Washington Administrative Code

The effective date of this regulation, WAC 284-50-010 through 284-50-230, shall be April 1, 1973.[Order R-73-1, § 284-50-230, filed 2/28/73, effective 4/1/73.]

(1) The purpose of this section is to effectuate the provisions of sections 1 and 2, chapter 173, Laws of 1988, by establishing the requirements and exceptions with respect to coverage for the formulas necessary for the treatment of phenylketonuria (PKU).(2) Every group disabilit…

(1) The purpose of this regulation is to effectuate the provisions of RCW 48.20.393 and 48.21.225, by establishing definitions for the exceptions to coverage for mammograms. This regulation shall apply to every group and individual disability insurance contract, which is delivere…

The purpose of this regulation, WAC 285-50-300 through 284-50-435, is to implement RCW 48.20.450 through 48.20.470 so as to provide reasonable standardization and simplification of terms and coverages of individual disability insurance policies in order to facilitate public under…

This regulation shall apply to all individual disability insurance policies delivered or issued for delivery in this state on and after the effective date hereof, except it shall not apply to individual policies issued pursuant to a conversion privilege under a policy of group or…

This regulation shall be effective on March 1, 1977, and shall be applicable to all individual disability insurance policies (except those specifically excluded from the scope of this regulation) delivered or issued for delivery in this state on and after such date: Provided, how…

Except as provided hereinafter, no individual disability insurance policy delivered or issued for delivery to any person in this state shall contain definitions respecting the matters set forth in this section unless such definitions comply with the requirements of this section.(…

(1) Except as provided in WAC 284-50-315(5), no policy shall contain provisions establishing a probationary or waiting period during which no coverage is provided under the policy subject to the further exception that a policy may specify a probationary or waiting period not to e…

(1) No disability insurance policy may contain a discretionary clause. "Discretionary clause" means a provision that purports to reserve discretion to an insurer, its agents, officers, employees, or designees in interpreting the terms of a policy or deciding eligibility for benef…

Minimum standards for benefits are prescribed for the categories of coverage noted in WAC 284-50-330 through 284-50-370. No individual disability insurance policy shall be delivered or issued for delivery in this state which does not meet the required minimum standards for its sp…

(1) A "noncancellable," "guaranteed renewable" or "noncancellable and guaranteed renewable" policy shall not provide for termination of coverage of the spouse solely because of the occurrence of an event specified for termination of coverage of the insured, other than nonpayment …

"Basic hospital expense coverage" is a policy of disability insurance which provides coverage for a period of not less than 31 days during any continuous hospital confinement for each person insured under the policy for expense incurred for necessary treatment and services render…

"Basic medical-surgical expense coverage" is a policy of disability insurance which provides coverage for each person insured under the policy for the expenses incurred for the necessary services rendered by a physician for treatment of an injury or sickness for at least the foll…

"Hospital confinement indemnity coverage" is a policy of disability insurance which principally provides daily benefits for hospital confinement on an indemnity basis in an amount not less than $10 per day and not less than 31 days during any one period of confinement for each pe…

(1) "Major medical expense coverage" is a disability insurance policy which provides hospital, medical and surgical expense coverage, to an aggregate maximum of not less than $10,000; copayment by the covered person not to exceed 25% of covered charges; a deductible stated on a p…

(1) "Disability income protection coverage" is a policy which provides for periodic payments, weekly or monthly, for a specified period during the continuance of disability resulting from either sickness or injury or a combination thereof which:(a) Provides that periodic payments…

"Accident only coverage" is a policy of accident insurance which provides coverage, singly or combination, for death, dismemberment, disability or hospital and medical care caused by accident. Accidental death and double dismemberment amounts under such a policy shall be at least…

(1) "Specified disease coverage" is a policy which meets one of the following definitions:(a) A policy which provides coverage for each person insured under the policy for a specifically named disease (or diseases) with a deductible amount not in excess of $250 and an overall agg…

"Limited benefit health insurance coverage" is any policy which provides benefits that are less than the minimum standards for benefits required under WAC 284-50-335 through 284-50-365, and which the commissioner approves as being in the public interest. Such policies may be deli…

(1) Each individual disability insurance policy shall include a renewal, continuation, or nonrenewal provision. The language or specifications of such provision must be consistent with the type of contract to be issued. Such provision shall be appropriately captioned, shall appea…

(1) Every individual disability insurance policy which excludes or limits, or reserves the right to exclude or limit, benefits for any treatment, procedure, facility, equipment, drug, drug usage, medical device, or supply (hereinafter individually and collectively referred to as …

(1) No individual disability insurance policy subject to this regulation shall be delivered or issued for delivery in this state unless an appropriate outline of coverage, as prescribed in WAC 284-50-385 through 284-50-425 is completed as to such policy and:(a) Is either delivere…

An outline of coverage, in substantially the following form, shall be issued in connection with policies meeting the standards of WAC 284-50-335.(company name)basic hospital expense coverage - outline of coverage(1) Read your policy carefully - This outline of coverage provides a…

An outline of coverage, in substantially the following form, shall be issued in connection with policies meeting the standards of WAC 284-50-340.(company name)basic medical-surgical expense coverageoutline of coverage(1) Read your policy carefully - This outline of coverage provi…

An outline of coverage, in substantially the following form, shall be issued in connection with policies meeting the standards of WAC 284-50-335 and 284-50-340.(company name)basic hospital and medical surgical expense coverageoutline of coverage(1) Read your policy carefully - Th…

An outline of coverage, in substantially the following form, shall be issued in connection with policies meeting the standards of WAC 284-50-345.(company name)hospital confinement indemnity coverageoutline of coverage(1) Read your policy carefully - This outline of coverage provi…

An outline of coverage, in substantially the following form, shall be issued in connection with policies meeting the standards of WAC 284-50-350.(company name)major medical expense coverageoutline of coverage(1) Read your policy carefully - This outline of coverage provides a ver…

An outline of coverage, in substantially the following form, shall be issued in connection with policies meeting the standards of WAC 284-50-355.(company name)disability income protection coverageoutline of coverage(1) Read your policy carefully - This outline of coverage provide…

An outline of coverage, in substantially the following form, shall be issued in connection with policies meeting the standards of WAC 284-50-360.(company name)accident only coverageoutline of coverage(1) Read your policy carefully - This outline of coverage provides a very brief …

An outline of coverage in substantially the following form, shall be issued in connection with policies meeting the standards of WAC 284-50-365.(company name)(specified disease) (specified accident) coverageoutline of coverage(1) Read your policy carefully - This outline of cover…

An outline of coverage, in substantially the following form, shall be issued in connection with policies which do not meet the minimum standards of WAC 284-50-335 through 284-50-365.(company name)limited benefit health coverageoutline of coverage(1) Read your policy carefully - T…

(1) Application forms shall include a question designed to elicit information as to whether the insurance to be issued is intended to replace any other disability insurance presently in force. A supplementary application or other form to be signed by the applicant containing such…

(1) All disability insurers offering individual policies that provide benefits in the form of illness-triggered fixed payments, hospital confinement fixed payments or other fixed payment insurance, must issue a disclosure form in substantially the format and content outlined belo…

(1) The purpose of this chapter is to:(a) Establish a uniform order of benefit determination under which plans pay claims;(b) Reduce duplication of benefits by permitting a reduction of the benefits to be paid by plans that, under rules established by this chapter, do not have to…

As used in this chapter, these words and terms have the following meanings, unless the context clearly indicates otherwise:(1) "Allowable expense," except as outlined below means any health care expense, including coinsurance or copayments and without reduction for any applicable…

(1) WAC 284-51-255, Appendix A contains a model COB provision for use in contracts. The use of this model COB provision is subject to the provisions of subsections (2), (3), and (4) of this section and to the provisions of this chapter.(2) WAC 284-51-260, Appendix B is a plain la…

(1) When a person is covered by two or more plans, the rules for determining the order of benefit payments are as follows:(a) The primary plan must pay or provide its benefits as if the secondary plan or plans did not exist.(b) If the primary plan is a closed panel plan and the s…

Issuers must use the following claims administration practices to expedite claim payments where coordination of benefits is involved:(1) Claim personnel must participate in continuing education programs.(2) All requests for information must be handled in an accurate and prompt ma…

(1) Each issuer must establish time limits for payment of a claim and may not unreasonably delay payment through the application of a coordination of benefits provision. Time limits established by a primary plan must be no less favorable than those contained in WAC 284-170-431. P…

A plan providing for coordination of benefits must contain a "facility of payment" provision substantially as follows: "If payments that should have been made under this plan are made by another plan, the issuer has the right, at its discretion, to remit to the other plan the amo…

A plan providing for coordination of benefits must contain a "right of recovery" provision substantially as follows: "The issuer has the right to recover excess payment whenever it has paid allowable expenses in excess of the maximum amount of payment necessary to satisfy the int…

(1) In determining the amount to be paid by the secondary plan on a claim, should the plan wish to coordinate benefits, the secondary plan must make payment in an amount so that, when combined with the amount paid by the primary plan, the total benefits paid or provided by all pl…

A plan must include the following statement in the enrollee contract or booklet provided to covered persons:"If you are covered by more than one health benefit plan, and you do not know which is your primary plan, you or your provider should contact any one of the health plans to…

In appropriate cases, issuers are encouraged to waive the investigation of possible other plan coverage on claims less than fifty dollars. However, if additional liability is incurred which raises the claim above fifty dollars, the entire liability may be included in the coordina…

(1) A secondary plan that provides benefits in the form of services may recover the reasonable cash value of the services from the primary plan, to the extent that benefits for the services are covered by the primary plan and have not already been paid or provided by the primary …

This chapter applies to all plans, as defined in WAC 284-51-195 that are issued, amended or renewed after December 31, 2007. All plans issued prior to January 1, 2008 must be compliant with this chapter on that date.[Statutory Authority: RCW 48.20.60 [48.20.060], 48.21.200, 48.44…

COORDINATION OF THIS CONTRACT'S BENEFITSWITH OTHER BENEFITSThe coordination of benefits (COB) provision applies when a person has health care coverage under more than one plan. Plan is defined below.The order of benefit determination rules govern the order in which each plan will…

COORDINATION OF BENEFITSIMPORTANT NOTICEThis is a summary of only a few of the provisions of your health plan to help you understand coordination of benefits, which can be very complicated. This is not a complete description of all of the coordination rules and procedures, and do…

(1) The purpose of this chapter is to establish rules pertaining to mandated conversion plans, and their specific standards and minimum benefits, to effectuate the provisions of RCW 48.21.260, 48.21.270, 48.44.370, 48.44.380, 48.46.450, and 48.46.460 (sections 3, 4, 6, 7, 9 and 1…

(1) Every insurer and every health care service contractor which issues group hospital or medical benefit plans shall make available to covered persons a choice of three conversion benefit plans which meet the requirements of WAC 284-52-040, 284-52-050, and 284-52-060, and every …