The national Medical Plans guide covers plan types (indemnity, HMO, PPO, POS, HDHP with HSA), cost sharing and the federal ACA rules. This guide covers the Washington rules:

• the three kinds of health carriers
• mandated coverage for newborns, children and maternity stays
• nondiscrimination rules
• independent review
• the disclosures a producer gives when selling or replacing health coverage

In Washington, the health line of authority is called disability.

Who sells health coverage

Washington licenses three kinds of health carriers:

• Disability insurers write health insurance under Title 48.
• Health care service contractors (HCSCs) (RCW 48.44.010) are provider-sponsored entities, not otherwise in the insurance business, that accept prepayment for health care services.
• HMOs (chapter 48.46 RCW) provide comprehensive health care services. At a minimum these include emergency and preventive care, inpatient hospital, and outpatient and physician care (RCW 48.46.020).

Individual health plan rates may not be used until 60 days after filing (RCW 48.46.060(4)).

Required coverage for children

• Newborns are covered from the moment of birth, including congenital anomalies. If extra premium is needed, the plan must allow at least 60 days from birth to enroll the child (RCW 48.46.250).
• Plans must offer coverage for children up to age 26 (RCW 48.44.215).
• A child can't be denied enrollment because the child was born outside marriage, isn't claimed as a tax dependent, or doesn't live with the parent or in the service area. When a court orders a parent to cover a child, the parent may enroll the child under family coverage outside the enrollment season (RCW 48.01.235).

Maternity (RCW 48.43.115)

• The attending provider, with the mother, decides how long the inpatient stay lasts.
• The newborn's coverage is no less than the mother's for at least three weeks, even with separate hospital admissions.

Nondiscrimination

• An HCSC may not deny coverage solely because of race, religion, national origin or disability (RCW 48.44.220).
• Benefit designs may not discriminate based on age, expected length of life, disability, degree of medical dependency, quality of life or other health conditions (WAC 284-43-5940).
• Health questions on an application must be clear and precise. A vague question doesn't require a "yes" answer (WAC 284-30-630).

Independent review (RCW 48.43.535)

• After exhausting the carrier's grievance process, or if the carrier misses its own deadlines, an enrollee may ask for review by an independent review organization (IRO).
• The Commissioner assigns IROs on a rotating basis to avoid conflicts.
• The carrier sends records by the third business day. The enrollee has at least five business days to add information.

Producer disclosures

• Replacement: when new accident and sickness coverage will replace existing coverage, the producer gives a replacement notice. Accident-only and single-premium nonrenewable policies are exempt (WAC 284-50-430).
• Fixed-payment policies, such as hospital indemnity, come with a standard disclosure given at solicitation and when the application is completed (WAC 284-50-440). It warns HDHP enrollees who contribute to an HSA to check with a tax advisor that they stay HSA-eligible.

Guaranty protection

The Washington Life and Disability Insurance Guaranty Association covers health benefit plans up to $500,000 (RCW 48.32A.025(3)).

Common exam traps

• In Washington, "disability insurance" means health insurance.
• An HCSC is a provider-sponsored prepaid plan, which is different from an HMO.
• Newborns are covered from birth. A premium-paying plan must allow at least 60 days to enroll.
• In a maternity stay, the provider and mother decide the length, not the insurer.
• Individual plan rates can't be used for 60 days after filing.
• A fixed-indemnity disclosure is given at solicitation, not at claim time.
• Accident-only policies need no replacement notice.