48.46.063 - Calculation of premiums -- Members of a purchasing pool--Adjusted community rating method -- Definitions.

Calculation of premiums — Members of a purchasing pool — Adjusted community rating method — Definitions.

(1) Premiums for health benefit plans for individuals who purchase the plan as a member of a purchasing pool:

     (a) Consisting of five hundred or more individuals affiliated with a particular industry;

     (b) To whom care management services are provided as a benefit of pool membership; and

     (c) Which allows contributions from more than one employer to be used towards the purchase of an individual's health benefit plan;

shall be calculated using the adjusted community rating method that spreads financial risk across the entire purchasing pool of which the individual is a member. Such rates are subject to the following provisions:

     (i) The health maintenance organization shall develop its rates based on an adjusted community rate and may only vary the adjusted community rate for:

     (A) Geographic area;

     (B) Family size;

     (C) Age;

     (D) Tenure discounts; and

     (E) Wellness activities.

     (ii) The adjustment for age in (c)(i)(C) of this subsection may not use age brackets smaller than five-year increments which shall begin with age twenty and end with age sixty-five. Individuals under the age of twenty shall be treated as those age twenty.

     (iii) The health maintenance organization shall be permitted to develop separate rates for individuals age sixty-five or older for coverage for which medicare is the primary payer, and coverage for which medicare is not the primary payer. Both rates are subject to the requirements of this subsection.

     (iv) The permitted rates for any age group shall be no more than four hundred twenty-five percent of the lowest rate for all age groups on January 1, 1996, four hundred percent on January 1, 1997, and three hundred seventy-five percent on January 1, 2000, and thereafter.

     (v) A discount for wellness activities shall be permitted to reflect actuarially justified differences in utilization or cost attributed to such programs.

     (vi) The rate charged for a health benefit plan offered under this section may not be adjusted more frequently than annually except that the premium may be changed to reflect:

     (A) Changes to the family composition;

     (B) Changes to the health benefit plan requested by the individual; or

     (C) Changes in government requirements affecting the health benefit plan.

     (vii) For the purposes of this section, a health benefit plan that contains a restricted network provision shall not be considered similar coverage to a health benefit plan that does not contain such a provision, provided that the restrictions of benefits to network providers result in substantial differences in claims costs. This subsection does not restrict or enhance the portability of benefits as provided in RCW 48.43.015.

     (viii) A tenure discount for continuous enrollment in the health plan of two years or more may be offered, not to exceed ten percent.

     (2) Adjusted community rates established under this section shall not be required to be pooled with the medical experience of health benefit plans offered to small employers under RCW 48.46.066.

     (3) As used in this section and RCW 48.46.066, "health benefit plan," "adjusted community rates," "small employer," and "wellness activities" mean the same as defined in RCW 48.43.005.

[2006 c 100 § 6.]

Notes: Legality of purchasing pools -- Federal opinion requested -- 2006 c 100: See note following RCW 48.20.028.