Washington Health Plan Disclosures

Time Insurance Company provides a variety of health plans designed to provide choices to consumers related to their insurance coverage. Choices include copayment options and a wide range of deductible and out-of-pocket amounts.

Outlines of Coverage


The Outlines of Coverage below provide a brief description of the important features of specific policies offered by Assurant Health to prospective enrollees in our Plans for Individuals & Families and our Plans for Small Businesses.  These documents provide summary information. For a complete listing of benefits, exclusions and limitations, please refer to the Insurance policy. In the event there are discrepancies with the information in this document, the terms and conditions of the coverage documents will govern.

For prospective customers, you can access a generic Outline of Coverage or SBC from assuranthealth.com.  Click on Individuals and Families, click on Major Medical Plans, then click View Summary of Benefits and Coverage under Additional Information section. Then follow the screen prompts to bring up the documents that you want to view.  You can download the PDFs right from our website.  For existing customers you can contact our Customer Care Center at the toll free number on the back of your ID card and request the documents from a Customer Care Specialist.  

Cost-Sharing and Premiums


Prospective Customers: Please refer to the proposal for specific information pertaining to your cost sharing requirements and premium.

Current Customers: Please refer to your Benefit Summary for specific information pertaining to your cost sharing requirements.  Premium can be found on the Account Summary or a copy of your most recent billing statement.

Prescription Drugs


Formulary:

The CVS Caremark Drug Formulary (Preferred Drug List) is a list of brand-name and generic drugs. This list was reviewed by an independent group of physicians and pharmacists, and it contains medications for many covered conditions. The purpose of the Drug Formulary is to promote the use of these cost-effective prescription medications when medically appropriate for Time Insurance Company members, and to help reduce your prescription drug costs. This list is reviewed and updated regularly. To view the Drug Formulary List online, please go to caremark.com.

You can access the Prescription Drug Guide on assuranthealth.com. Click Current Customers then go to the Prescription Benefits tab. You can view or download the Prescription Drug Guide or contact our Customer Care Center at the toll free number on the back of your ID card and request the Guide from a Customer Care Specialist. 

Brand Name Drug
A Prescription Drug for which a pharmaceutical company has received a patent or trade name.
Compounded Medications are considered Brand Name Drugs for purposes of determining payment of benefits.

Generic Drug
A Prescription Drug that:
  1. Has the same active ingredients as an equivalent Brand Name Drug or that can be used to treat the same condition as a Brand Name Drug; and
  2. Does not carry any drug manufacturer's brand name on the label; and
  3. Is not protected by a patent.
It must be listed as a Generic Drug by Our national drug data bank on the date it is purchased. Compounded Medications are not Generic Drugs. Medications that are commercially manufactured together and/or packaged together are not considered Generic Drugs, unless the entire combination product is specifically listed as a Generic Drug product by Our national drug data bank on the date it is purchased, and it must be approved by Us.

Grievance Process


Appeal of Adverse Benefit Determinations

In addition to any specific terms that are defined under the Definitions section of the contract, the following terms are used in, and apply to, this section and have the meanings given below:
  1. An "adverse benefit determination" means:
    • a denial, reduction, or termination of, a benefit; or
    • a failure to provide a benefit; or
    • a failure to make payment, in whole or in part, of a claim.

  2. An adverse benefit determination includes any utilization review decision that a request for a benefit under the policy does not meet our requirements for medical necessity, appropriateness, health care setting, level of care, or effectiveness, or that it is determined to be an experimental or investigational service, and the benefit is therefore denied, reduced, or terminated, or payment is not provided or made, either in whole or in part.

  3. An "appellant" means an applicant or a covered person, and, when designated, his or her representative.

  4. Health care practitioners or facilities seeking expedited review of an adverse benefit determination on behalf of an appellant may act as the appellant's representative even if the appellant has not formally notified us of the designation.

  5. An “internal appeal” or “internal review" means an appellant's request for us to review and reconsider an adverse benefit determination.

  6. An “external appeal” or “external review” means the request by an appellant for an independent review organization (“IRO”) to determine whether our internal review decision(s) are correct.

  7. A “concurrent expedited review” means the initiation of both the expedited internal review and expedited external review simultaneously.
Notice of Adverse Benefit Determinations
We will provide you with written or electronic notification of an adverse benefit determination. The notification will be provided:
  1. To you, or to your authorized representative; and
  2. To the health care practitioner or facility, if the adverse benefit determination involves the pre-service denial of treatment.
Our notice will include the following information:
  1. The specific reasons for the adverse benefit determination;
  2. The specific policy sections on which our determination is based;
  3. Our review procedures, including your right to request a free copy of our records related to the adverse benefit determination;
  4. The time limits applicable to a review of the adverse benefit determination; and
  5. Your right to present evidence as part of a review.
If the adverse benefit determination is based on medical necessity, decisions related to experimental or investigational services, or a similar exclusion or limit involving the exercise of professional judgment, we will also provide an explanation of the scientific or clinical basis for the determination, and the manner in which the terms of the policy were applied to the medical circumstances.

If an internal rule, guideline, protocol, or other similar criterion was relied on in making the adverse benefit determination, we will also provide information regarding the specific rule, guideline, protocol, or other similar criterion that was relied on.

You have the right to review our records of relevant information, including evidence used by us that influenced or supported our decision to make the adverse benefit determination. You may request that we identify the medical, vocational, or other experts whose advice was obtained in connection with the adverse benefit determination, even if the advice was not relied on in making the determination.

Review of Adverse Benefit Determinations, Generally
We have established a comprehensive process for the appeal and review of adverse benefit determinations.

You have the right to request a review of an adverse benefit determination. An appellant has the opportunity for both internal review and external review of an adverse benefit determination.

You may contact Washington’s designated ombudsman’s office at any time for assistance with questions and complaints. This contact is available through the Office of the Insurance Commissioner’s Consumer Protection Division.    

Office of the Washington State Insurance Commissioner
Consumer Protection Division
PO Box 40256
Olympia, WA  98504-0256
Insurance Consumer Hotline:  (800) 562-6900

Internal Appeal
As part of the review process, you have the opportunity for internal review of an adverse benefit determination. An appellant seeking review of an adverse benefit determination must use our internal review process.

We will accept a request for internal review if we receive the appeal within 180 days of the appellant's receipt of an adverse benefit determination from us. We will notify an appellant of our receipt of the internal review request within 72 hours of our receipt.

If we reverse our initial adverse benefit determination, at any time during the review process, we will provide the appellant with written or electronic notification of the reversal decision immediately, but in no event more than 2 business days from the date of our decision.

At the time the request for review is submitted, if the adverse benefit determination is related to services currently being received as an inpatient, or for which a continuous course of treatment is medically necessary, we will continue to provide coverage for the services (if requested by you) during the review process. If the review decision supports our initial adverse benefit determination, you may be responsible for the cost of the continued services.  

When we receive a written request for internal review, we will reconsider the adverse benefit determination. We will notify the appellant of our internal review decision within 14 calendar days of our receipt of the appeal. If, however, the adverse benefit determination involves experimental or investigational services, we will notify the appellant of our internal review decision within 20 days of our receipt of the appeal.

For good cause, we may extend our time to make a decision by up to 16 additional calendar days, without the appellant's written consent. We will notify the appellant of the extension, and the reason for the extension.

We may request further extension of our response time only if the appellant consents to our specific request, the appellant’s consent is reduced to writing, and we include a specific agreed upon date for determination. The appellant is not required to consent to our request for further extension of the response time.

We will provide the appellant, free of charge, with any new or additional evidence or rationale considered by us in connection with the claim. The information will be provided sufficiently in advance to ensure the appellant has reasonable opportunity to respond prior to the date our internal review must be completed. If the appellant requests an extension of time to respond to the new or additional rationale or evidence, we will extend our determination date for at least 2 days.

An appellant may submit information, documents, written comments, records, evidence, and testimony, including information and records obtained through a second opinion. An appellant may review our file, and may obtain a free copy of all documents, records, and information relevant to any claim that is the subject of the determination being appealed.

We will wholly review and investigate the appealed adverse benefit determination, and consider all information submitted by the appellant prior to issuing a review determination. We do not require two levels of internal review.

Exhaustion of Internal Appeal Remedies
If we do not adhere to our requirements for internal appeal, the internal review process is considered exhausted, and the appellant may request external review without receiving an internal review determination from us.

The appellant may request a written explanation of the violation from us, and we must provide such explanation within 10 calendar days. The written explanation will include a specific description of our basis, if any, for asserting that the violation should not cause the internal review process to be considered exhausted.

We may challenge the appellant’s request for external review either in court, or to the independent review organization (IRO).

The court or IRO may determine that we have demonstrated that a violation was for good cause, or was due to matters beyond our control, and that the violation occurred in the context of an ongoing, good faith exchange of information between us and the appellant. If it is determined that the internal review process is not exhausted, within 10 days of our receipt of the IRO’s determination or of the entry of the court's final order, we will provide the appellant with notice that they may resubmit and pursue the internal appeal.

Internal Appeal Decision
We will deliver written notification of our internal review decision to the appellant. The written determination will include:
  1. The actual reason(s) for our decision;
  2. Instructions on how to obtain further review of the adverse benefit determination, if applicable;
  3. A summary of our clinical rationale for the decision; and
  4. Instructions on how to obtain the clinical review criteria used to make our decision.
The appellant has 180 calendar days to file a request for external review. If external review is not requested, the internal appeal decision is final and binding.

Expedited Review
An expedited review of an adverse benefit determination is allowable at any time in the review process, if:
  1. The appellant is currently receiving, or is prescribed, treatment or benefits that would end because of the adverse benefit determination; or
  2. The treating health care practitioner or facility believes that a delay in treatment, based on the standard review time, may seriously jeopardize the patient’s life, overall health or ability to regain maximum function, or would subject the patient to severe and intolerable pain; or
  3. The adverse benefit determination is related to an issue related to admission, availability of care, continued stay, or emergency medical condition services where the patient has not been discharged from the emergency room or transport service.
If the treating health care practitioner or facility determines that a delay could jeopardize the patient’s health or ability to regain maximum function, we will acknowledge the need for expedited review, and treat the review request as such, including the need for an expedited determination of an external review.

Expedited review is not available if the treatment has already been delivered and the review involves payment for the delivered treatment, if the situation is not urgent, or if the situation does not involve the delivery of services for an existing condition, illness, or disease.

An expedited review may be filed orally, or in writing, by you, your authorized representative, or your health care practitioner.

If we require additional information to determine whether the service or treatment being reviewed is covered under the policy, or eligible for benefits, we will request such information as soon as possible after receiving the request for expedited review.

We will respond to an expedited review request as expeditiously as possible, preferably within 24 hours, but in no case longer than 72 hours.

Our response to an expedited review request may be delivered orally, and will be issued in writing within 72 hours of the date of our decision.

Concurrent Expedited Review
You have the right to request concurrent expedited review of adverse benefit determinations. When a concurrent expedited review is requested, we will not extend the timelines by making consecutive determinations. We will apply the requisite timelines concurrently.

We may deny a request for concurrent expedited review only if the conditions for expedited review are not met. We will not require exhaustion of internal review if an appellant requests concurrent expedited review.

External Appeal
When the internal review of an adverse benefit determination is final, or is considered exhausted, you may have the right to request an independent external review of our internal appeal decision. If an independent external review is requested, we will cooperatively participate in the external review process.

You have the right to external review of adverse benefit determinations based on medical necessity, appropriateness, health care setting, level of care, or that the requested service or supply is not efficacious or otherwise unjustified under evidence-based medical criteria.

We will use the rotational registry system of certified independent review organizations (IRO) established by the Office of the Washington State Insurance Commissioner, and available on the insurance commissioner's web site (www.insurance.wa.gov).

Within 1 day of assignment of the IRO, we will notify the appellant of the name of, and contact information for, the IRO.

The IRO will accept additional written information from the appellant for up to 5 business days after it receives the assignment, and will consider this additional information when conducting the review. Upon receipt of any information provided by the appellant to the IRO, we may reverse our final internal review decision. If that happens, we will immediately notify the IRO and the appellant.

An IRO must make its determination within the following time limits:
  1. If the review is not expedited, within 15 days after receiving necessary information, or within 20 days after receiving the assignment, whichever is earlier.  In exceptional circumstances where information is incomplete, the determination may be delayed until no later than 25 days after receiving the assignment.

  2. An IRO must provide notice of its ruling, and basis for the determination, within 2 business days of making a determination.

  3. If the review is an expedited review, within 72 hours after receiving all necessary information, or within 8 days after receiving the assignment, whichever is earlier. If information on whether a review is expedited is not provided to the IRO, the IRO will presume that it is not an expedited review.
An IRO must provide notice of its ruling, and basis for the determination, immediately upon making a determination.

Appeals Process:
Administrative or Claims appeals must be received in writing, except in MA, NM, IN, WA and MN.  Grievances that require a review of medical records will need a signed authorization from the covered person or their authorized representative’s* signature.

For policies issued in the states of MA, NM, IN, WA and MN we can take Administrative and Claims appeals over the phone.  The appeal may be initiated by the covered person or an authorized representative*.  Contact our Customer Care Center at the toll free number on the back of your ID card.  Our Customer Resolution team will send a written confirmation of receipt to the Covered Person within 48 hours of the initial call.
 
*An authorized representative means an insured's guardian, conservator, Power of Attorney (POA), family member or provider of service that has been designated in writing by the insured or by law.

For appeals received in writing, out Customer Resolution team will send a written confirmation of receipt within 5 business days. A written resolution of the grievance will be provided within 30 business days of receipt of the oral or written grievance.

Appeals in writing can be addressed to:

Assurant Health
PO Box 624
Milwaukee WI 53201-0624

Network Providers/Network Directories

Prospective and existing customers can look for doctors or hospitals in networks on the specific network websites. You can access our network page from assuranthealth.com.  Click Current Customers, go to “Provider Network” tab, and click "Find a doctor or provider", select your state and then select the link to the network you are searching.  This will take you to an online directory.  Since the network directory can change often, you should always check to make sure you doctor or hospital is part of the network.  You can also request assistance from our Customer Care Specialists over the phone to verify if a doctor or hospital is part of a network.  

List of Additional Disclosures


HIPAA Privacy Policy:  
You can access our Notice of Privacy Practices at assuranthealth.com at the bottom of the website or contact our Customer Care Center at the toll free number on the back of your ID card and request a copy of the Notice mailed or emailed to you.

Legal Notice:  
You can access our Legal Notice at assuranthealth.com at the bottom of the website or contact our Customer Care Center at the toll free number on the back of your ID card and request a copy of the Notice mailed or emailed to you.

Member’s Rights and Responsibilities:  
Existing customers can access our "Rights and Responsibilities" information at assuranthealth.com at the bottom of the website or contact our Customer Care Center at the toll free number on the back of your ID card and request a copy of these Rights and Responsibilities be mailed to you.

Questions regarding any of the Rights and Responsibilities can be submitted in writing to:

Assurant Health
PO Box 624
Milwaukee WI 53201-0624

Open Enrollment Notice for Individual Medical Plans:
You can access the Open Enrollment Notice for Non-Grandfathered Individual Medical Plans from assuranthealth.com.  Click on Current Customers, then click on State Notices in the More Important Links section.  Then locate the Open Enrollment notice you want to view.  You can download the PDFs right from our website.

Summary of Benefits and Coverage (SBC) & Uniform Glossary:  
For prospective customers, you can access a generic Outline of Coverage or SBC from assuranthealth.com.  Click on Individuals and Families, click on Major Medical Plans, then click View Summary of Benefits and Coverage under Additional Information section.  Then follow the screen prompts to bring up the documents that you want to view.  You can download the PDFs right from our website.  For existing customers you can contact our Customer Care Center at the toll free number on the back of your ID card and request the documents from a Customer Care Specialist.