Washington State Office of the Insurance Commissioner Regulatory Issues

October 31, 2016 – WSHA, Hospitals Respond to OIC Balance Billing Law Proposal

The Office of the Insurance Commissioner (OIC) recently circulated a stakeholder draft bill related to out-of-network billing, sometimes referred to as “surprise bills.” The bill is meant to address the situation where a patient receives services at a hospital or other facility that is part of their health plan’s network, but receive care from providers who are not contracted with the plan. In these cases patients can incur greater than expected costs. The OIC and legislators have indicated there will be a bill introduced for the upcoming legislative session.

The draft bill includes a number of components found in bills passed in other states, including balance billing prohibitions, notification requirements, arbitration provisions, and a default rate for out-of-network services. WSHA and other organizations have provided initial comments, though it is unclear what will be in the actual bill that is introduced in the Washington State Legislature.

WSHA is convening a special task force of members to discuss alternative ways to deal with the issue.  (Andrew Busz)

October 24, 2016 – WSHA Comments on OIC Prior Authorization Rules Stakeholder Draft

On September 23, the Office of the Insurance Commissioner (OIC) released a third iteration of stakeholder draft rules concerning prior authorizations. We are pleased that the OIC has undertaken a rule making process on prior authorization and is trying to provide more transparency around some of the requirements. The latest draft maintains many important provisions and protections specifically requested by WSHA, including:

  • Carriers would have greater accountability for prior authorization reviews by third-party benefit managers and contractors
  • Changes to prior authorizations would be subject to same notification requirements as contract amendments
  • Carriers must provide greater transparency of clinical criteria and pre-service requirements for services subject to prior authorization
  • Carriers would be required to provide retrospective review when extenuating circumstances prevent the provider from obtaining prior authorization in advance of services

We are disappointed that the draft does not do more to require carriers to provide clinical and financial justification for new requirements, but believe the draft rule is a big step forward to increasing transparency and accountability. WSHA submitted a comment letter supporting the changes and testified at an October 5 stakeholder meeting.

We believe the OIC will next make some additional changes based on stakeholder comments and issue a proposed rule as part of the formal (CR-102) rulemaking process. (Andrew Busz)

August 22, 2016 – WSHA Responds to Insurance Commissioner’s Draft Rule on Prior Authorization

WSHA recently submitted a comment letter and provided in-person comments in response to stakeholder draft rules released by the Office of the Insurance Commissioner (OIC) on prior authorization requirements.  WSHA, WSMA, and many of our members have been asking the OIC to more carefully regulate this process in order to reduce administrative overhead for providers and enable speedier provision of care. The OIC plans at least one additional iteration of the stakeholder draft prior to the formal rule process.

WSHA appreciates that the current stakeholder draft includes a number of provisions addressing issues we requested.  For example, it increases the accountability for benefit managers and third party administrators contracted by health plans. It also clarifies how health plans must notify providers of new services requiring prior authorization. There are several elements not included in the draft, however, that WSHA would like to see added.  We are requesting that any new prior authorization requirements be medically and financially justified.  We are also asking for exemptions from prior authorizations in extenuating circumstances.  We hope the OIC will address these in subsequent drafts.

WSHA appreciates the Commissioner’s willingness to draft rules regarding prior authorizations. We plan to submit detailed comments throughout the process. Please provide us with copies of your comments and let us know your thoughts so we can reflect them in our additional comments.

A copy of the CR-101 and initial comments previously submitted to the OIC are available here, including previous comments submitted by WSHA.  (Andrew Busz)

July 8, 2016 – OIC Begins Rulemaking on Prior Authorizations

The Office of the Insurance Commissioner recently announced a CR-101 to start rulemaking on prior authorization processes and transparency was recently filed with the Code Reviser’s Office. In an effort to facilitate access to covered services, the Commissioner wishes to standardize the process of prior authorization when such a program is in effect. These rules are intended to streamline the prior authorization process and to ensure it is more transparent for consumers and providers.

The OIC has accepted written comments and held a stakeholder meeting to inform the Commissioner’s position on the issue. A copy of the CR-101 and initial comments previously submitted to the OIC are available here, including comments submitted by WSHA. The Commissioner’s office plans to release a stakeholder draft in the next few weeks, with additional opportunity to comment. The OIC will accept comments on the CR-101 by August 4, 2016.  (Andrew Busz)

 

June 9, 2016 – WSHA Submits Comment Letter to Insurance Commissioner Regarding Prior Authorization Rule Changes

WSHA recently sent the Office of the Insurance Commissioner (OIC) a comment letter and recommendations in response to the OIC’s request for comments related to health plan prior authorizations.  The OIC is considering rulemaking to streamline the prior authorization process and make it easier for consumers and providers to get prior authorizations.  Both WSHA and the Washington State Medical Association have encouraged the OIC to explore rule changes within the department’s authority to ensure prior authorization requirements and processes are transparent and reasonable.

The OIC will be accepting stakeholder comments through June 17.  We encourage hospitals that want to comment directly to the OIC to refer to the WSHA draft comments and add their own specific comments.  In our letter, WSHA focused on specific areas of concern that were identified its prior authorization work group and are considered within the OIC’s rulemaking authority. The letter included recommendations regarding transparency, timeliness of response, handling of extenuating circumstances, and evaluation of new prior authorization requirements. The OIC is interested in obtaining a range of information from stakeholders, including identification of best practices, failed attempts at streamlining, and current deficiencies in current regulations regarding prior authorization.

Following the comment period, we expect the OIC to share a stakeholder draft of specific rule changes for additional review and comment.

To view WSHA’s comment letter click here.

To view the OIC announcement and email address to submit stakeholder comments, click here.

(Andrew Busz)

April 2, 2016 – Insurance Commissioner to Begin Rulemaking on Prior Authorizations

The Office of the Insurance Commissioner (OIC) recently announced its intent to begin rulemaking to provide more specific requirements relating to health plan prior authorizations.   The rules would seek to provide greater transparency and predictability for the prior authorization process and minimize the burden of the process on consumers.  Both WSHA and the Washington State Medical Association have met with OIC staff encouraging the OIC to explore rule changes within the Department’s authority to ensure prior authorization processes are transparent and reasonable. We will be very involved in the rulemaking process as it unfolds and continue to communicate with you as more information is known. (Andrew Busz).

March 15, 2016 –OIC To Review Proposed Acquisition of Group Health by Kaiser

The Office of the Insurance Commissioner (OIC) has announced its plans to review the proposed acquisition of Group Health Cooperative by California-based Kaiser Foundation Health Plan, Inc.  The OIC review will examine how the proposed sale could affect the overall stability of Washington State’s health insurance market, including impacts on competition and consumer choice. The OIC’s two phase review includes development of recommendations by specialized OIC staff and then a public hearing process by Commissioner Mike Kreidler, who will act as the hearing officer on this matter. WSHA appreciates the transparency and open communication about the proposed acquisition from both the OIC and Group Health. Further information on the OIC process and opportunity for public comment are available on the OIC’s website. Additional information on the planned acquisition is available on the Group Health website.

March 24, 2015 – WSHA Continues Work with OIC on Network Adequacy Rulemaking

Beginning in 2013, WSHA members expressed significant concern regarding state rulemaking on network adequacy requirements for commercial insurers. These rules were developed by the Washington State Office of the Insurance Commissioner (OIC) based on changes in health care delivery and access as part of health care reform. In response to member concerns especially with the change in mileage access standards for rural areas, WSHA made network adequacy a priority. WSHA has worked closely with the OIC to provide input on hospital concerns and to encourage increased transparency in the rulemaking process. WHSA has regular meetings with key OIC staff to discuss concerns and upcoming work. WSHA is pleased that OIC’s most recent exposure drafts on network adequacy have shown increased efforts to add transparency and responsiveness to the rulemaking process.

WSHA will continue to monitor the insurance networks carefully, and we strongly encourage our members to provide any examples of reduced access to both OIC and WSHA. If you encounter an insured person having difficulty with getting needed care, please help them file a complaint. The OIC’s complaint system is available here. Feedback to WSHA can be emailed to Zosia Stanley, Policy Director, Access at ZosiaS@wsha.org.

March 12, 2015 – OIC Begins Next Round of Network Adequacy Rulemaking

The Office of the Insurance Commissioner (OIC) has issued an exposure draft seeking stakeholder input regarding a new round of network adequacy rulemaking. The OIC completed two rounds of network adequacy rulemaking in 2014. This new exposure draft, including provisions delayed from the 2014 rulemaking process, concerns network maintenance requirements and requirements for issuers to monitor networks and report information to the OIC. Comments on the exposure draft are due to the OIC by Friday, March 20, 2015.

We are monitoring the 2015 networks carefully to see if access has deteriorated as a result of new OIC rules. We strongly encourage our members to send us any examples of reduced access so we can share these with the OIC. (Zosia Stanley, ZosiaS@wsha.org; 206-216-2511)

July 29, 2014 – OIC Begins Second Round of Network Adequacy Rulemaking

The Office of the Insurance Commissioner (OIC) has issued a preproposal statement of inquiry seeking stakeholder input regarding a second round of network adequacy rulemaking.  The OIC just completed the first round of network adequacy rulemaking in April. WSHA strongly objected to some of these new rules, including provisions requiring less access to health care in rural areas than what is required in urban areas. This new round of rulemaking, which concerns provisions not addressed by the rules adopted in April, will allow WSHA to continue our discussions with the OIC regarding access to care standards.

We are monitoring the 2015 networks carefully to see if access has deteriorated as a result of these new rules, and we strongly encourage our members to send us any examples of reduced access so we can share these with the OIC.  (Barbara Gorham, barbarag@wsha.org; 206-216-2512)

April 28, 2014 – OIC Finalizes Network Adequacy Rules

Despite objections from insurers, providers, hospitals and others, the Office of the Insurance Commissioner has made final its draft network adequacy rule.  WHSA had asked the Commissioner in our official comments to withdraw the rule to allow for more stakeholder input.  We are concerned that access to health care, particularly in rural areas, could be diminished by these rules.  The rule requires hospital access within 30 minutes of enrollees in urban areas, but within 60 minutes of enrollees in rural areas.  We see no reason for this distinction, assuming there are available providers in rural areas willing to contract at reasonable rates. The rule also makes it very easy for carriers to be exempt from its network adequacy standards. This is because the rule says the OIC will not consider rates when determining whether a carrier made a good faith effort to contract.  It also says the carrier need only submit “substantial evidence” of a good faith effort, and not “clear and convincing evidence,” which the OIC had included in a previous version of the rule at WSHA’s request.  (Barbara Gorham, BarbaraG@wsha.org; 206-216-2512)

April 21, 2014 – WSHA Requests Insurance Commissioner to Withdraw Draft Network Adequacy Rules.

WHSA has submitted comments on the Washington State Office of the Insurance Commissioner’s draft network adequacy rules, and has asked the Commissioner to withdraw the rule to allow for more stakeholder input.  We are concerned that access to health care, particularly in rural areas, could be diminished by these rules.  The draft rule requires hospital access within 30 minutes of enrollees in urban areas, but within 60 minutes of enrollees in rural areas.  We see no reason for there to be less access to care in rural areas, assuming there are providers available and willing to contract at reasonable rates. The draft rule also makes it very easy for carriers to be exempt from its network adequacy standards. This is because the draft rule says the OIC will not consider rates when determining whether a carrier made a good faith effort to contract. It also says the carrier need only submit “substantial evidence” of a good faith effort, and not “clear and convincing evidence,” which the OIC had included in a previous version of the rule at WSHA’s request. (Barbara Gorham, BarbaraG@wsha.org; 206-216-2512)

March 31, 2014 – WSHA Requests a Meeting with Commissioner Kreidler to Discuss Network Adequacy Rules

WHSA has sent a letter to the Washington State Insurance Commissioner, Mike Kreidler, requesting an urgent meeting to discuss the official draft network adequacy rules issued by the Office of the Insurance Commissioner (OIC) on March 19. These draft rules are problematic for two major reasons. First, the draft rule requires hospital access within 30 minutes of enrollees in urban areas, but within 60 minutes of enrollees in rural areas.  We see no reason for there to be less access to care in rural areas, assuming there are providers available and willing to contract at reasonable rates. Second, the draft rule makes it very easy for carriers to be exempt from its network adequacy standards. This is because the draft rule says the OIC will not consider rates when determining whether a carrier made a good faith effort to contract. It also says the carrier need only submit “substantial evidence” of a good faith effort, and not “clear and convincing evidence,” which the OIC had included in a previous version of the rule at WSHA’s request. (Barbara Gorham, BarbaraG@wsha.org; 206-216-2512)

February 21, 2014 – WSHA Submits Comments to the OIC Regarding Draft Network Adequacy Rules

WSHA has submitted comments on a new version of draft network adequacy rules distributed to stakeholders by the Office of the Insurance Commissioner on February 14.  These regulations would make substantial changes to the state’s network adequacy requirements for commercial health insurers, including Exchange plans.  WSHA has strongly objected to a provision in the new draft rule that creates a different standard for access to acute care in rural areas.  The rule currently requires a hospital within 60 minutes of enrollees in rural areas and 30  minutes of enrollees in urban areas.  WSHA also strongly objects to a provision in the rule allowing insurers in counties with fewer than 50,000 people to automatically be exempt from the rule’s requirements.

The OIC is expected to issue the official draft rule soon. The new regulations are expected to be finalized in March, and will apply to the 2015 plan approval process during the summer of 2014.  Barbara Gorham, BarbaraG@wsha.org

February 21, 2014 – WSHA Submits Comments to the OIC Regarding Draft Network Adequacy Rules

WSHA has submitted comments on a new version of draft network adequacy rules distributed to stakeholders by the Office of the Insurance Commissioner on February 14.  These regulations would make substantial changes to the state’s network adequacy requirements for commercial health insurers, including Exchange plans.  WSHA has strongly objected to a provision in the new draft rule that creates a different standard for access to acute care in rural areas.  The rule currently requires a hospital within 60 minutes of enrollees in rural areas and 30  minutes of enrollees in urban areas.  WSHA also strongly objects to a provision in the rule allowing insurers in counties with fewer than 50,000 people to automatically be exempt from the rule’s requirements.

The OIC is expected to issue the official draft rule soon. The new regulations are expected to be finalized in March, and will apply to the 2015 plan approval process during the summer of 2014.  Barbara Gorham, BarbaraG@wsha.org

December 20, 2013 – WSHA Submits Comments to the OIC Regarding Draft Network Adequacy Rules

WSHA has submitted comments on an 80-page stakeholder draft of new network adequacy rules. On December 4, 2013, the Office of the Insurance Commissioner distributed to stakeholders a draft of proposed regulations making substantial changes to the state’s network adequacy requirements for commercial health insurers, including Exchange plans.  The stakeholder draft contains specific access standards for the Insurance Commissioner to consider when determining network adequacy, including requirements for access to both primary care and specialty care.  Unfortunately, the draft does not have a similar requirement for hospitals, so we have requested there be a hospital within 25 miles of 90% of enrollees in both rural and urban areas.  In addition to these access standards, the stakeholder draft addresses a number of other issues, including spot contracting, prior authorization, tiered networks, access to mental health services, and access to essential community providers.

The OIC is expected to issue the official draft rule soon. The new regulations are expected to be finalized in February, and will apply to the 2015 plan approval process during the summer of 2014.  Barbara Gorham, BarbaraG@wsha.org

October 22, 2013 – WSHA Submits Comments to the OIC Regarding Network Adequacy Rules

Along with the Washington State Medical Association and seven other organizations, WSHA has submitted comments to the Office of the Insurance Commissioner regarding rulemaking for new network adequacy standards governing commercial health plans.   These new rules will be in effect for Qualified Health Plans participating in the Exchange in 2015.   The Office of the Insurance Commissioner filed its Preproposal Statement of Inquiry on September 18, 2013.  The text of the proposed rule is expected to be released soon.  Barbara Gorham, barbarag@wsha.org

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