Unless otherwise specifically
provided, the definitions in this section apply throughout this
chapter.
(1) "Adjusted community rate" means the rating method used
to establish the premium for health plans adjusted to reflect
actuarially demonstrated differences in utilization or cost
attributable to geographic region, age, family size, and use of
wellness activities.
(2) "Adverse benefit determination" means a denial,
reduction, or termination of, or a failure to provide or make
payment, in whole or in part, for a benefit, including a denial,
reduction, termination, or failure to provide or make payment
that is based on a determination of an enrollee's or applicant's
eligibility to participate in a plan, and including, with respect
to group health plans, a denial, reduction, or termination of, or
a failure to provide or make payment, in whole or in part, for a
benefit resulting from the application of any utilization review,
as well as a failure to cover an item or service for which
benefits are otherwise provided because it is determined to be
experimental or investigational or not medically necessary or
appropriate.
(3) "Applicant" means a person who applies for enrollment in
an individual health plan as the subscriber or an enrollee, or
the dependent or spouse of a subscriber or enrollee.
(4) "Basic health plan" means the plan described under
chapter 70.47 RCW, as revised from time to time.
(5) "Basic health plan model plan" means a health plan as
required in RCW 70.47.060(2)(e).
(6) "Basic health plan services" means that schedule of
covered health services, including the description of how those
benefits are to be administered, that are required to be
delivered to an enrollee under the basic health plan, as revised
from time to time.
(7) "Catastrophic health plan" means:
(a) In the case of a contract, agreement, or policy covering
a single enrollee, a health benefit plan requiring a calendar
year deductible of, at a minimum, one thousand seven hundred
fifty dollars and an annual out-of-pocket expense required to be
paid under the plan (other than for premiums) for covered
benefits of at least three thousand five hundred dollars, both
amounts to be adjusted annually by the insurance commissioner;
and
(b) In the case of a contract, agreement, or policy covering
more than one enrollee, a health benefit plan requiring a
calendar year deductible of, at a minimum, three thousand five
hundred dollars and an annual out-of-pocket expense required to
be paid under the plan (other than for premiums) for covered
benefits of at least six thousand dollars, both amounts to be
adjusted annually by the insurance commissioner; or
(c) Any health benefit plan that provides benefits for
hospital inpatient and outpatient services, professional and
prescription drugs provided in conjunction with such hospital
inpatient and outpatient services, and excludes or substantially
limits outpatient physician services and those services usually
provided in an office setting.
In July 2008, and in each July thereafter, the insurance
commissioner shall adjust the minimum deductible and
out-of-pocket expense required for a plan to qualify as a
catastrophic plan to reflect the percentage change in the
consumer price index for medical care for a preceding twelve
months, as determined by the United States department of labor.
The adjusted amount shall apply on the following January 1st.
(8) "Certification" means a determination by a review
organization that an admission, extension of stay, or other
health care service or procedure has been reviewed and, based on
the information provided, meets the clinical requirements for
medical necessity, appropriateness, level of care, or
effectiveness under the auspices of the applicable health benefit
plan.
(9) "Concurrent review" means utilization review conducted
during a patient's hospital stay or course of treatment.
(10) "Covered person" or "enrollee" means a person covered
by a health plan including an enrollee, subscriber, policyholder,
beneficiary of a group plan, or individual covered by any other
health plan.
(11) "Dependent" means, at a minimum, the enrollee's legal
spouse and dependent children who qualify for coverage under the
enrollee's health benefit plan.
(12) "Emergency medical condition" means a medical condition
manifesting itself by acute symptoms of sufficient severity,
including severe pain, such that a prudent layperson, who
possesses an average knowledge of health and medicine, could
reasonably expect the absence of immediate medical attention to
result in a condition (a) placing the health of the individual,
or with respect to a pregnant woman, the health of the woman or
her unborn child, in serious jeopardy, (b) serious impairment to
bodily functions, or (c) serious dysfunction of any bodily organ
or part.
(13) "Emergency services" means a medical screening
examination, as required under section 1867 of the social
security act (42 U.S.C. 1395dd), that is within the capability of
the emergency department of a hospital, including ancillary
services routinely available to the emergency department to
evaluate that emergency medical condition, and further medical
examination and treatment, to the extent they are within the
capabilities of the staff and facilities available at the
hospital, as are required under section 1867 of the social
security act (42 U.S.C. 1395dd) to stabilize the patient.
Stabilize, with respect to an emergency medical condition, has
the meaning given in section 1867(e)(3) of the social security
act (42 U.S.C. 1395dd(e)(3)).
(14) "Employee" has the same meaning given to the term, as
of January 1, 2008, under section 3(6) of the federal employee
retirement income security act of 1974.
(15) "Enrollee point-of-service cost-sharing" means amounts
paid to health carriers directly providing services, health care
providers, or health care facilities by enrollees and may include
copayments, coinsurance, or deductibles.
(16) "Final external review decision" means a determination
by an independent review organization at the conclusion of an
external review.
(17) "Final internal adverse benefit determination" means an
adverse benefit determination that has been upheld by a health
plan or carrier at the completion of the internal appeals
process, or an adverse benefit determination with respect to
which the internal appeals process has been exhausted under the
exhaustion rules described in RCW 48.43.530 and 48.43.535.
(18) "Grandfathered health plan" means a group health plan
or an individual health plan that under section 1251 of the
patient protection and affordable care act, P.L. 111-148 (2010)
and as amended by the health care and education reconciliation
act, P.L. 111-152 (2010) is not subject to subtitles A or C of
the act as amended.
(19) "Grievance" means a written complaint submitted by or
on behalf of a covered person regarding: (a) Denial of payment
for medical services or nonprovision of medical services included
in the covered person's health benefit plan, or (b) service
delivery issues other than denial of payment for medical services
or nonprovision of medical services, including dissatisfaction
with medical care, waiting time for medical services, provider or
staff attitude or demeanor, or dissatisfaction with service
provided by the health carrier.
(20) "Health care facility" or "facility" means hospices
licensed under chapter 70.127 RCW, hospitals licensed under
chapter 70.41 RCW, rural health care facilities as defined in RCW 70.175.020, psychiatric hospitals licensed under chapter 71.12 RCW, nursing homes licensed under chapter 18.51 RCW, community
mental health centers licensed under chapter 71.05 or 71.24 RCW,
kidney disease treatment centers licensed under chapter 70.41 RCW, ambulatory diagnostic, treatment, or surgical facilities
licensed under chapter 70.41 RCW, drug and alcohol treatment
facilities licensed under chapter 70.96A RCW, and home health
agencies licensed under chapter 70.127 RCW, and includes such
facilities if owned and operated by a political subdivision or
instrumentality of the state and such other facilities as
required by federal law and implementing regulations.
(21) "Health care provider" or "provider" means:
(a) A person regulated under Title 18 or chapter 70.127 RCW,
to practice health or health-related services or otherwise
practicing health care services in this state consistent with
state law; or
(b) An employee or agent of a person described in (a) of
this subsection, acting in the course and scope of his or her
employment.
(22) "Health care service" means that service offered or
provided by health care facilities and health care providers
relating to the prevention, cure, or treatment of illness,
injury, or disease.
(23) "Health carrier" or "carrier" means a disability
insurer regulated under chapter 48.20 or 48.21 RCW, a health care
service contractor as defined in RCW 48.44.010, or a health
maintenance organization as defined in RCW 48.46.020, and
includes "issuers" as that term is used in the patient protection
and affordable care act (P.L. 111-148).
(24) "Health plan" or "health benefit plan" means any
policy, contract, or agreement offered by a health carrier to
provide, arrange, reimburse, or pay for health care services
except the following:
(a) Long-term care insurance governed by chapter 48.84 or 48.83 RCW;
(b) Medicare supplemental health insurance governed by
chapter 48.66 RCW;
(c) Coverage supplemental to the coverage provided under
chapter 55, Title 10, United States Code;
(d) Limited health care services offered by limited health
care service contractors in accordance with RCW 48.44.035;
(e) Disability income;
(f) Coverage incidental to a property/casualty liability
insurance policy such as automobile personal injury protection
coverage and homeowner guest medical;
(g) Workers' compensation coverage;
(h) Accident only coverage;
(i) Specified disease or illness-triggered fixed payment
insurance, hospital confinement fixed payment insurance, or other
fixed payment insurance offered as an independent, noncoordinated
benefit;
(j) Employer-sponsored self-funded health plans;
(k) Dental only and vision only coverage; and
(l) Plans deemed by the insurance commissioner to have a
short-term limited purpose or duration, or to be a student-only
plan that is guaranteed renewable while the covered person is
enrolled as a regular full-time undergraduate or graduate student
at an accredited higher education institution, after a written
request for such classification by the carrier and subsequent
written approval by the insurance commissioner.
(25) "Material modification" means a change in the actuarial
value of the health plan as modified of more than five percent
but less than fifteen percent.
(26) "Open enrollment" means a period of time as defined in
rule to be held at the same time each year, during which
applicants may enroll in a carrier's individual health benefit
plan without being subject to health screening or otherwise
required to provide evidence of insurability as a condition for
enrollment.
(27) "Preexisting condition" means any medical condition,
illness, or injury that existed any time prior to the effective
date of coverage.
(28) "Premium" means all sums charged, received, or
deposited by a health carrier as consideration for a health plan
or the continuance of a health plan. Any assessment or any
"membership," "policy," "contract," "service," or similar fee or
charge made by a health carrier in consideration for a health
plan is deemed part of the premium. "Premium" shall not include
amounts paid as enrollee point-of-service cost-sharing.
(29) "Review organization" means a disability insurer
regulated under chapter 48.20 or 48.21 RCW, health care service
contractor as defined in RCW 48.44.010, or health maintenance
organization as defined in RCW 48.46.020, and entities affiliated
with, under contract with, or acting on behalf of a health
carrier to perform a utilization review.
(30) "Small employer" or "small group" means any person,
firm, corporation, partnership, association, political
subdivision, sole proprietor, or self-employed individual that is
actively engaged in business that employed an average of at least
one but no more than fifty employees, during the previous
calendar year and employed at least one employee on the first day
of the plan year, is not formed primarily for purposes of buying
health insurance, and in which a bona fide employer-employee
relationship exists. In determining the number of employees,
companies that are affiliated companies, or that are eligible to
file a combined tax return for purposes of taxation by this
state, shall be considered an employer. Subsequent to the
issuance of a health plan to a small employer and for the purpose
of determining eligibility, the size of a small employer shall be
determined annually. Except as otherwise specifically provided,
a small employer shall continue to be considered a small employer
until the plan anniversary following the date the small employer
no longer meets the requirements of this definition. A
self-employed individual or sole proprietor who is covered as a
group of one must also: (a) Have been employed by the same small
employer or small group for at least twelve months prior to
application for small group coverage, and (b) verify that he or
she derived at least seventy-five percent of his or her income
from a trade or business through which the individual or sole
proprietor has attempted to earn taxable income and for which he
or she has filed the appropriate internal revenue service form
1040, schedule C or F, for the previous taxable year, except a
self-employed individual or sole proprietor in an agricultural
trade or business, must have derived at least fifty-one percent
of his or her income from the trade or business through which the
individual or sole proprietor has attempted to earn taxable
income and for which he or she has filed the appropriate internal
revenue service form 1040, for the previous taxable year.
(31) "Special enrollment" means a defined period of time of
not less than thirty-one days, triggered by a specific qualifying
event experienced by the applicant, during which applicants may
enroll in the carrier's individual health benefit plan without
being subject to health screening or otherwise required to
provide evidence of insurability as a condition for enrollment.
(32) "Standard health questionnaire" means the standard
health questionnaire designated under chapter 48.41 RCW.
(33) "Utilization review" means the prospective, concurrent,
or retrospective assessment of the necessity and appropriateness
of the allocation of health care resources and services of a
provider or facility, given or proposed to be given to an
enrollee or group of enrollees.
(34) "Wellness activity" means an explicit program of an
activity consistent with department of health guidelines, such
as, smoking cessation, injury and accident prevention, reduction
of alcohol misuse, appropriate weight reduction, exercise,
automobile and motorcycle safety, blood cholesterol reduction,
and nutrition education for the purpose of improving enrollee
health status and reducing health service costs.
[2011 c 315 § 2; 2011 c 314 § 3. Prior: 2010 c 292 § 1; prior: 2008 c 145 § 20; 2008 c 144 § 1; prior: 2007 c 296 § 1; 2007 c 259 § 32; 2006 c 25 § 16; 2004 c 244 § 2; prior: 2001 c 196 § 5; 2001 c 147 § 1; 2000 c 79 § 18; prior: 1997 c 231 § 202; 1997 c 55 § 1; 1995 c 265 § 4.]
NOTES:
Reviser's note: This section was amended by 2011 c 314 § 3 and by 2011 c 315 § 2, each without reference to the other. Both amendments are incorporated in the publication of this section under RCW 1.12.025(2). For rule of construction, see RCW 1.12.025(1).
Intent -- 2011 c 315: "The federal patient protection and
affordable care act (P.L. 111-148) prohibits insurance carriers
from applying preexisting condition limitations for persons under
age nineteen, beginning on or after September 23, 2010. The
guidance from the United States department of health and human
services provides some direction for the implementation of the
new policy requirement, and the office of the insurance
commissioner further clarified open enrollment requirements to
help prevent disruption in the individual health insurance
marketplace. It is the intent of this act to:
(1) Maintain access to individual plan options for persons
under age nineteen; and
(2) Provide clarity for the establishment of open enrollment
and special open enrollment periods that balance access to
guaranteed issue coverage with efforts that protect market
stability." [2011 c 315 § 1.]
Application -- 2010 c 292: "This act applies to policies issued or renewed on or after January 1, 2011." [2010 c 292 § 9.]
Contingent effective date -- 2010 c 292 §§ 1 and 2: "Sections 1 and 2 of this act take effect one hundred eighty days [September 29, 2010] after the date the insurance commissioner certifies to the secretary of the senate, the chief clerk of the house of representatives, and the code reviser's office that federal legislation has been signed into law by the President of the United States that includes guaranteed issue for individuals who purchase health coverage through the individual or small group markets." [2010 c 292 § 11.]
Severability -- Effective date -- 2008 c 145: See RCW 48.83.900 and 48.83.901.
Severability -- Subheadings not law -- 2007 c 259: See notes following RCW 41.05.033.
Application -- 2004 c 244: See note following RCW 48.21.045.
Effective date -- 2001 c 196: See note following RCW 48.20.025.
Effective date -- Severability -- 2000 c 79: See notes following RCW 48.04.010.
Short title -- 1997 c 231: "This act shall be known as the consumer assistance and insurance market stabilization act." [1997 c 231 § 402.]
Part headings and captions not law -- 1997 c 231: "Part headings and section captions used in this act are not part of the law." [1997 c 231 § 403.]
Severability -- 1997 c 231: "If any provision of this act or its application to any person or circumstance is held invalid, the remainder of the act or the application of the provision to other persons or circumstances is not affected." [1997 c 231 § 404.]
Effective dates -- 1997 c 231: "(1) Sections 104 through 108
and 301 of this act take effect January 1, 1998.
(2) Section 111 of this act is necessary for the immediate
preservation of the public peace, health, or safety, or support
of the state government and its existing public institutions, and
takes effect July 1, 1997.
(3) Section 205 of this act is necessary for the immediate
preservation of the public peace, health, or safety, or support
of the state government and its existing public institutions, and
takes effect immediately." [1997 c 231 § 405.]
Effective date -- 1997 c 55: "This act is necessary for the immediate preservation of the public peace, health, or safety, or support of the state government and its existing public institutions, and takes effect immediately [April 16, 1997]." [1997 c 55 § 2.]
Captions not law -- Effective dates -- Savings -- Severability -- 1995 c 265: See notes following RCW 70.47.015.