefit design.
HTMLPDF284-43-5100Formulary changes.
HTMLPDF284-43-5110Cost-sharing for prescription drugs.
HTMLPDF284-43-5130Health plan disclosure requirements.
HTMLPDF284-43-5150Unfair practice relating to health coverage.
HTMLPDF284-43-5151Unfair practice relating to gender affirming treatment and services.
HTMLPDF284-43-5170Prescription drug benefit disclosures.
HTMLPDF284-43-5200Anticancer medication.
HTMLPDF284-43-5400Purpose and scope.
HTMLPDF284-43-5410Definitions.
HTMLPDF284-43-5420Clinical trials.
HTMLPDF284-43-5440Medical necessity determination.
HTMLPDF284-43-5600Essential health benefits package benchmark reference plan.
HTMLPDF284-43-5602Essential health benefits package benchmark reference plan.
HTMLPDF284-43-5620Plan design.
HTMLPDF284-43-5622Plan design.
HTMLPDF284-43-5640Essential health benefit categories.
HTMLPDF284-43-5642Essential health benefit categories.
HTMLPDF284-43-5700Essential health benefit category—Pediatric oral services.
HTMLPDF284-43-5702Essential health benefit category—Pediatric oral services.
HTMLPDF284-43-5720Purpose and scope—Pediatric dental benefits for health benefit plans sold outside of the health benefit exchange.
HTMLPDF284-43-5740Definitions.
HTMLPDF284-43-5760Pediatric dental benefits design—Methods of satisfying requirements.
HTMLPDF284-43-5780Pediatric vision services.
HTMLPDF284-43-5782Pediatric vision services.
HTMLPDF284-43-5800Plan cost-sharing and benefit substitutions and limitations.
HTMLPDF284-43-5820Representations regarding coverage.
HTMLPDF284-43-5900Effective date.
HTMLPDF284-43-5910Prohibition on organ transplant waiting periods.
HTMLPDF284-43-5920Health plan rescission.
HTMLPDF284-43-5930Qualified health plan marketing and benefit design.
HTMLPDF284-43-5935Definitions.
HTMLPDF284-43-5937Hearing instrument coverage.
HTMLPDF284-43-5940Nondiscrimination in health plans, short-term limited duration medical plans and student-only health plans.
HTMLPDF284-43-5950Access for individuals with limited-English proficiency and individuals with disabilities.
HTMLPDF284-43-5960Meaningful access for individuals with limited-English proficiency.
HTMLPDF284-43-5965Effective communication for people with disabilities.
HTMLPDF284-43-5970Equal program access on the basis of sex.
HTMLPDF284-43-5975Designation of responsible employee and adoption of grievance procedures.
HTMLPDF284-43-5980Notice requirement.
SUBCHAPTER I
HEALTH PLAN RATES
HTMLPDF284-43-6000Authority and purpose.
HTMLPDF284-43-6010Applicability and scope.
HTMLPDF284-43-6020Definitions.
HTMLPDF284-43-6040Demonstration that benefits provided are not reasonable in relation to the amount charged for a contract per RCW 48.44.020 and 48.46.060.
HTMLPDF284-43-6100Contents of individual and small group filings.
SUBCHAPTER J
HEALTH PLANS, STAND-ALONE DENTAL PLANS AND STAND-ALONE VISION PLANS—FILING REQUIREMENTS
HTMLPDF284-43-6500Applicability and scope.
HTMLPDF284-43-6520Definitions.
HTMLPDF284-43-6540Summary for group contract filings other than small group contract filings.
HTMLPDF284-43-6560When a carrier is required to file.
HTMLPDF284-43-6580General contents of all filings.
HTMLPDF284-43-6590Requirements for mitigating inequity in the health insurance market.
HTMLPDF284-43-6600Issuer filing of attestation form, transparency tools.
HTMLPDF284-43-6620Experience records.
HTMLPDF284-43-6640Evaluating experience data.
HTMLPDF284-43-6660Summary for individual and small group contract filings.
HTMLPDF284-43-6680Geographic rating area factor development.
HTMLPDF284-43-6681Geographic rating area factor development on or after January 1, 2019.
HTMLPDF284-43-6700Geographic rating area designation.
HTMLPDF284-43-6701Geographic rating area designation on or after January 1, 2019.
SUBCHAPTER K
MENTAL HEALTH AND SUBSTANCE USE DISORDER
HTMLPDF284-43-7000Scope and intent—Parity in mental health and substance use disorder benefits.
HTMLPDF284-43-7010Definitions.
HTMLPDF284-43-7020Classification of benefits.
HTMLPDF284-43-7040Measuring plan benefits—Financial requirements and quantitative treatment limitations.
HTMLPDF284-43-7060Measuring plan benefits—Nonquantitative treatment limitations.
HTMLPDF284-43-7080Prohibited exclusions.
HTMLPDF284-43-7100Required disclosures.
HTMLPDF284-43-7120Compliance and reporting of quantitative parity analysis.
SUBCHAPTER L
REPRODUCTIVE HEALTH CARE AND CONTRACEPTION
HTMLPDF284-43-7200Purpose and scope.
HTMLPDF284-43-7210Definitions.
HTMLPDF284-43-7220Coverage required.
HTMLPDF284-43-7230Services provided without discrimination, prohibited limitations, and confidentiality.
HTMLPDF284-43-7240Access to contraceptive services and supplies.
HTMLPDF284-43-7250Filing requirements.
HTMLPDF284-43-7260Deductibles for over-the-counter contraceptives and voluntary male sterilization in HSA qualifying plans.
HTMLPDF284-43-7270Access to prenatal vitamins and breast pumps.
SUBCHAPTER M
SHORT-TERM LIMITED DURATION MEDICAL PLANS
HTMLPDF284-43-8000Definition of short-term limited duration medical plan.
HTMLPDF284-43-8010Standard disclosure form for short-term limited duration medical plans.
HTMLPDF284-43-8020Commissioner's approval required.
HTMLPDF284-43-8030Short-term limited duration medical plan cancellation and rescission.
HTMLPDF284-43-8100Definitions.
HTMLPDF284-43-8110Requirements for Pathway 1 Association Health Plan form filings related to the bona fide status of Pathway 1 Associations.
HTMLPDF284-43-8120Requirements for governmental plans.
HTMLPDF284-43-8130Association health plan compliance with statutory or regulatory changes.
HTMLPDF284-43-8140Transition of plans purchased by association members.
SUBCHAPTER N
HEALTH CARE SHARING MINISTRIES
HTMLPDF284-43-8210Definitions.
HTMLPDF284-43-8220Prompt reply to the commissioner required.
HTMLPDF284-43-8230Continuously sharing medical expenses.