48.43.720  <<  48.43.725 >>   48.43.730

Exclusion of mandated benefits from health planCarrier requirementsNoticeFeesCommissioner's duties.

(1) A health carrier that excludes, under state or federal law, any benefit required or mandated by this title or rules adopted by the commissioner from any health plan or student health plan shall:
(a) Notify each enrollee in writing of the following:
(i) Which benefits the health plan or student health plan does not cover; and
(ii) Alternate ways in which the enrollees may access excluded benefits in a timely manner;
(b) Ensure that enrollees have prompt access to the information required under this subsection; and
(c) Clearly and legibly include the information specified in (a)(i) and (ii) of this subsection in any of its marketing materials that include a list of benefits covered under the plan. The information must also be listed in the benefit booklet and posted on the carrier's health plan or student health plan web site.
(2) For the purpose of mitigating inequity in the health insurance market, unless waived by the commissioner pursuant to (c) of this subsection, the commissioner must assess a fee on any health carrier offering a health plan or student health plan if the health plan or student health plan excludes, under state or federal law, any essential health benefit or coverage that is otherwise required or mandated by this title or rules adopted by the commissioner.
(a) The commissioner shall set the fee in an amount that is the actuarial equivalent of costs attributed to the provision and administration of the excluded benefit. As part of its rate filing, a health carrier subject to this subsection (2) must submit to the commissioner an estimate of the amount of the fee, including supporting documentation of its methods for estimating the fee. The carrier must include in its supporting documentation a certification by a member of the American academy of actuaries that the estimated fee is the actuarial equivalent of costs attributed to the provision and administration of the excluded benefit.
(b) Fees paid under this section must be deposited into the general fund.
(c) The commissioner may waive the fee assessed under this subsection (2) if he or she finds that the carrier excluding a mandated benefit for a health plan or student health plan provides health plan enrollees or student health plan enrollees alternative access to all excluded mandated benefits.
(3) Beginning July 1, 2021, the commissioner shall provide on its web site written notice of the carrier requirements in this section and information on alternate ways in which enrollees may access excluded benefits in a timely manner.
(4) Nothing in this section limits the authority of the commissioner to take enforcement action if a health carrier unlawfully fails to comply with the provisions of this title.
(5) The commissioner shall adopt any rules necessary to implement this section.
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