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Office of the Insurance Commissioner Rules
Rules proposed by the Office of the Insurance
Commissioner to implement the "Patient Bill of Rights" ch5,
laws of 2000 (E2SSB 6199)
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(13) "Health carrier" or "carrier" means
a disability insurance company regulated under chapter 48.20
or 48.21 RCW, a health care service contractor as defined
in RCW 48.44.010, and a health maintenance organization as
defined in RCW 48.46.020.
(14) "Health plan" or "plan" means any individual or group
policy, contract, or agreement offered by a health carrier
to provide, arrange, reimburse, or pay for health care service
except the following:
- Long-term care insurance governed by chapter 48.84 RCW;
- Medicare supplemental health insurance governed by chapter
48.66 RCW;
- Limited health care service offered by limited health
care service contractors in accordance with RCW 48.44.035;
- Disability income;
- Coverage incidental to a property/casualty liability insurance
policy such as automobile personal injury protection coverage
and homeowner guest medical;
- Workers' compensation coverage;
- Accident only coverage;
- Specified disease and hospital confinement indemnity when
marketed solely as a supplement to a health plan;
- Employer-sponsored self-funded health plans;
- Dental only and vision only coverage; and
- 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.
(15) "Managed care plan" means a health plan that coordinates
the provision of covered health care services to a covered person
through the use of a primary care provider and a network.
(16) "Medically necessary" or "medical necessity" in regard
to mental health services is a carrier determination as to whether
a health service is a covered benefit if the service is consistent
with generally recognized standards within a relevant health
profession.
(17) "Mental health provider" means a health care provider or
a health care facility authorized by state law to provide mental
health services.
(18) "Mental health services" means in-patient or out-patient
treatment, partial hospitalization or out-patient treatment
to manage or ameliorate the effects of a mental disorder listed
in the Diagnostic and Statistical Manual (DSM) IV published
by the American Psychiatric Association, excluding diagnoses
and treatments for substance abuse, 291.0 through 292.9 and
303.0 through 305.9.
(19) "Network" means the group of participating providers and
facilities providing health care services to a particular health
plan. A health plan network for carriers offering more than
one health plan may be smaller in number than the total number
of participating providers and facilities for all plans offered
by the carrier.
(20) "Out-patient therapeutic visit" or "out-patient visit"
means a clinical treatment session with a mental health provider
of a duration consistent with relevant professional standards
used by the carrier to determine medical necessity for the particular
service being rendered, as defined in Physicians Current Procedural
Terminology, published by the American Medical Association.
(21) "Participating provider" and "participating facility" means
a facility or provider who, under a contract with the health
carrier or with the carrier's contractor or subcontractor, has
agreed to provide health care services to covered persons with
an expectation of receiving payment, other than coinsurance,
copayments, or deductibles, from the health carrier rather than
from the covered person.
(22) "Person" means an individual, a corporation, a partnership,
an association, a joint venture, a joint stock company, a trust,
an unincorporated organization, any similar entity, or any combination
of the foregoing.
(23) "Primary care provider" means a participating provider
who supervises, coordinates, or provides initial care or continuing
care to a covered person, and who may be required by the health
carrier to initiate a referral for specialty care and maintain
supervision of health care services rendered to the covered
person.
(24) "Preexisting condition" means any medical condition, illness,
or injury that existed any time prior to the effective date
of coverage.
(25) "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.
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