48.41.160 - Pool policy requirements -- Continued coverage -- Rate changes -- Continuation.

Pool policy requirements — Continued coverage — Rate changes — Continuation.

(1) On or before December 31, 2007, the pool shall cancel all existing pool policies and replace them with policies that are identical to the existing policies except for the inclusion of a provision providing for a guarantee of the continuity of coverage consistent with this section. As a means to minimize the number of policy changes for enrollees, replacement policies provided under this subsection also may include the plan modifications authorized in RCW 48.41.100, 48.41.110, and 48.41.120.

     (2) A pool policy shall contain a guarantee of the individual's right to continued coverage, subject to the provisions of subsections (4) and (5) of this section.

     (3) The guarantee of continuity of coverage required by this section shall not prevent the pool from canceling or nonrenewing a policy for:

     (a) Nonpayment of premium;

     (b) Violation of published policies of the pool;

     (c) Failure of a covered person who becomes eligible for medicare benefits by reason of age to apply for a pool medical supplement plan, or a medicare supplement plan or other similar plan offered by a carrier pursuant to federal laws and regulations;

     (d) Failure of a covered person to pay any deductible or copayment amount owed to the pool and not the provider of health care services;

     (e) Covered persons committing fraudulent acts as to the pool;

     (f) Covered persons materially breaching the pool policy; or

     (g) Changes adopted to federal or state laws when such changes no longer permit the continued offering of such coverage.

     (4)(a) The guarantee of continuity of coverage provided by this section requires that if the pool replaces a plan, it must make the replacement plan available to all individuals in the plan being replaced. The replacement plan must include all of the services covered under the replaced plan, and must not significantly limit access to the kind of services covered under the replacement plan through unreasonable cost-sharing requirements or otherwise. The pool may also allow individuals who are covered by a plan that is being replaced an unrestricted right to transfer to a fully comparable plan.

     (b) The guarantee of continuity of coverage provided by this section requires that if the pool discontinues offering a plan: (i) The pool must provide notice to each individual of the discontinuation at least ninety days prior to the date of the discontinuation; (ii) the pool must offer to each individual provided coverage under the discontinued plan the option to enroll in any other plan currently offered by the pool for which the individual is otherwise eligible; and (iii) in exercising the option to discontinue a plan and in offering the option of coverage under (b)(ii) of this subsection, the pool must act uniformly without regard to any health status-related factor of enrolled individuals or individuals who may become eligible for this coverage.

     (c) The pool cannot replace or discontinue a plan under this subsection (4) until it has completed an evaluation of the impact of replacing the plan upon:

     (i) The cost and quality of care to pool enrollees;

     (ii) Pool financing and enrollment;

     (iii) The board's ability to offer comprehensive and other plans to its enrollees;

     (iv) Other items identified by the board.

     In its evaluation, the board must request input from the constituents represented by the board members.

     (d) The guarantee of continuity of coverage provided by this section does not apply if the pool has zero enrollment in a plan.

     (5) The pool may not change the rates for pool policies except on a class basis, with a clear disclosure in the policy of the pool's right to do so.

     (6) A pool policy offered under this chapter shall provide that, upon the death of the individual in whose name the policy is issued, every other individual then covered under the policy may elect, within a period specified in the policy, to continue coverage under the same or a different policy.

[2007 c 259 § 27; 1987 c 431 § 16.]

Notes: Severability -- Subheadings not law -- 2007 c 259: See notes following RCW 41.05.033.