WAC 284-212-053

(1) If an issuer makes a determination pursuant to RCW 48.212.090(2) that a policyholder's care and safety needs are not being met by the policyholder's current care setting or provider upon transition from the benefits provided under chapter 50B.04 RCW, the issuer must:

(a) Notify the policyholder in writing of the determination and the substantial clinical or other information supporting the determination;

(b) Notify the policyholder in writing of the effective date of the change in care setting or provider, which must be effective 90 days after the transition from the benefits provided under chapter 50B.04 RCW;

(c) Notify the policyholder in writing of their right to appeal the determination through an independent third-party review and how such an appeal may be submitted by the policyholder;

(d) Assist the policyholder in understanding the appeal process. Issuers may not use procedures or practices that discourage policyholders from exercising their right to appeal;

(e) Cooperate with a representative authorized in writing by the policyholder;

(f) Consider all information submitted by the policyholder;

(g) Provide written notice of resolution of the appeal to the policyholder and, with the permission of the policyholder, to the policyholder's providers that explains the independent third-party review decision and the substantial clinical or other reasons for the decision; and

(h) Resolve policyholder appeals within 30 days of receipt of the written appeal. For good cause, an issuer may extend the time it takes to resolve an appeal by up to 15 calendar days without the policyholder's written consent, and must notify the policyholder of the extension and the reason for the extension. The issuer may request further extension of its response time only if the policyholder consents to a specific request for a further extension, the consent is reduced to writing, and includes a specific agreed-upon date for determination. In the request for the policyholder's consent, the issuer must explain that waiver of the response time is not compulsory.

(2) Issuers shall contract with at least one independent third-party reviewer who will adjudicate policyholder appeals. The contracted independent third-party reviewer(s) must have expertise in long-term care insurance.

(3) Issuers shall notify the commissioner annually by March 1st of the name and contact information of their contracted independent third-party reviewer(s).

(4) Issuers shall maintain a record of all policyholder appeals submitted pursuant to RCW 48.212.090(2) and must annually furnish this information to the commissioner, including if no policyholder appeals were received. The format is set forth in WAC 284-212-054.