Washington Code 48.46.460 – Conversion agreement — Restrictions and requirements — Rules
Current as of: 2023 | Check for updates
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(1) A health maintenance organization must offer a conversion agreement for comprehensive health care services and shall not require proof of insurability as a condition for issuance of the conversion agreement.
Terms Used In Washington Code 48.46.460
- Commissioner: means the insurance commissioner. See Washington Code 48.46.020
- Comprehensive health care services: means basic consultative, diagnostic, and therapeutic services rendered by licensed health professionals together with emergency and preventive care, inpatient hospital, outpatient and physician care, at a minimum, and any additional health care services offered by the health maintenance organization. See Washington Code 48.46.020
- Health maintenance organization: means any organization receiving a certificate of registration by the commissioner under this chapter which provides comprehensive health care services to enrolled participants of such organization on a group practice per capita prepayment basis or on a prepaid individual practice plan, except for an enrolled participant's responsibility for copayments and/or deductibles, either directly or through contractual or other arrangements with other institutions, entities, or persons, and which qualifies as a health maintenance organization pursuant to RCW 48. See Washington Code 48.46.020
- person: may be construed to include the United States, this state, or any state or territory, or any public or private corporation or limited liability company, as well as an individual. See Washington Code 1.16.080
(2) A conversion agreement may not contain an exclusion for preexisting conditions for an applicant.
(3) A conversion agreement need not provide benefits identical to those provided under the group agreement. The conversion agreement may contain provisions requiring the person covered by the conversion agreement to pay reasonable deductibles and copayments, except for preventive service benefits as defined in 45 C.F.R. § 147.130 (2010), implementing sections 2701 through 2763, 2791, and 2792 of the public health service act (42 U.S.C. § 300gg through 300gg-63, 300gg-91, and 300gg-92), as amended.
(4) The insurance commissioner shall adopt rules to establish minimum benefit standards for conversion agreements.
(5) The commissioner shall adopt rules to establish specific standards for conversion agreement provisions. These rules may include but are not limited to:
(a) Terms of renewability;
(b) Nonduplication of coverage;
(c) Benefit limitations, exceptions, and reductions; and
(d) Definitions of terms.
NOTES:
Effective date—2019 c 33: See note following RCW 48.43.005.
Legislative intent—Severability—1984 c 190: See notes following RCW 48.21.250.