RCW 41.05.004
Intent
—
Use of word "board."
It is the intent of the legislature that the word "board" be read to mean both the school employees' benefits board and the public employees' benefits board throughout this chapter. The use of "board" should be liberally construed to mean both boards, to the extent not in conflict with state or federal law. In no case shall either board be limited from exercising its individual authority as authorized within this chapter.
[
2018 c 260 s 5
.]
RCW 41.05.006
Purpose.
(1) The legislature recognizes that (a) the state is a major purchaser of health care services, (b) the increasing costs of such health care services are posing and will continue to pose a great financial burden on the state, (c) it is the state's policy, consistent with the best interests of the state, to provide comprehensive health care as an employer, to public employees, officials, their dependents, and to those who are dependent on the state for necessary medical care, and (d) it is imperative that the state begin to develop effective and efficient health care delivery systems and strategies for procuring health care services in order for the state to continue to purchase the most comprehensive health care possible.
(2) It is therefore the purpose of this chapter to establish the Washington state health care authority whose purpose shall be to (a) develop health care benefit programs that provide access to at least one comprehensive benefit plan funded to the fullest extent possible by the employer, and a health savings account/high deductible health plan option as defined in section 1201 of the medicare prescription drug improvement and modernization act of 2003, as amended, for eligible public employees, officials, and their dependents, and (b) study all state purchased health care, alternative health care delivery systems, and strategies for the procurement of health care services and make recommendations aimed at minimizing the financial burden which health care poses on the state, public employees, and its charges, while at the same time allowing the state to provide the most comprehensive health care options possible.
[
2023 c 51 s 1
;
2018 c 260 s 2
;
2006 c 299 s 1
;
1988 c 107 s 2
.]
RCW 41.05.008
Duties of employing agencies.
(1) Every employing agency shall carry out all actions required by the authority under this chapter including, but not limited to, those necessary for the operation of benefit plans, education of employees, claims administration, and appeals process.
(2) Employing agencies shall report all data relating to employees eligible to participate in benefits or plans administered by the authority in a format designed and communicated by the authority.
[
2009 c 537 s 1
;
2005 c 143 s 4
.]
NOTES:
Effective date
—
2009 c 537:
"This act takes effect January 1, 2010." [
2009 c 537 s 9
.]
RCW 41.05.009
Determination of public employee eligibility for benefits.
(1) The authority, or an employing agency at the authority's direction, shall initially determine and periodically review whether a public employee is eligible for benefits pursuant to the criteria established under this chapter.
(2) An employing agency shall inform a public employee in writing whether or not he or she is eligible for benefits when initially determined and upon any subsequent change, including notice of the public employee's right to an appeal.
[
2023 c 51 s 2
;
2018 c 260 s 3
;
2015 c 116 s 1
;
2009 c 537 s 2
.]
NOTES:
Effective date
—
2009 c 537:
See note following RCW 41.05.008
.
RCW 41.05.0091
Eligibility exists prior to January 1, 2010.
An employee determined eligible for benefits prior to January 1, 2010, shall not have his or her eligibility terminated pursuant to the criteria established under chapter 537, Laws of 2009 unless the termination is the result of: (1) A voluntary reduction in work hours; or (2) the employee's employment with an agency other than the agency by which he or she was determined eligible prior to January 1, 2010.
[
2009 c 537 s 10
.]
NOTES:
Effective date
—
2009 c 537:
See note following RCW 41.05.008
.
RCW 41.05.011
Definitions.
The definitions in this section apply throughout this chapter unless the context clearly requires otherwise.
(1) "Authority" means the Washington state health care authority.
(2) "Board" means the public employees' benefits board established under RCW 41.05.055
and the school employees' benefits board established under RCW 41.05.740
.
(3) "Dependent care assistance program" means a benefit plan whereby employees and school employees may pay for certain employment related dependent care with pretax dollars as provided in the salary reduction plan under this chapter pursuant to 26 U.S.C. Sec. 129 or other sections of the internal revenue code.
(4) "Director" means the director of the authority.
(5) "Emergency service personnel killed in the line of duty" means law enforcement officers and firefighters as defined in RCW 41.26.030, members of the Washington state patrol retirement fund as defined in RCW 43.43.120, and reserve officers and firefighters as defined in RCW 41.24.010
who die as a result of injuries sustained in the course of employment as determined consistent with Title
51
RCW by the department of labor and industries.
(6)(a) "Employee" for the public employees' benefits board program includes all employees of the state, whether or not covered by civil service; elected and appointed officials of the executive branch of government, including full-time members of boards, commissions, or committees; justices of the supreme court and judges of the court of appeals and the superior courts; and members of the state legislature. Pursuant to contractual agreement with the authority, "employee" may also include: (i) Employees of a county, municipality, or other political subdivision of the state and members of the legislative authority of any county, city, or town who are elected to office after February 20, 1970, if the legislative authority of the county, municipality, or other political subdivision of the state submits application materials to the authority to provide any of its insurance programs by contract with the authority, as provided in RCW 41.04.205
and
41.05.021
(1)(g); (ii) employees of employee organizations representing state civil service employees, at the option of each such employee organization; (iii) through December 31, 2019, employees of a school district if the authority agrees to provide any of the school districts' insurance programs by contract with the authority as provided in RCW 28A.400.350
; (iv) employees of a tribal government, if the governing body of the tribal government seeks and receives the approval of the authority to provide any of its insurance programs by contract with the authority, as provided in RCW 41.05.021
(1) (f) and (g); (v) employees of the Washington health benefit exchange if the governing board of the exchange established in RCW 43.71.020
seeks and receives approval of the authority to provide any of its insurance programs by contract with the authority, as provided in RCW 41.05.021
(1) (g) and (n); and (vi) through December 31, 2019, employees of a charter school established under chapter
28A.710
RCW. "Employee" does not include: Adult family home providers; unpaid volunteers; patients of state hospitals; inmates; students of institutions of higher education as determined by their institution; and any others not expressly defined as employees under this chapter or by the authority under this chapter.
(b) Effective January 1, 2020, "school employee" for the school employees' benefits board program includes:
(i) All employees of school districts and charter schools established under chapter
28A.710
RCW;
(ii) Represented employees of educational service districts;
(iii) Effective January 1, 2024, all employees of educational service districts; and
(iv) Effective January 1, 2024, pursuant to contractual agreement with the authority, "school employee" may also include: (A) Employees of employee organizations representing school employees, at the option of each such employee organization; and (B) employees of a tribal school as defined in RCW 28A.715.010, if the governing body of the tribal school seeks and receives the approval of the authority to provide any of its insurance programs by contract with the authority, as provided in RCW 41.05.021
(1) (f) and (g).
(7) "Employee group" means employees of a similar employment type, such as administrative, represented classified, nonrepresented classified excluding such employees in educational service districts until December 31, 2023, confidential, represented certificated, or nonrepresented certificated excluding such employees in educational service districts until December 31, 2023, within a school employees' benefits board organization.
(8)(a) "Employer" for the public employees' benefits board program means the state of Washington.
(b) "Employer" for the school employees' benefits board program means school districts and educational service districts and charter schools established under chapter
28A.710
RCW.
(9)(a) "Employer group" for the public employees' benefits board program means those counties, municipalities, political subdivisions, the Washington health benefit exchange, tribal governments, and employee organizations representing state civil service employees obtaining employee benefits through a contractual agreement with the authority to participate in benefit plans developed by the public employees' benefits board.
(b) "Employer group" for the school employees' benefits board program means an employee organization representing school employees and a tribal school as defined in RCW 28A.715.010, obtaining employee benefits through a contractual agreement with the authority to participate in benefit plans developed by the school employees' benefits board.
(10)(a) "Employing agency" for the public employees' benefits board program means a division, department, or separate agency of state government, including an institution of higher education; a county, municipality, or other political subdivision; and a tribal government covered by this chapter.
(b) "Employing agency" for the school employees' benefits board program means school districts, educational service districts, and charter schools.
(11) "Faculty" means an academic employee of an institution of higher education whose workload is not defined by work hours but whose appointment, workload, and duties directly serve the institution's academic mission, as determined under the authority of its enabling statutes, its governing body, and any applicable collective bargaining agreement.
(12) "Flexible benefit plan" means a benefit plan that allows public employees to choose the level of health care coverage provided and the amount of employee or school employee contributions from among a range of choices offered by the authority.
(13) "Flexible spending arrangement" means a benefit plan whereby public employees may reduce their salary before taxes to pay for medical expenses not reimbursed by insurance as provided in the salary reduction plan under this chapter pursuant to 26 U.S.C. Sec. 125 or other sections of the internal revenue code.
(14) "Insuring entity" means an insurer as defined in chapter
48.01
RCW, a health care service contractor as defined in chapter
48.44
RCW, or a health maintenance organization as defined in chapter
48.46
RCW.
(15) "Participant" means an individual who fulfills the eligibility and enrollment requirements under the salary reduction plan.
(16) "Plan year" means the time period established by the authority.
(17) "Premium payment plan" means a benefit plan whereby public employees may pay their share of group health plan premiums with pretax dollars as provided in the salary reduction plan under this chapter pursuant to 26 U.S.C. Sec. 125 or other sections of the internal revenue code.
(18) "Public employee" has the same meaning as employee and school employee.
(19) "Retired or disabled school employee" means:
(a) Persons who separated from employment with a school district or educational service district and are receiving a retirement allowance under chapter
41.32
or
41.40
RCW as of September 30, 1993;
(b) Persons who separate from employment with a school district, educational service district, or charter school on or after October 1, 1993, and immediately upon separation receive a retirement allowance under chapter
41.32, 41.35, or
41.40
RCW;
(c) Persons who separate from employment with a school district, educational service district, or charter school due to a total and permanent disability, and are eligible to receive a deferred retirement allowance under chapter
41.32, 41.35, or
41.40
RCW.
(20) "Salary" means a public employee's monthly salary or wages.
(21) "Salary reduction plan" means a benefit plan whereby public employees may agree to a reduction of salary on a pretax basis to participate in the dependent care assistance program, flexible spending arrangement, or premium payment plan offered pursuant to 26 U.S.C. Sec. 125 or other sections of the internal revenue code.
(22) "School employees' benefits board organization" means a public school district or educational service district or charter school established under chapter
28A.710
RCW that is required to participate in benefit plans provided by the school employees' benefits board.
(23) "School year" means school year as defined in RCW 28A.150.203
(11).
(24) "Seasonal employee" means a state employee hired to work during a recurring, annual season with a duration of three months or more, and anticipated to return each season to perform similar work.
(25) "Separated employees" means persons who separate from employment with an employer as defined in:
(a)(i) RCW 41.32.010
(17) on or after July 1, 1996; or
(ii) RCW 41.35.010
on or after September 1, 2000; or
(iii) RCW 41.40.010
on or after March 1, 2002;
and who are at least age fifty-five and have at least ten years of service under the teachers' retirement system plan 3 as defined in RCW 41.32.010
(33), the Washington school employees' retirement system plan 3 as defined in RCW 41.35.010, or the public employees' retirement system plan 3 as defined in RCW 41.40.010
; or
(b) For the purposes of RCW 41.05.080
:
(i) RCW 41.32.010
on or after January 1, 2024; or
(ii) RCW 41.35.010
on or after January 1, 2024; or
(iii) RCW 41.40.010
on or after January 1, 2024; and who are at least age 55 and have at least 20 years of service under the teachers' retirement system plan 2 as defined in RCW 41.32.010, the Washington school employees' retirement system plan 2 as defined in RCW 41.35.010, or the public employees' retirement system plan 2 as defined in RCW 41.40.010
.
(26) "State purchased health care" or "health care" means medical and behavioral health care, pharmaceuticals, and medical equipment purchased with state and federal funds by the department of social and health services, the department of health, the basic health plan, the state health care authority, the department of labor and industries, the department of corrections, the department of veterans affairs, and local school districts.
(27) "Tribal government" means an Indian tribal government as defined in section 3(32) of the employee retirement income security act of 1974, as amended, or an agency or instrumentality of the tribal government, that has government offices principally located in this state.
[
2023 c 164 s 1
;
2023 c 51 s 3
;
2023 c 13 s 2
;
2019 c 411 s 4
;
2018 c 260 s 4
;
2017 3rd sp.s. c 13 s 802
. Prior:
2016 c 241 s 136
;
2016 c 67 s 2
; prior:
2015 c 116 s 2
;
2013 c 2 s 306
(Initiative Measure No. 1240, approved November 6, 2012);
2012 c 87 s 22
; prior:
2011 1st sp.s. c 15 s 54
;
2009 c 537 s 3
;
2008 c 229 s 2
; prior:
2007 c 488 s 2
;
2007 c 114 s 2
;
2005 c 143 s 1
;
2001 c 165 s 2
; prior:
2000 c 247 s 604
;
2000 c 230 s 3
;
1998 c 341 s 706
;
1996 c 39 s 21
;
1995 1st sp.s. c 6 s 2
;
1994 c 153 s 2
; prior:
1993 c 492 s 214
;
1993 c 386 s 5
;
1990 c 222 s 2
;
1988 c 107 s 3
.]
NOTES:
Reviser's note:
(1) The definitions in this section have been alphabetized pursuant to RCW 1.08.015
(2)(k).
(2)
This section was amended by 2023 c 13 s 2, 2023 c 51 s 3, and by 2023 c 164 s 1, without reference to one another. All amendments are incorporated in the publication of this section under RCW 1.12.025
(2). For rule of construction, see RCW 1.12.025
(1).
Effective date
—
2023 c 164:
"This act takes effect January 1, 2024." [
2023 c 164 s 2
.]
Finding
—
Intent
—
2023 c 13:
"The legislature finds that employees and employers are benefited by consistency and mobility in public employee health care.
Therefore it is the intent of the legislature to expand access to benefits provided by the school employees' benefits board to employees of tribal schools and employee organizations representing school employees." [
2023 c 13 s 1
.]
Intent
—
2017 3rd sp.s. c 13:
See note following RCW 28A.150.410
.
Collective bargaining agreements not impaired
—
2017 3rd sp.s. c 13:
See note following RCW 41.56.139
.
Effective date
—
2016 c 241:
See RCW 28A.710.901
.
Effective date
—
2012 c 87 ss 4, 16, 18, and 19-23:
See note following RCW 43.71.030
.
Spiritual care services
—
2012 c 87:
See RCW 43.71.901
.
Effective date
—
Findings
—
Intent
—
Report
—
Agency transfer
—
References to head of health care authority
—
Draft legislation
—
2011 1st sp.s. c 15:
See notes following RCW 74.09.010
.
Effective date
—
2009 c 537:
See note following RCW 41.05.008
.
Effective date
—
2008 c 229:
See note following RCW 41.05.295
.
Short title
—
2007 c 488:
See note following RCW 43.43.285
.
Intent
—
2007 c 114:
"Consistent with the centennial accord, the new millennium agreement, related treaties, and federal and state law, it is the intent of the legislature to authorize tribal governments to participate in public employees' benefits board programs to the same extent that counties, municipalities, and other political subdivisions of the state are authorized to do so." [
2007 c 114 s 1
.]
Effective date
—
2007 c 114:
"This act takes effect January 1, 2009." [
2007 c 114 s 8
.]
Effective date
—
2001 c 165 s 2:
"Section 2 of this act takes effect March 1, 2002." [
2001 c 165 s 5
.]
Effective date
—
Application
—
2001 c 165:
"This act is necessary for the immediate preservation of the public peace, health, or safety, or support of the state government and its existing public institutions, and except for section 2 of this act takes effect immediately [May 7, 2001]. This act applies to all surviving spouses and dependent children of (1) emergency service personnel and (2) members of the law enforcement officers' and firefighters' retirement system plan 2, killed in the line of duty." [
2006 c 345 s 2
;
2001 c 165 s 6
.]
Reviser's note:
Contractual right not granted
—
2006 c 345: See note following RCW 41.26.510
.
Effective date
—
2000 c 230:
See note following RCW 41.35.630
.
Effective date
—
1998 c 341:
See RCW 41.35.901
.
Effective dates
—
1996 c 39:
See note following RCW 41.32.010
.
Effective date
—
1995 1st sp.s. c 6:
See note following RCW 28A.400.410
.
Intent
—
1994 c 153:
"It is the intent of the legislature to increase access to health insurance for retired and disabled state and school district employees and to increase equity between state and school employees and between state and school retirees." [
1994 c 153 s 1
.]
Effective dates
—
1994 c 153:
"This act shall take effect January 1, 1995, except section 15 of this act, which takes effect October 1, 1995." [
1994 c 153 s 16
.]
Findings
—
Intent
—
1993 c 492:
See notes following RCW 43.20.050
.
Short title
—
Savings
—
Reservation of legislative power
—
Effective dates
—
1993 c 492:
See RCW 43.72.910
through
43.72.915
.
Intent
—
1993 c 386:
See note following RCW 28A.400.391
.
Effective date
—
1993 c 386 ss 1, 2, 4-6, 8-10, and 12-16:
See note following RCW 28A.400.391
.
RCW 41.05.013
State purchased health care programs
—
Uniform policies.
(1) The authority shall coordinate state agency efforts to develop and implement uniform policies across state purchased health care programs that will ensure prudent, cost-effective health services purchasing, maximize efficiencies in administration of state purchased health care programs, improve the quality of care provided through state purchased health care programs, and reduce administrative burdens on health care providers participating in state purchased health care programs. The policies adopted should be based, to the extent possible, upon the best available scientific and medical evidence and shall endeavor to address:
(a) Methods of formal assessment, such as a health technology assessment under RCW 70.14.080
through
70.14.130
. Consideration of the best available scientific evidence does not preclude consideration of experimental or investigational treatment or services under a clinical investigation approved by an institutional review board;
(b) Monitoring of health outcomes, adverse events, quality, and cost-effectiveness of health services;
(c) Development of a common definition of medical necessity; and
(d) Exploration of common strategies for disease management and demand management programs, including asthma, diabetes, heart disease, and similar common chronic diseases. Strategies to be explored include individual asthma management plans.
(2) The director may invite health care provider organizations, carriers, other health care purchasers, and consumers to participate in efforts undertaken under this section.
(3) For the purposes of this section "best available scientific and medical evidence" means the best available clinical evidence derived from systematic research.
[
2023 c 51 s 4
;
2006 c 307 s 8
;
2005 c 462 s 3
;
2003 c 276 s 1
.]
NOTES:
Captions not law
—
Conflict with federal requirements
—
2006 c 307:
See notes following RCW 70.14.080
.
Findings
—
2005 c 462:
See note following RCW 28A.210.370
.
Rule making
—
2003 c 276:
"Agencies administering state purchased health care programs shall cooperatively adopt rules necessary to implement this act." [
2003 c 276 s 2
.]
RCW 41.05.014
Applications, enrollment forms, and eligibility certification documents
—
Signatures.
(1) The director may require applications, enrollment forms, and eligibility certification documents for benefits that are administered by the authority under this chapter and chapter
70.47
RCW to be signed by the person submitting them. The director may accept electronic signatures.
(2) For the purpose of this section, "electronic signature" means an electronic sound, symbol, or process attached to or logically associated with a record and executed or adopted by a person with the intent to sign the record.
[
2020 c 57 s 84
;
2009 c 201 s 2
.]
RCW 41.05.015
Medical director
—
Appointment of personnel.
The director shall designate a medical director who is licensed under chapter
18.57
or
18.71
RCW. The director shall also appoint such professional personnel and other assistants and employees, including professional medical screeners, as may be reasonably necessary to carry out the provisions of this chapter and chapters
74.09, 71.05, 71.24, and
71.34
RCW and other applicable law. The medical screeners must be supervised by one or more physicians whom the director or the director's designee shall appoint.
[
2023 c 51 s 5
;
2018 c 201 s 7001
;
2011 1st sp.s. c 15 s 55
;
2000 c 5 s 16
.]
NOTES:
Findings
—
Intent
—
Effective date
—
2018 c 201:
See notes following RCW 41.05.018
.
Effective date
—
Findings
—
Intent
—
Report
—
Agency transfer
—
References to head of health care authority
—
Draft legislation
—
2011 1st sp.s. c 15:
See notes following RCW 74.09.010
.
Intent
—
Purpose
—
2000 c 5:
See RCW 48.43.500
.
Application
—
Short title
—
Captions not law
—
Construction
—
Severability
—
Application to contracts
—
Effective dates
—
2000 c 5:
See notes following RCW 48.43.500
.
RCW 41.05.017
Provisions applicable to health plans offered under this chapter.
Each health plan that provides medical insurance offered under this chapter, including plans created by insuring entities, plans not subject to the provisions of Title
48
RCW, and plans created under RCW 41.05.140, are subject to the provisions of RCW 48.43.500, 70.02.045, 48.43.505
through
48.43.535, 48.43.537, 48.43.545, 48.43.550, 70.02.110, 70.02.900, 48.43.190, 48.43.083, 48.43.0128, 48.43.780, 48.43.435, 48.43.815, 48.200.020
through
48.200.280, 48.200.300
through
48.200.320, 48.43.440, 48.43.845, 48.43.732, and chapter
48.49
RCW.
[
2025 c 389 s 3
;
2025 c 171 s 2
. Prior:
2024 c 251 s 5
;
2024 c 242 s 10
; prior:
2022 c 236 s 3
;
2022 c 228 s 2
;
2022 c 10 s 2
;
2021 c 280 s 2
;
2019 c 427 s 21
;
2016 c 139 s 4
;
2008 c 304 s 2
;
2007 c 502 s 2
;
2000 c 5 s 20
.]
NOTES:
Reviser's note:
This section was amended by 2025 c 171 s 2 and by 2025 c 389 s 3, each without reference to the other. Both amendments are incorporated in the publication of this section under RCW 1.12.025
(2). For rule of construction, see RCW 1.12.025
(1).
Finding
—
Intent
—
2025 c 389:
See note following RCW 48.43.732
.
Effective date
—
2024 c 251:
See note following RCW 70.41.495
.
Short title
—
2021 c 280:
See note following RCW 49.60.178
.
Findings
—
Intent
—
Effective date
—
2019 c 427:
See RCW 48.49.003
and
48.49.900
.
Savings
—
Severability
—
Effective date
—
2007 c 502:
See notes following RCW 48.43.083
.
Intent
—
Purpose
—
2000 c 5:
See RCW 48.43.500
.
Application
—
Short title
—
Captions not law
—
Construction
—
Severability
—
Application to contracts
—
Effective dates
—
2000 c 5:
See notes following RCW 48.43.500
.
RCW 41.05.018
Transfer of certain behavioral health-related powers, duties, and functions from the department of social and health services.
(1) The powers, duties, and functions of the department of social and health services pertaining to the behavioral health system and purchasing function of the behavioral health administration, except for oversight and management of state-run mental health institutions and licensing and certification activities, are hereby transferred to the Washington state health care authority to the extent necessary to carry out the purposes of chapter 201, Laws of 2018. All references to the secretary or the department of social and health services in the Revised Code of Washington shall be construed to mean the director of the health care authority or the health care authority when referring to the functions transferred in this section.
(2)(a) All reports, documents, surveys, books, records, files, papers, or written material in the possession of the department of social and health services pertaining to the powers, duties, and functions transferred shall be delivered to the custody of the health care authority. All cabinets, furniture, office equipment, motor vehicles, and other tangible property employed by the department of social and health services in carrying out the powers, duties, and functions transferred shall be made available to the health care authority. All funds, credits, or other assets held by the department of social and health services in connection with the powers, duties, and functions transferred shall be assigned to the health care authority.
(b) Any appropriations made to the department of social and health services for carrying out the powers, functions, and duties transferred shall, on July 1, 2018, be transferred and credited to the health care authority.
(c) Whenever any question arises as to the transfer of any personnel, funds, books, documents, records, papers, files, equipment, or other tangible property used or held in the exercise of the powers and the performance of the duties and functions transferred, the director of financial management shall make a determination as to the proper allocation and certify the same to the state agencies concerned.
(3) All rules and all pending business before the department of social and health services pertaining to the powers, duties, and functions transferred shall be continued and acted upon by the health care authority. All existing contracts and obligations shall remain in full force and shall be performed by the health care authority.
(4) The transfer of the powers, duties, functions, and personnel of the department of social and health services shall not affect the validity of any act performed before July 1, 2018.
(5) If apportionments of budgeted funds are required because of the transfers directed by this section, the director of financial management shall certify the apportionments to the agencies affected, the state auditor, and the state treasurer. Each of these shall make the appropriate transfer and adjustments in funds and appropriation accounts and equipment records in accordance with the certification.
(6) On July 1, 2018, all employees of the department of social and health services engaged in performing the powers, functions, and duties transferred to the health care authority are transferred to the health care authority. All employees classified under chapter
41.06
RCW, the state civil service law, are assigned to the health care authority to perform their usual duties upon the same terms as formerly, without any loss of rights, subject to any action that may be appropriate thereafter in accordance with the laws and rules governing state civil service law.
(7) Positions in any bargaining unit within the health care authority existing on July 1, 2018, will not be removed from an existing bargaining unit as a result of this section unless and until the existing bargaining unit is modified by the public employment relations commission pursuant to Title 391 WAC. The portions of any bargaining units of employees at the department of social and health services existing on July 1, 2018, that are transferred to the health care authority shall be considered separate appropriate units within the health care authority unless and until modified by the public employment relations commission pursuant to Title 391 WAC. The exclusive bargaining representatives recognized as representing the portions of the bargaining units of employees at the department of social and health services existing on July 1, 2018, shall continue as the exclusive bargaining representatives of the transferred bargaining units without the necessity of an election.
(8) The public employment relations commission may review the appropriateness of the collective bargaining units that are a result of the transfer from the department of social and health services to the health care authority under chapter 201, Laws of 2018. The employer or the exclusive bargaining representative may petition the public employment relations commission to review the bargaining units in accordance with this section.
(9) On July 1, 2018, the health care authority must enter into an agreement with the department of health to ensure coordination of preventative behavioral health services or other necessary agreements to carry out the intent of chapter 201, Laws of 2018.
(10) The health care authority may enter into agreements as necessary with the department of social and health services to carry out the transfer of duties as set forth in chapter 201, Laws of 2018.
[
2018 c 201 s 10001
.]
NOTES:
Findings
—
Intent
—
2018 c 201:
"The legislature finds that:
(1) Washington state government must be organized to be efficient, cost-effective, and responsive to its residents.
(2) Pursuant to existing legislative direction, Washington state continues to transform how it delivers behavioral health services by integrating the financing and delivery of behavioral and physical health care by 2020. Integration will improve prevention and treatment of behavioral health conditions. Integration, leading to better whole person care, should also enable many individuals to avoid commitment at the state psychiatric hospitals or divert from jails, and support them in leading healthy, productive lives.
(3) The responsibility for oversight, purchasing, and management of Washington state's community behavioral health system is currently split between the department of social and health services, which is the state's behavioral health authority, and the health care authority, which is the single state medicaid agency responsible for state health care purchasing.
(4) The health care authority is the state's primary health care purchaser. Integrating and consolidating the oversight and purchasing of state behavioral health care into a single state agency at the health care authority will align core operations and provide better, coordinated, and more cost-effective services, with the ultimate goal of achieving whole person care.
(5) The legislature therefore intends to consolidate state behavioral health care purchasing and oversight within the health care authority, positioning the state to use its full purchasing power to get the greatest value for its investment. The department of social and health services will continue to operate the state mental health institutions, with the intent of further analyzing the future proper alignment of these services.
(6) Similar to the issues with our disparate purchasing programs, the responsibility for licensing and certification of behavioral health providers and facilities is currently spread across multiple agencies, with the department of social and health services regulating some behavioral health providers and the department of health regulating others.
(7) The department of health is responsible for the majority of licensing and certification of health care providers and facilities. The state will best be able to ensure patient safety and reduce administrative burdens of licensing and certification of behavioral health providers and facilities by consolidating those functions within a single agency at the department of health. This change will streamline processes leading to improved patient safety outcomes.
(8) The legislature therefore intends to integrate and consolidate the behavioral health licensing and certification functions within the department of health." [
2018 c 201 s 1001
.]
Effective date
—
2018 c 201:
"Except as provided in section 11005 of this act, this act takes effect July 1, 2018." [
2018 c 201 s 11006
.]
RCW 41.05.021
State health care authority
—
Director
—
Cost control and delivery strategies
—
Health information technology
—
Managed competition
—
Rules.
(1) The Washington state health care authority is created within the executive branch. The authority shall have a director appointed by the governor, with the consent of the senate. The director shall serve at the pleasure of the governor. The director may employ a deputy director, and such assistant directors and special assistants as may be needed to administer the authority, who shall be exempt from chapter
41.06
RCW, and any additional staff members as are necessary to administer this chapter. The director may delegate any power or duty vested in him or her by law, including authority to make final decisions and enter final orders in hearings conducted under chapter
34.05
RCW. The primary duties of the authority shall be to: Administer insurance benefits for employees, retired or disabled state and school employees, and school employees; administer the basic health plan pursuant to chapter
70.47
RCW; administer the children's health program pursuant to chapter
74.09
RCW; study state purchased health care programs in order to maximize cost containment in these programs while ensuring access to quality health care; implement state initiatives, joint purchasing strategies, and techniques for efficient administration that have potential application to all state-purchased health services; and administer grants that further the mission and goals of the authority. The authority's duties include, but are not limited to, the following:
(a) To administer health care benefit programs for employees, retired or disabled state and school employees, and school employees as specifically authorized in RCW 41.05.065
and
41.05.740
and in accordance with the methods described in RCW 41.05.075, 41.05.140, and other provisions of this chapter;
(b) To analyze state purchased health care programs and to explore options for cost containment and delivery alternatives for those programs that are consistent with the purposes of those programs, including, but not limited to:
(i) Creation of economic incentives for the persons for whom the state purchases health care to appropriately utilize and purchase health care services, including the development of flexible benefit plans to offset increases in individual financial responsibility;
(ii) Utilization of provider arrangements that encourage cost containment, including but not limited to prepaid delivery systems, utilization review, and prospective payment methods, and that ensure access to quality care, including assuring reasonable access to local providers, especially for employees and school employees residing in rural areas;
(iii) Coordination of state agency efforts to purchase drugs effectively as provided in RCW 70.14.050
;
(iv) Development of recommendations and methods for purchasing medical equipment and supporting services on a volume discount basis;
(v) Development of data systems to obtain utilization data from state purchased health care programs in order to identify cost centers, utilization patterns, provider and hospital practice patterns, and procedure costs, utilizing the information obtained pursuant to RCW 41.05.031
; and
(vi) In collaboration with other state agencies that administer state purchased health care programs, private health care purchasers, health care facilities, providers, and carriers:
(A) Use evidence-based medicine principles to develop common performance measures and implement financial incentives in contracts with insuring entities, health care facilities, and providers that:
(I) Reward improvements in health outcomes for individuals with chronic diseases, increased utilization of appropriate preventive health services, and reductions in medical errors; and
(II) Increase, through appropriate incentives to insuring entities, health care facilities, and providers, the adoption and use of information technology that contributes to improved health outcomes, better coordination of care, and decreased medical errors;
(B) Through state health purchasing, reimbursement, or pilot strategies, promote and increase the adoption of health information technology systems, including electronic medical records, by hospitals as defined in RCW 70.41.020, integrated delivery systems, and providers that:
(I) Facilitate diagnosis or treatment;
(II) Reduce unnecessary duplication of medical tests;
(III) Promote efficient electronic physician order entry;
(IV) Increase access to health information for consumers and their providers; and
(V) Improve health outcomes;
(C) Coordinate a strategy for the adoption of health information technology systems;
(c) To analyze areas of public and private health care interaction;
(d) To provide information and technical and administrative assistance to the board;
(e) To review and approve or deny applications from counties, municipalities, and other political subdivisions of the state to provide state-sponsored insurance or self-insurance programs to their employees in accordance with the provisions of RCW 41.04.205
and (g) of this subsection, setting the premium contribution for approved groups as outlined in RCW 41.05.050
;
(f) To review and approve or deny the application when the governing body of a tribal government or tribal school applies to transfer their employees to an insurance or self-insurance program administered by the public employees' benefits board or by the school employees' benefits board. In the event of an employee transfer pursuant to this subsection (1)(f), members of the governing body are eligible to be included in such a transfer if the members are authorized by the tribal government or tribal school to participate in the insurance program being transferred from and subject to payment by the members of all costs of insurance for the members. The authority shall: (i) Establish the conditions for participation; (ii) have the sole right to reject the application; and (iii) set the premium contribution for approved groups as outlined in RCW 41.05.050
. Approval of the application by the authority transfers the employees and dependents involved to the insurance, self-insurance, or health care program administered by the public employees' benefits board or the school employees' benefits board;
(g) To ensure the continued status of the employee insurance or self-insurance programs administered under this chapter as a governmental plan under section 3(32) of the employee retirement income security act of 1974, as amended, the authority shall limit the participation of employer groups, including providing for the participation of those employees whose services are substantially all in the performance of essential governmental functions, but not in the performance of commercial activities. Charter schools established under chapter
28A.710
RCW are employers and are school employees' benefits board organizations unless:
(i) The authority receives guidance from the internal revenue service or the United States department of labor that participation jeopardizes the status of plans offered under this chapter as governmental plans under the federal employees' retirement income security act or the internal revenue code; or
(ii) The charter schools are not in compliance with regulations issued by the internal revenue service and the United States treasury department pertaining to section 414(d) of the federal internal revenue code;
(h) To establish billing procedures and collect funds from school employees' benefits board organizations in a way that minimizes the administrative burden on districts;
(i) Through December 31, 2019, to publish and distribute to nonparticipating school districts and educational service districts by October 1st of each year a description of health care benefit plans available through the authority and the estimated cost if school districts and educational service district employees were enrolled;
(j) To apply for, receive, and accept grants, gifts, and other payments, including property and service, from any governmental or other public or private entity or person, and make arrangements as to the use of these receipts to implement initiatives and strategies developed under this section;
(k) To issue, distribute, and administer grants that further the mission and goals of the authority;
(l) To adopt rules consistent with this chapter as described in RCW 41.05.160
including, but not limited to:
(i) Setting forth the criteria established by the public employees' benefits board under RCW 41.05.065, and by the school employees' benefits board under RCW 41.05.740, for determining whether a public employee is eligible for benefits;
(ii) Establishing an appeal process in accordance with chapter
34.05
RCW by which a public employee may appeal an eligibility determination;
(iii) Establishing a process to assure that the eligibility determinations of an employing agency comply with the criteria under this chapter, including the imposition of penalties as may be authorized by the board;
(m)(i) To administer the medical services programs established under chapter
74.09
RCW as the designated single state agency for purposes of Title XIX of the federal social security act;
(ii) To administer the state children's health insurance program under chapter
74.09
RCW for purposes of Title XXI of the federal social security act;
(iii) To enter into agreements with the department of social and health services for administration of medical care services programs under Titles XIX and XXI of the social security act and programs under chapters
71.05, 71.24, and
71.34
RCW. The agreements shall establish the division of responsibilities between the authority and the department with respect to mental health, substance use disorders, and long-term care services, including services for persons with developmental disabilities. The agreements shall be revised as necessary, to comply with the final implementation plan adopted under section 116, chapter 15, Laws of 2011 1st sp. sess.;
(iv) To adopt rules to carry out the purposes of chapter
74.09
RCW;
(v) To appoint such advisory committees or councils as may be required by any federal statute or regulation as a condition to the receipt of federal funds by the authority. The director may appoint statewide committees or councils in the following subject areas: (A) Health facilities; (B) children and youth services; (C) blind services; (D) medical and health care; (E) drug abuse and alcoholism; (F) rehabilitative services; and (G) such other subject matters as are or come within the authority's responsibilities. The statewide councils shall have representation from both major political parties and shall have substantial consumer representation. Such committees or councils shall be constituted as required by federal law or as the director in his or her discretion may determine. The members of the committees or councils shall hold office for three years except in the case of a vacancy, in which event appointment shall be only for the remainder of the unexpired term for which the vacancy occurs. No member shall serve more than two consecutive terms. Members of such state advisory committees or councils may be paid their travel expenses in accordance with RCW 43.03.050
and
43.03.060
as now existing or hereafter amended;
(n) To review and approve or deny the application from the governing board of the Washington health benefit exchange to provide public employees' benefits board state-sponsored insurance or self-insurance programs to employees of the exchange. The authority shall (i) establish the conditions for participation; (ii) have the sole right to reject an application; and (iii) set the premium contribution for approved groups as outlined in RCW 41.05.050
.
(2) The public employees' benefits board and the school employees' benefits board may implement strategies to promote managed competition among employee and school employee health benefit plans. Strategies may include but are not limited to:
(a) Standardizing the benefit package;
(b) Soliciting competitive bids for the benefit package;
(c) Limiting the state's contribution to a percent of the lowest priced qualified plan within a geographical area;
(d) Monitoring the impact of the approach under this subsection with regards to: Efficiencies in health service delivery, cost shifts to subscribers, access to and choice of managed care plans statewide, and quality of health services. The health care authority shall also advise on the value of administering a benchmark employer-managed plan to promote competition among managed care plans.
[
2023 c 51 s 6
;
2023 c 13 s 3
. Prior:
2018 c 260 s 6
;
2018 c 201 s 7002
;
2017 3rd sp.s. c 13 s 803
;
2012 c 87 s 23
;
2011 1st sp.s. c 15 s 56
;
2009 c 537 s 4
; prior:
2007 c 274 s 1
;
2007 c 114 s 3
;
2006 c 103 s 2
;
2005 c 446 s 1
;
2002 c 142 s 1
;
1999 c 372 s 4
;
1997 c 274 s 1
;
1995 1st sp.s. c 6 s 7
;
1994 c 309 s 1
; prior:
1993 c 492 s 215
;
1993 c 386 s 6
;
1990 c 222 s 3
;
1988 c 107 s 4
.]
NOTES:
Reviser's note:
This section was amended by 2023 c 13 s 3 and by 2023 c 51 s 6, each without reference to the other. Both amendments are incorporated in the publication of this section under RCW 1.12.025
(2). For rule of construction, see RCW 1.12.025
(1).
Finding
—
Intent
—
2023 c 13:
See note following RCW 41.05.011
.
Findings
—
Intent
—
Effective date
—
2018 c 201:
See notes following RCW 41.05.018
.
Intent
—
2017 3rd sp.s. c 13:
See note following RCW 28A.150.410
.
Collective bargaining agreements not impaired
—
2017 3rd sp.s. c 13:
See note following RCW 41.56.139
.
Effective date
—
2012 c 87 ss 4, 16, 18, and 19-23:
See note following RCW 43.71.030
.
Spiritual care services
—
2012 c 87:
See RCW 43.71.901
.
Effective date
—
Findings
—
Intent
—
Report
—
Agency transfer
—
References to head of health care authority
—
Draft legislation
—
2011 1st sp.s. c 15:
See notes following RCW 74.09.010
.
Effective date
—
2009 c 537:
See note following RCW 41.05.008
.
Intent
—
Effective date
—
2007 c 114:
See notes following RCW 41.05.011
.
Intent
—
2006 c 103:
"(1) The legislature recognizes that improvements in the quality of health care lead to better health care outcomes for the residents of Washington state and contain health care costs. The improvements are facilitated by the adoption of electronic medical records and other health information technologies.
(2) It is the intent of the legislature to encourage all hospitals, integrated delivery systems, and providers in the state of Washington to adopt health information technologies by the year 2012." [
2006 c 103 s 1
.]
Effective date
—
1997 c 274:
"This act is necessary for the immediate preservation of the public peace, health, or safety, or support of the state government and its existing public institutions, and takes effect July 1, 1997." [
1997 c 274 s 10
.]
Effective date
—
1995 1st sp.s. c 6:
See note following RCW 28A.400.410
.
Findings
—
Intent
—
1993 c 492:
See notes following RCW 43.20.050
.
Short title
—
Savings
—
Reservation of legislative power
—
Effective dates
—
1993 c 492:
See RCW 43.72.910
through
43.72.915
.
Intent
—
1993 c 386:
See note following RCW 28A.400.391
.
Effective date
—
1993 c 386 ss 1, 2, 4-6, 8-10, and 12-16:
See note following RCW 28A.400.391
.
RCW 41.05.022
State agent for purchasing health services
—
Single community-rated risk pool.
(1) The health care authority is hereby designated as the single state agent for purchasing health services.
(2) On and after January 1, 1995, at least the following state-purchased health services programs shall be merged into a single, community-rated risk pool: Health benefits for groups of employees of school districts and educational service districts that voluntarily purchase health benefits as provided in RCW 41.05.011
through December 31, 2019; health benefits for employees; health benefits for eligible retired or disabled school employees not eligible for parts A and B of medicare; and health benefits for eligible state retirees not eligible for parts A and B of medicare.
(3) On and after January 1, 2020, health benefits for groups of school employees of school employees' benefits board organizations shall be merged into a single, community-rated risk pool separate and distinct from the pool described in subsection (2) of this section.
(4) By December 15, 2018, the health care authority, in consultation with the board, shall submit to the appropriate committees of the legislature a complete analysis of the most appropriate risk pool for the retired and disabled school employees, to include at a minimum an analysis of the size of the nonmedicare and medicare retiree enrollment pools, the impacts on cost for state and school district retirees of moving retirees from one pool to another, the need for and the amount of an ongoing retiree subsidy allocation from the active school employees, and the timing and suggested approach for a transition from one risk pool to another.
(5) At a minimum, and regardless of other legislative enactments, the state health services purchasing agent shall:
(a) Require that a public agency that provides subsidies for a substantial portion of services now covered under the basic health plan use uniform eligibility processes, insofar as may be possible, and ensure that multiple eligibility determinations are not required;
(b) Require that a health care provider or a health care facility that receives funds from a public program provide care to state residents receiving a state subsidy who may wish to receive care from them, and that an insuring entity that receives funds from a public program accept enrollment from state residents receiving a state subsidy who may wish to enroll with them;
(c) Strive to integrate purchasing for all publicly sponsored health services in order to maximize the cost control potential and promote the most efficient methods of financing and coordinating services;
(d) Consult regularly with the governor, the legislature, and state agency directors whose operations are affected by the implementation of this section; and
(e) Ensure the control of benefit costs under managed competition by adopting rules to prevent an employing agency from entering into an agreement with employees or employee organizations when the agreement would result in increased utilization in board plans or reduce the expected savings of managed competition.
[
2018 c 260 s 7
;
2017 3rd sp.s. c 13 s 804
;
1995 1st sp.s. c 6 s 3
;
1994 c 153 s 3
;
1993 c 492 s 227
.]
NOTES:
Intent
—
2017 3rd sp.s. c 13:
See note following RCW 28A.150.410
.
Collective bargaining agreements not impaired
—
2017 3rd sp.s. c 13:
See note following RCW 41.56.139
.
Effective date
—
1995 1st sp.s. c 6:
See note following RCW 28A.400.410
.
Intent
—
Effective dates
—
1994 c 153:
See notes following RCW 41.05.011
.
Findings
—
Intent
—
1993 c 492:
See notes following RCW 43.20.050
.
Short title
—
Savings
—
Reservation of legislative power
—
Effective dates
—
1993 c 492:
See RCW 43.72.910
through
43.72.915
.
RCW 41.05.023
Chronic care management program
—
Uniform medical plan
—
Definitions.
(1) The health care authority, in collaboration with the department of health, shall design and implement a chronic care management program for employees and school employees enrolled in the state's self-insured uniform medical plan. Programs must be evidence based, facilitating the use of information technology to improve quality of care and must improve coordination of primary, acute, and long-term care for those enrollees with multiple chronic conditions. The authority shall consider expansion of existing medical home and chronic care management programs. The authority shall use best practices in identifying those employees and school employees best served under a chronic care management model using predictive modeling through claims or other health risk information.
(2) For purposes of this section:
(a) "Medical home" means a site of care that provides comprehensive preventive and coordinated care centered on the patient needs and assures high quality, accessible, and efficient care.
(b) "Chronic care management" means the authority's program that provides care management and coordination activities for health plan enrollees determined to be at risk for high medical costs. "Chronic care management" provides education and training and/or coordination that assist program participants in improving self-management skills to improve health outcomes and reduce medical costs by educating clients to better utilize services.
[
2018 c 260 s 8
;
2007 c 259 s 6
.]
NOTES:
Subheadings not law
—
2007 c 259:
See note following RCW 7.70.060
.
RCW 41.05.026
Contracts
—
Proprietary data, trade secrets, actuarial formulas, statistics, cost and utilization data
—
Exemption from public inspection
—
Executive sessions.
(1) When soliciting proposals for the purpose of awarding contracts for goods or services, the director shall, upon written request by the bidder, exempt from public inspection and copying such proprietary data, trade secrets, or other information contained in the bidder's proposal that relate to the bidder's unique methods of conducting business or of determining prices or premium rates to be charged for services under terms of the proposal.
(2) When soliciting information for the development, acquisition, or implementation of state purchased health care services, the director shall, upon written request by the respondent, exempt from public inspection and copying such proprietary data, trade secrets, or other information submitted by the respondent that relate to the respondent's unique methods of conducting business, data unique to the product or services of the respondent, or to determining prices or rates to be charged for services.
(3) Actuarial formulas, statistics, cost and utilization data, or other proprietary information submitted upon request of the director, board, or a technical review committee created to facilitate the development, acquisition, or implementation of state purchased health care under this chapter by a contracting insurer, health care service contractor, health maintenance organization, vendor, or other health services organization may be withheld at any time from public inspection when necessary to preserve trade secrets or prevent unfair competition.
(4) The board or a technical review committee created to facilitate the development, acquisition, or implementation of state purchased health care under this chapter, may hold an executive session in accordance with chapter
42.30
RCW during any regular or special meeting to discuss information submitted in accordance with subsections (1) through (3) of this section.
(5) A person who challenges a request for or designation of information as exempt under this section is entitled to seek judicial review pursuant to chapter
42.56
RCW.
[
2018 c 260 s 9
;
2017 3rd sp.s. c 13 s 805
;
2005 c 274 s 277
;
2003 c 277 s 2
;
1991 c 79 s 1
;
1990 c 222 s 6
.]
NOTES:
Intent
—
2017 3rd sp.s. c 13:
See note following RCW 28A.150.410
.
Collective bargaining agreements not impaired
—
2017 3rd sp.s. c 13:
See note following RCW 41.56.139
.
RCW 41.05.028
Health plan reimbursement rates.
(1) For purposes of this section:
(a) "Contractor" means a health carrier that provides medical insurance offered to public employees and their covered dependents under this chapter, or a third-party administrator contracted by the authority to provide medical coverage to public employees under this chapter.
(b) "The total amount medicare would have reimbursed for the same or similar services" means the amount of reimbursement for a claim that would be paid as if the centers for medicare and medicaid services reimbursed the claim, including applicable postclaim settlements.
(2)(a) Claims submitted for reimbursement under this section must include all the current year centers for medicare and medicaid services required modifiers so that all rebates, incentives, or adjustments that would have applied if reimbursed by medicare apply.
(b) The authority shall adopt rules to determine the equivalent amount of reimbursement for services with a low volume of medicare experience or for which there is no applicable centers for medicare and medicaid services reimbursement for a service.
(3) Beginning January 1, 2027, each contractor, for its health plans that provide medical coverage offered to public employees and their covered dependents, must meet the following requirements:
(a) Except as provided in (b) of this subsection, reimbursement to any in-network hospital licensed under chapter
70.41
RCW located in Washington for inpatient and outpatient hospital services shall be the lesser of billed charges, the contractor's contracted rate for the hospital, or 200 percent of the total amount medicare would have reimbursed for the same or similar services;
(b) Reimbursement for inpatient and outpatient hospital services to any in-network hospital licensed under chapter
70.41
RCW primarily engaged in the care and treatment of children located in:
(i) King county, shall be the lesser of billed charges, the contractor's contracted rate for the hospital, or 150 percent of the hospital-specific medicaid inpatient ratio of cost to charges as determined by the authority; and
(ii) Pierce county, shall be the lesser of billed charges, the contractor's contracted rate for the hospital, or 190 percent of the hospital-specific medicaid inpatient ratio of cost to charges as determined by the authority;
(c) Reimbursement for services provided by rural hospitals certified by the centers for medicare and medicaid services as critical access hospitals may not be less than 101 percent of allowable costs as defined by the United States centers for medicare and medicaid services for purposes of medicare cost reporting;
(d) Reimbursement for in-network primary care services, as defined by the authority, may not be less than 150 percent of the total amount medicare would have reimbursed for the same or similar services;
(e) Reimbursement for in-network nonfacility-based behavioral health services, as defined by the authority, may not be less than 150 percent of the total amount medicare would have reimbursed for the same or similar services;
(f) Except as provided in (g) of this subsection, reimbursement to any out-of-network hospital licensed under chapter
70.41
RCW located in Washington for inpatient and outpatient hospital services shall be the lesser of billed charges or 185 percent of the total amount medicare would have reimbursed for the same or similar services;
(g) Reimbursement for inpatient and outpatient hospital services provided by a hospital licensed under chapter
70.41
RCW and located in Washington to any out-of-network hospital primarily engaged in the care and treatment of children located in:
(i) King county, shall be the lesser of billed charges or 135 percent of the hospital-specific medicaid inpatient ratio of cost to charges as determined by the authority; and
(ii) Pierce county, shall be the lesser of billed charges or 175 percent of the hospital-specific medicaid inpatient ratio of cost to charges as determined by the authority; and
(h) A provider who is reimbursed in accordance with (f) or (g) of this subsection may not charge to or collect from the patient or a person who is financially responsible for the patient an amount in addition to the reimbursement paid under (f) or (g) of this subsection other than cost-sharing amounts authorized by the terms of the health plan.
(4) Except as provided in subsection (3)(c) of this section, this section does not apply to:
(a) Rural hospitals certified by the centers for medicare and medicaid services as sole community hospitals or critical access hospitals except for hospitals that are owned or operated by a health system that owns or operates more than two acute care hospitals licensed under chapter
70.41
RCW;
(b) Hospitals located on an island operating within a public hospital district in Skagit county; or
(c) Hospitals that are not currently designated as a critical access hospital, do not meet current federal eligibility requirements for designation as a critical access hospital, have combined medicaid and medicare inpatient days greater than 60 percent of all hospital inpatient days, and are located on the land of a federally recognized Indian tribe.
(5) Nothing in this section prohibits a contractor from reimbursing a hospital through a nonfee-for-service payment methodology, so long as the payments incentivize higher quality or improved health outcomes and the contractor continues to comply with the reimbursement requirements in this section.
(6) Premiums must take into account changes in reimbursement for hospital, primary care, and behavioral health services anticipated to result from the application of this section.
(7) At the request of the authority for monitoring, enforcement, or program and quality improvement activities, a contractor must provide cost and quality of care information and data to the authority and may not enter into an agreement with a provider or third party that would restrict the contractor from providing this information or data.
(8)(a) By December 31, 2030, the authority, in consultation with the office of the insurance commissioner, shall provide a report to the governor's office and relevant committees of the legislature analyzing the initial impacts of this section on network access, enrollee premiums and cost sharing, and state expenditures for medical coverage offered to public employees under this chapter. The report may include recommendations for legislative changes to the policy established in this section.
(b) By December 31, 2034, the authority, in consultation with the office of the insurance commissioner, shall provide a second report to the governor's office and relevant committees of the legislature providing an updated analysis on the impacts of this section on network access, enrollee premiums and cost sharing, and state expenditures for medical coverage offered to public employees under this chapter. The report may include recommendations for legislative changes to the policy established in this section.
(9) For the purposes of this section, reimbursement for inpatient and outpatient services does not include charges for professional services.
(10) The authority may adopt rules to implement this section, including rules for levying fines and taking other contract actions it deems necessary to enforce compliance with this section.
[
2025 c 373 s 1
.]
RCW 41.05.031
Health information technology office
—
Agencies to establish health care information systems.
The Washington state health information technology office is located within the authority. The following state agencies are directed to cooperate with the authority to establish appropriate health care information systems in their programs: The department of social and health services, the department of health, the department of labor and industries, the basic health plan, the department of veterans affairs, the department of corrections, the department of children, youth, and families, and the superintendent of public instruction.
The authority, in conjunction with these agencies and in collaboration with Washington technology solutions, shall determine:
(1) Definitions of health care services;
(2) Health care data elements common to all agencies;
(3) Health care data elements unique to each agency; and
(4) A mechanism for program and budget review of health care data.
[
2024 c 54 s 34
;
2023 c 51 s 7
;
1990 c 222 s 4
;
1988 c 107 s 5
.]
RCW 41.05.035
Exchange of health information
—
Advisory board, discretionary
—
Director's authority.
(1) The director shall design, implement, and maintain a consumer-centric health information infrastructure and the state electronic health record repositories that will facilitate the secure exchange of health information when and where needed and shall:
(a) Complete the plan of initial implementation, including but not limited to determining the technical infrastructure for the state electronic health record repositories and the account locator service, setting criteria and standards for health record repositories, and determining oversight of the state health records service;
(b) Implement the first state health record repositories as funding allows;
(c) Involve health care consumers in meaningful ways in the design, implementation, oversight, and dissemination of information on the state health record repositories system; and
(d) Promote adoption of electronic medical records and health information exchange through continuation of the Washington health information collaborative, and by working with private payors and other organizations in restructuring reimbursement to provide incentives for providers to adopt electronic medical records in their practices.
(2) The director may establish an advisory board, a stakeholder committee, and subcommittees to assist in carrying out the duties under this section. The director may reappoint health information infrastructure advisory board members to assure continuity and shall appoint any additional representatives that may be required for their expertise and experience.
(a) The director shall appoint the chair of the advisory board, chairs, and cochairs of the stakeholder committee, if formed;
(b) Meetings of the board, stakeholder committee, and any advisory group are subject to chapter
42.30
RCW, the open public meetings act, including RCW 42.30.110
(1)(l), which authorizes an executive session during a regular or special meeting to consider proprietary or confidential nonpublished information; and
(c) The members of the board, stakeholder committee, and any advisory group:
(i) Shall agree to the terms and conditions imposed by the director regarding conflicts of interest as a condition of appointment;
(ii) Are immune from civil liability for any official acts performed in good faith as members of the board, stakeholder committee, or any advisory group.
(3) Members of the board may be compensated for participation in accordance with a personal services contract to be executed after appointment and before commencement of activities related to the work of the board. Members of the stakeholder committee shall not receive compensation but shall be reimbursed under RCW 43.03.050
and
43.03.060
.
(4) The director may work with public and private entities to develop and encourage the use of personal health records which are portable, interoperable, secure, and respectful of patients' privacy.
(5) The director may enter into contracts to issue, distribute, and administer grants that are necessary or proper to carry out this section.
[
2023 c 51 s 8
;
2007 c 259 s 10
.]
NOTES:
Subheadings not law
—
2007 c 259:
See note following RCW 7.70.060
.
RCW 41.05.036
Health information
—
Definitions.
The definitions in this section apply throughout RCW 41.05.039
through
41.05.046
unless the context clearly requires otherwise.
(1) "Director" means the director of the state health care authority under this chapter.
(2) "Exchange" means the methods or medium by which health care information may be electronically and securely exchanged among authorized providers, payors, and patients within Washington state.
(3) "Health care provider" or "provider" has the same meaning as in RCW 48.43.005
.
(4) "Health data provider" means an organization that is a primary source for health-related data for Washington residents, including but not limited to:
(a) The children's health immunizations linkages and development profile immunization registry provided by the department of health pursuant to chapter
43.70
RCW;
(b) Commercial laboratories providing medical laboratory testing results;
(c) Prescription drugs clearinghouses, such as the national patient health information network; and
(d) Diagnostic imaging centers.
(5) "Lead organization" means a private sector organization or organizations designated by the director to lead development of processes, guidelines, and standards under chapter 300, Laws of 2009.
(6) "Payor" means public purchasers, as defined in this section, carriers licensed under chapters
48.20, 48.21, 48.44, 48.46, and
48.62
RCW, and the Washington state health insurance pool established in chapter
48.41
RCW.
(7) "Public purchaser" means the department of social and health services, the department of labor and industries, and the health care authority.
(8) "Secretary" means the secretary of the department of health.
[
2011 1st sp.s. c 15 s 57
;
2009 c 300 s 2
.]
NOTES:
Effective date
—
Findings
—
Intent
—
Report
—
Agency transfer
—
References to head of health care authority
—
Draft legislation
—
2011 1st sp.s. c 15:
See notes following RCW 74.09.010
.
Finding
—
2009 c 300:
"The legislature finds that:
(1) The inability to securely share critical health information between practitioners inhibits the delivery of safe, efficient care, as evidenced by:
(a) Adverse drug events that result in an average of seven hundred seventy thousand injuries and deaths each year; and
(b) Duplicative services that add to costs and jeopardize patient well-being;
(2) Consumers are unable to act as fully informed participants in their care unless they have ready access to their own health information;
(3) The blue ribbon commission on health care costs and access found that the development of a system to provide electronic access to patient information anywhere in the state was a key to improving health care; and
(4) In 2005, the legislature established a health information infrastructure advisory board to develop a strategy for the adoption and use of health information technologies that are consistent with emerging national standards and promote interoperability of health information systems." [
2009 c 300 s 1
.]
RCW 41.05.037
Nurse hotline, when funded.
To the extent that funding is provided specifically for this purpose, the director shall provide all persons enrolled in health plans under this chapter and chapters
70.47
and
74.09
RCW with access to a twenty-four hour, seven day a week nurse hotline.
[
2011 1st sp.s. c 15 s 58
;
2007 c 259 s 15
.]
NOTES:
Effective date
—
Findings
—
Intent
—
Report
—
Agency transfer
—
References to head of health care authority
—
Draft legislation
—
2011 1st sp.s. c 15:
See notes following RCW 74.09.010
.
Subheadings not law
—
2007 c 259:
See note following RCW 7.70.060
.
RCW 41.05.039
Health information
—
Secure access
—
Lead organization
—
Director's duties.
(1) By August 1, 2009, the director shall designate one or more lead organizations to coordinate development of processes, guidelines, and standards to:
(a) Improve patient access to and control of their own health care information and thereby enable their active participation in their own care; and
(b) Implement methods for the secure exchange of clinical data as a means to promote:
(i) Continuity of care;
(ii) Quality of care;
(iii) Patient safety; and
(iv) Efficiency in medical practices.
(2) The lead organization designated by the director under this section shall:
(a) Be representative of health care privacy advocates, providers, and payors across the state;
(b) Have expertise and knowledge in the major disciplines related to the secure exchange of health data;
(c) Be able to support the costs of its work without recourse to state funding. The director and the lead organization are authorized and encouraged to seek federal funds, including funds from the federal American recovery and reinvestment act, as well as solicit, receive, contract for, collect, and hold grants, donations, and gifts to support the implementation of this section and RCW 41.05.042
;
(d) In collaboration with the director, identify and convene work groups, as needed, to accomplish the goals of this section and RCW 41.05.042
;
(e) Conduct outreach and communication efforts to maximize the adoption of the guidelines, standards, and processes developed by the lead organization;
(f) Submit regular updates to the director on the progress implementing the requirements of this section and RCW 41.05.042
; and
(g) With the director, report to the legislature December 1, 2009, and on December 1st of each year through December 1, 2012, on progress made, the time necessary for completing tasks, and identification of future tasks that should be prioritized for the next improvement cycle.
(3) Within available funds as specified in subsection (2)(c) of this section, the director shall:
(a) Participate in and review the work and progress of the lead organization, including the establishment and operation of work groups for this section and RCW 41.05.042
; and
(b) Consult with the office of the attorney general to determine whether:
(i) An antitrust safe harbor is necessary to enable licensed carriers and providers to develop common rules and standards; and, if necessary, take steps, such as implementing rules or requesting legislation, to establish a safe harbor; and
(ii) Legislation is needed to limit provider liability if their health records are missing health information despite their participation in the exchange of health information.
(4) The lead organization or organizations shall take steps to minimize the costs that implementation of the processes, guidelines, and standards may have on participating entities, including providers.
[
2023 c 51 s 9
;
2009 c 300 s 3
.]
NOTES:
Findings
—
2009 c 300:
See note following RCW 41.05.036
.
RCW 41.05.042
Health information
—
Processes, guidelines, and standards.
By December 1, 2011, the lead organization shall, consistent with the federal health insurance portability and accountability act, develop processes, guidelines, and standards that address:
(1) Identification and prioritization of high value health data from health data providers. High value health data include:
(a) Prescriptions;
(b) Immunization records;
(c) Laboratory results;
(d) Allergies; and
(e) Diagnostic imaging;
(2) Processes to request, submit, and receive data;
(3) Data security, including:
(a) Storage, access, encryption, and password protection;
(b) Secure methods for accepting and responding to requests for data;
(c) Handling unauthorized access to or disclosure of individually identifiable patient health information, including penalties for unauthorized disclosure; and
(d) Authentication of individuals, including patients and providers, when requesting access to health information, and maintenance of a permanent audit trail of such requests, including:
(i) Identification of the party making the request;
(ii) The data elements reported; and
(iii) Transaction dates;
(4) Materials written in plain language that explain the exchange of health information and how patients can effectively manage such information, including the use of online tools for that purpose;
(5) Materials for health care providers that explain the exchange of health information and the secure management of such information.
[
2009 c 300 s 4
.]
NOTES:
Findings
—
2009 c 300:
See note following RCW 41.05.036
.
RCW 41.05.046
Health information
—
Conflict with federal requirements.
If any provision in RCW 41.05.036, 41.05.039, and
41.05.042
conflicts with existing or new federal requirements, the director shall recommend modifications, as needed, to assure compliance with the aims of RCW 41.05.036, 41.05.039, and
41.05.042
and federal requirements.
[
2023 c 51 s 10
;
2009 c 300 s 5
.]
NOTES:
Findings
—
2009 c 300:
See note following RCW 41.05.036
.
RCW 41.05.050
Contributions for employees and dependents.
(1)(a) Every employer and employer group as defined in RCW 41.05.011
shall provide contributions to insurance and health care plans for its employees and their dependents, the content of such plans to be determined by the authority.
(b) Contributions paid by employer groups for their employees, shall include an amount determined by the authority to pay such administrative expenses of the authority as are necessary to administer the plans for employees of those groups.
(2) To account for any increased cost of benefit plans developed by the board, the authority may develop a rate surcharge applicable to participating employer groups as defined in RCW 41.05.011
.
(3) The contributions of any: (a) Department, division, or separate agency of the state government; (b) county, municipal, or other political subdivisions; (c) any tribal government as are covered by this chapter; and (d) school districts, educational service districts, and charter schools, shall be set by the authority, subject to the approval of the governor for availability of funds as specifically appropriated by the legislature for that purpose. Insurance and health care contributions for ferry employees shall be governed by RCW 47.64.270
.
(4)(a) For all groups of educational service district employees enrolling in plans developed by the public employees' benefits board after January 1, 2020, and until January 1, 2024, the authority shall collect from each participating educational service district an amount equal to the composite rate charged to state agencies, plus an amount equal to the employee premiums by plan and by family size as would be charged to employees, only if the authority determines that this method of billing the educational service districts will not result in a material difference between revenues from educational service districts and expenditures made by the authority on behalf of educational service districts and their employees. The authority may collect these amounts in accordance with the educational service district fiscal year, as described in RCW 28A.505.030
.
(b)(i) Beginning January 1, 2020, all school districts, represented employees of educational service districts, and charter schools shall commence participation in the school employees' benefits board program established under RCW 41.05.740
. All school districts, represented employees of educational service districts, charter schools, and all school district employee groups participating in the public employees' benefits board plans before January 1, 2020, shall thereafter participate in the school employees' benefits board program administered by the authority. All school districts, represented employees of educational service districts, and charter schools shall provide contributions to the authority for insurance and health care plans for school employees and their dependents. These contributions must be provided to the authority for all eligible school employees eligible for benefits under RCW 41.05.740
(6)(d), including school employees who have waived their coverage; contributions to the authority are not required for individuals eligible for benefits under RCW 41.05.740
(6)(e) who waive their coverage.
(ii) Beginning January 1, 2024, all educational service districts shall participate in the school employees' benefits board program.
(5) The authority shall transmit a recommendation for the amount of the employer contributions to the governor and the director of financial management for inclusion in the proposed budgets submitted to the legislature.
[
2023 c 13 s 4
;
2019 c 411 s 5
;
2018 c 260 s 10
;
2017 3rd sp.s. c 13 s 806
;
2016 c 67 s 3
;
2009 c 537 s 5
;
2007 c 114 s 4
;
2005 c 518 s 919
;
2003 c 158 s 1
. Prior:
2002 c 319 s 4
;
2002 c 142 s 2
; prior:
1995 1st sp.s. c 6 s 22
;
1994 c 309 s 2
;
1994 c 153 s 4
; prior:
1993 c 492 s 216
;
1993 c 386 s 7
;
1988 c 107 s 18
;
1987 c 122 s 4
;
1984 c 107 s 1
;
1983 c 15 s 20
;
1983 c 2 s 9
; prior:
1982 1st ex.s. c 34 s 2
;
1981 c 344 s 6
;
1979 c 151 s 55
;
1977 ex.s. c 136 s 4
; 1975-'76 2nd ex.s. c 106 s 4;
1975 1st ex.s. c 38 s 2
;
1973 1st ex.s. c 147 s 3
;
1970 ex.s. c 39 s 5
.]
NOTES:
Finding
—
Intent
—
2023 c 13:
See note following RCW 41.05.011
.
Intent
—
2017 3rd sp.s. c 13:
See note following RCW 28A.150.410
.
Collective bargaining agreements not impaired
—
2017 3rd sp.s. c 13:
See note following RCW 41.56.139
.
Effective date
—
2009 c 537:
See note following RCW 41.05.008
.
Intent
—
Effective date
—
2007 c 114:
See notes following RCW 41.05.011
.
Effective date
—
2005 c 518:
See note following RCW 28A.600.110
.
Intent
—
2002 c 319:
See note following RCW 41.04.208
.
Effective date
—
1995 1st sp.s. c 6:
See note following RCW 28A.400.410
.
Intent
—
Effective dates
—
1994 c 153:
See notes following RCW 41.05.011
.
Findings
—
Intent
—
1993 c 492:
See notes following RCW 43.20.050
.
Short title
—
Savings
—
Reservation of legislative power
—
Effective dates
—
1993 c 492:
See RCW 43.72.910
through
43.72.915
.
Effective date
—
1993 c 386 ss 3, 7, and 11:
See note following RCW 41.04.205
.
Intent
—
1993 c 386:
See note following RCW 28A.400.391
.
Severability
—
1983 c 2:
See note following RCW 18.71.030
.
Severability
—
1981 c 344:
"If any provision of this act or its application to any person or circumstance is held invalid, the remainder of the act or the application of the provision to other persons or circumstances is not affected." [
1981 c 344 s 8
.]
Effective date
—
Conditions prerequisite to implementing sections
—
1977 ex.s. c 136:
"This 1977 amendatory act is necessary for the immediate preservation of the public peace, health, and safety, the support of the state government and its existing public institutions, and shall take effect on July 1, 1977: PROVIDED, That if the state operating budget appropriations act does not contain the funds necessary for the implementation of this 1977 amendatory act in an appropriated amount sufficient to fully fund the employer's contribution to the state employee insurance benefits program which is established by the board in accordance with RCW 41.05.050
(2) and (3) as now or hereafter amended, sections 1, 5, and 6 of this 1977 amendatory act shall be null and void." [
1977 ex.s. c 136 s 8
.]
Effective date
—
Effect of veto
—
1973 1st ex.s. c 147:
"This bill shall not take effect until the funds necessary for its implementation have been specifically appropriated by the legislature and such appropriation itself has become law. It is the intention of the legislature that if the governor shall veto this section or any item thereof, none of the provisions of this bill shall take effect." [
1973 1st ex.s. c 147 s 10
.]
Savings
—
1973 1st ex.s. c 147:
"Nothing contained in this 1973 amendatory act shall be deemed to amend, alter or affect the provisions of Chapter 23, Laws of 1972, Extraordinary Session, and RCW 28B.10.840
through
28B.10.844
as now or hereafter amended." [
1973 1st ex.s. c 147 s 13
.]
Severability
—
1973 1st ex.s. c 147:
"If any provision of this 1973 amendatory act, or its application to any person or circumstances is held invalid, the remainder of the act, or the application of the provision to other persons or circumstances is not affected." [
1973 1st ex.s. c 147 s 9
.]
Severability
—
1970 ex.s. c 39:
"If any provision of this act, or its application to any person or circumstance is held invalid, the remainder of the act, or the application of the provision to other persons or circumstances is not affected." [
1970 ex.s. c 39 s 14
.]
RCW 41.05.055
Public employees' benefits board
—
Members.
(1) The public employees' benefits board is created within the authority. The function of the public employees' benefits board is to design and approve insurance benefit plans for employees and to establish eligibility criteria for participation in insurance benefit plans.
(2) The public employees' benefits board shall be composed of nine members through December 31, 2019, and of eight members thereafter, appointed by the governor as follows:
(a) Two representatives of state employees, one of whom shall represent an employee union certified as exclusive representative of at least one bargaining unit of classified employees, and one of whom is retired, is covered by a program under the jurisdiction of the public employees' benefits board, and represents an organized group of retired public employees;
(b) Through December 31, 2019, two representatives of school district employees, one of whom shall represent an association of school employees as a nonvoting member, and one of whom is retired, and represents an organized group of retired school employees. Thereafter, and only while retired school employees are served by the public employees' benefits board, only the retired representative shall serve on the public employees' benefits board;
(c) Four members with experience in health benefit management and cost containment, one of whom shall be a nonvoting member; and
(d) The director.
(3) The governor shall appoint the initial members of the public employees' benefits board to staggered terms not to exceed four years. Members appointed thereafter shall serve two-year terms. Members of the public employees' benefits board shall be compensated in accordance with RCW 43.03.250
and shall be reimbursed for their travel expenses while on official business in accordance with RCW 43.03.050
and
43.03.060
. The public employees' benefits board shall prescribe rules for the conduct of its business. The director shall serve as chair of the public employees' benefits board. Meetings of the public employees' benefits board shall be at the call of the chair.
[
2018 c 260 s 11
;
2017 3rd sp.s. c 13 s 807
;
2009 c 537 s 6
;
1995 1st sp.s. c 6 s 4
;
1994 c 36 s 1
;
1993 c 492 s 217
;
1989 c 324 s 1
;
1988 c 107 s 7
.]
NOTES:
Intent
—
2017 3rd sp.s. c 13:
See note following RCW 28A.150.410
.
Collective bargaining agreements not impaired
—
2017 3rd sp.s. c 13:
See note following RCW 41.56.139
.
Effective date
—
2009 c 537:
See note following RCW 41.05.008
.
Effective date
—
1995 1st sp.s. c 6:
See note following RCW 28A.400.410
.
Effective date
—
1994 c 36:
"This act is necessary for the immediate preservation of the public peace, health, or safety, or support of the state government and its existing public institutions, and shall take effect immediately [March 21, 1994]." [
1994 c 36 s 2
.]
Findings
—
Intent
—
1993 c 492:
See notes following RCW 43.20.050
.
Short title
—
Savings
—
Reservation of legislative power
—
Effective dates
—
1993 c 492:
See RCW 43.72.910
through
43.72.915
.
RCW 41.05.065
Public employees' benefits board
—
Duties
—
Eligibility
—
Definitions
—
Penalties.
(1) The public employees' benefits board shall study all matters connected with the provision of health care coverage, life insurance, liability insurance, accidental death and dismemberment insurance, and disability income insurance or any of, or a combination of, the enumerated types of insurance for employees and their dependents on the best basis possible with relation both to the welfare of the employees and to the state. However, liability insurance shall not be made available to dependents.
(2) The public employees' benefits board shall develop employee benefit plans that include comprehensive health care benefits for employees. In developing these plans, the public employees' benefits board shall consider the following elements:
(a) Methods of maximizing cost containment while ensuring access to quality health care;
(b) Development of provider arrangements that encourage cost containment and ensure access to quality care, including but not limited to prepaid delivery systems and prospective payment methods;
(c)(i) Wellness initiatives that focus on proven strategies, such as smoking cessation, injury and accident prevention, reduction of alcohol misuse, appropriate weight reduction, exercise, automobile and motorcycle safety, blood cholesterol reduction, and nutrition education.
(ii)(A) As of January 1, 2028, the public employees' benefits board shall no longer offer the smart health program, which includes the wellness incentive and the smart health online portal.
(B) Employees who have met the eligibility requirements to receive a wellness incentive by December 31, 2027, will still receive the wellness incentive in plan year 2028.
(C) Employees are not eligible to earn a wellness incentive as of January 1, 2028;
(d) Utilization review procedures including, but not limited to a cost-efficient method for prior authorization of services, hospital inpatient length of stay review, requirements for use of outpatient surgeries and second opinions for surgeries, review of invoices or claims submitted by service providers, and performance audit of providers;
(e) Effective coordination of benefits; and
(f) Minimum standards for insuring entities.
(3) To maintain the comprehensive nature of employee health care benefits, benefits provided to employees shall be substantially equivalent to the state employees' health benefit plan in effect on January 1, 1993. Nothing in this subsection shall prohibit changes or increases in employee point-of-service payments or employee premium payments for benefits or the administration of a high deductible health plan in conjunction with a health savings account. The public employees' benefits board may establish employee eligibility criteria which are not substantially equivalent to employee eligibility criteria in effect on January 1, 1993.
(4) Except if bargained for under chapter
41.80
RCW, the public employees' benefits board shall design benefits and determine the terms and conditions of employee and retired or disabled school employee participation and coverage, including establishment of eligibility criteria subject to the requirements of this chapter. Employer groups obtaining benefits through contractual agreement with the authority for employees defined in RCW 41.05.011
(6)(a) (i) through (vi) may contractually agree with the authority to benefits eligibility criteria which differs from that determined by the public employees' benefits board. The eligibility criteria established by the public employees' benefits board shall be no more restrictive than the following:
(a) Except as provided in (b) through (e) of this subsection, an employee is eligible for benefits from the date of employment if the employing agency anticipates he or she will work an average of at least eighty hours per month and for at least eight hours in each month for more than six consecutive months. An employee determined ineligible for benefits at the beginning of his or her employment shall become eligible in the following circumstances:
(i) An employee who works an average of at least eighty hours per month and for at least eight hours in each month and whose anticipated duration of employment is revised from less than or equal to six consecutive months to more than six consecutive months becomes eligible when the revision is made.
(ii) An employee who works an average of at least eighty hours per month over a period of six consecutive months and for at least eight hours in each of those six consecutive months becomes eligible at the first of the month following the six-month averaging period.
(b) A seasonal employee is eligible for benefits from the date of employment if the employing agency anticipates that he or she will work an average of at least eighty hours per month and for at least eight hours in each month of the season. A seasonal employee determined ineligible at the beginning of his or her employment who works an average of at least eighty hours per month over a period of six consecutive months and at least eight hours in each of those six consecutive months becomes eligible at the first of the month following the six-month averaging period. A benefits-eligible seasonal employee who works a season of less than nine months shall not be eligible for the employer contribution during the off season, but may continue enrollment in benefits during the off season by self-paying for the benefits. A benefits-eligible seasonal employee who works a season of nine months or more is eligible for the employer contribution through the off season following each season worked.
(c) Faculty are eligible as follows:
(i) Faculty who the employing agency anticipates will work half–time or more for the entire instructional year or equivalent nine-month period are eligible for benefits from the date of employment. Eligibility shall continue until the beginning of the first full month of the next instructional year, unless the employment relationship is terminated, in which case eligibility shall cease the first month following the notice of termination or the effective date of the termination, whichever is later.
(ii) Faculty who the employing agency anticipates will not work for the entire instructional year or equivalent nine-month period are eligible for benefits at the beginning of the second consecutive quarter or semester of employment in which he or she is anticipated to work, or has actually worked, half-time or more. Such an employee shall continue to receive uninterrupted employer contributions for benefits if the employee works at least half-time in a quarter or semester. Faculty who the employing agency anticipates will not work for the entire instructional year or equivalent nine-month period, but who actually work half-time or more throughout the entire instructional year, are eligible for summer or off-quarter or off-semester coverage. Faculty who have met the criteria of this subsection (4)(c)(ii), who work at least two quarters or two semesters of the academic year with an average academic year workload of half-time or more for three quarters or two semesters of the academic year, and who have worked an average of half-time or more in each of the two preceding academic years shall continue to receive uninterrupted employer contributions for benefits if he or she works at least half-time in a quarter or semester or works two quarters or two semesters of the academic year with an average academic workload each academic year of half-time or more for three quarters or two semesters. Eligibility under this section ceases immediately if this criteria is not met.
(iii) Faculty may establish or maintain eligibility for benefits by working for more than one institution of higher education. When faculty work for more than one institution of higher education, those institutions shall prorate the employer contribution costs, or if eligibility is reached through one institution, that institution will pay the full employer contribution. Faculty working for more than one institution must alert his or her employers to his or her potential eligibility in order to establish eligibility.
(iv) The employing agency must provide written notice to faculty who are potentially eligible for benefits under this subsection (4)(c) of their potential eligibility.
(v) To be eligible for maintenance of benefits through averaging under (c)(ii) of this subsection, faculty must provide written notification to his or her employing agency or agencies of his or her potential eligibility.
(vi) For the purposes of this subsection (4)(c):
(A) "Academic year" means summer, fall, winter, and spring quarters or summer, fall, and spring semesters;
(B) "Half-time" means one-half of the full-time academic workload as determined by each institution; except that for community and technical college faculty, half-time academic workload is calculated according to RCW 28B.50.489
.
(d) A legislator is eligible for benefits on the date his or her term begins. All other elected and full-time appointed officials of the legislative and executive branches of state government are eligible for benefits on the date his or her term begins or they take the oath of office, whichever occurs first.
(e) A justice of the supreme court and judges of the court of appeals and the superior courts become eligible for benefits on the date he or she takes the oath of office.
(f) Except as provided in (c)(i) and (ii) of this subsection, eligibility ceases for any employee the first of the month following termination of the employment relationship.
(g) In determining eligibility under this section, the employing agency may disregard training hours, standby hours, or temporary changes in work hours as determined by the authority under this section.
(h) Insurance coverage for all eligible employees begins on the first day of the month following the date when eligibility for benefits is established. If the date eligibility is established is the first working day of a month, insurance coverage begins on that date.
(i) Eligibility for an employee whose work circumstances are described by more than one of the eligibility categories in (a) through (e) of this subsection shall be determined solely by the criteria of the category that most closely describes the employee's work circumstances.
(j) Except for an employee eligible for benefits under (b) or (c)(ii) of this subsection, an employee who has established eligibility for benefits under this section shall remain eligible for benefits each month in which he or she is in pay status for eight or more hours, if (i) he or she remains in a benefits-eligible position and (ii) leave from the benefits-eligible position is approved by the employing agency. A benefits-eligible seasonal employee is eligible for the employer contribution in any month of his or her season in which he or she is in pay status eight or more hours during that month. Eligibility ends if these conditions are not met, the employment relationship is terminated, or the employee voluntarily transfers to a noneligible position.
(k) For the purposes of this subsection, the public employees' benefits board shall define "benefits-eligible position."
(5) The public employees' benefits board may authorize premium contributions for an employee and the employee's dependents in a manner that encourages the use of cost-efficient managed health care systems.
(6)(a) For any open enrollment period following August 24, 2011, the public employees' benefits board shall offer a health savings account option for employees that conforms to section 223, Part VII of subchapter B of chapter 1 of the internal revenue code of 1986. The public employees' benefits board shall comply with all applicable federal standards related to the establishment of health savings accounts.
(b) By November 30, 2015, and each year thereafter, the authority shall submit a report to the relevant legislative policy and fiscal committees that includes the following:
(i) Public employees' benefits board health plan cost and service utilization trends for the previous three years, in total and for each health plan offered to employees;
(ii) For each health plan offered to employees, the number and percentage of employees and dependents enrolled in the plan, and the age and gender demographics of enrollees in each plan;
(iii) Any impact of enrollment in alternatives to the most comprehensive plan, including the high deductible health plan with a health savings account, upon the cost of health benefits for those employees who have chosen to remain enrolled in the most comprehensive plan.
(7) Notwithstanding any other provision of this chapter, for any open enrollment period following August 24, 2011, the public employees' benefits board shall offer a high deductible health plan in conjunction with a health savings account developed under subsection (6) of this section.
(8) Employees shall choose participation in one of the health care benefit plans developed by the public employees' benefits board and may be permitted to waive coverage under terms and conditions established by the public employees' benefits board.
(9) In addition to the benefits offering authority under this chapter, the public employees' benefits board may study, establish evaluation criteria, and, subject to the availability of funding, offer the following employee-paid, voluntary benefits:
(a) Emergency transportation;
(b) Identity protection;
(c) Legal aid;
(d) Long-term care insurance;
(e) Noncommercial personal automobile insurance;
(f) Personal homeowner's or renter's insurance;
(g) Pet insurance;
(h) Specified disease or illness-triggered fixed payment insurance, hospital confinement fixed payment insurance, or other fixed payment insurance offered as an independent, noncoordinated benefit regulated by the office of the insurance commissioner; and
(i) Travel insurance.
(10) The public employees' benefits board may establish penalties to be imposed by the authority when the eligibility determinations of an employing agency fail to comply with the criteria under this chapter.
[
2025 c 396 s 1
;
2025 c 339 s 1
;
2018 c 260 s 12
;
2015 c 116 s 3
;
2011 1st sp.s. c 8 s 1
;
2009 c 537 s 7
. Prior:
2007 c 156 s 10
;
2007 c 114 s 5
;
2006 c 299 s 2
; prior:
2005 c 518 s 920
;
2005 c 195 s 1
;
2003 c 158 s 2
;
2002 c 142 s 3
;
1996 c 140 s 1
;
1995 1st sp.s. c 6 s 5
;
1994 c 153 s 5
; prior:
1993 c 492 s 218
;
1993 c 386 s 9
;
1988 c 107 s 8
.]
NOTES:
Reviser's note:
This section was amended by 2025 c 339 s 1 and by 2025 c 396 s 1, each without reference to the other. Both amendments are incorporated in the publication of this section under RCW 1.12.025
(2). For rule of construction, see RCW 1.12.025
(1).
Effective date
—
2009 c 537:
See note following RCW 41.05.008
.
Intent
—
Effective date
—
2007 c 114:
See notes following RCW 41.05.011
.
Effective date
—
2005 c 518:
See note following RCW 28A.600.110
.
Effective date
—
2005 c 195:
"This act is necessary for the immediate preservation of the public peace, health, or safety, or support of the state government and its existing public institutions, and takes effect July 1, 2005." [
2005 c 195 s 4
.]
Effective date
—
1995 1st sp.s. c 6:
See note following RCW 28A.400.410
.
Intent
—
Effective dates
—
1994 c 153:
See notes following RCW 41.05.011
.
Findings
—
Intent
—
1993 c 492:
See notes following RCW 43.20.050
.
Short title
—
Savings
—
Reservation of legislative power
—
Effective dates
—
1993 c 492:
See RCW 43.72.910
through
43.72.915
.
Intent
—
1993 c 386:
See note following RCW 28A.400.391
.
Effective date
—
1993 c 386 ss 1, 2, 4-6, 8-10, and 12-16:
See note following RCW 28A.400.391
.
RCW 41.05.066
Domestic partner benefits.
A certificate of domestic partnership qualified under the provisions of RCW 26.60.030
shall be recognized as evidence of a state registered domestic partnership fulfilling all necessary eligibility criteria for the partner of the public employee to receive benefits. Nothing in this section affects the requirements of domestic partners to complete documentation related to federal tax status that may currently be required by the board for public employees choosing to make premium payments on a pretax basis.
[
2023 c 51 s 11
;
2018 c 260 s 13
;
2015 c 116 s 4
;
2007 c 156 s 9
.]
RCW 41.05.068
Federal employer incentive program
—
Authority to participate.
The authority may participate as an employer-sponsored program established in section 1860D-22 of the medicare prescription drug, improvement, and modernization act of 2003, P.L. 108-173 et seq., to receive federal employer subsidy funds for continuing to provide retired employee health coverage, including a pharmacy benefit. The director, in consultation with the office of financial management, shall evaluate participation in the employer incentive program, including but not limited to any necessary program changes to meet the eligibility requirements that employer-sponsored retiree health coverage provide prescription drug coverage at least equal to the actuarial value of standard prescription drug coverage under medicare part D. Any employer subsidy moneys received from participation in the federal employer incentive program shall be deposited in the state general fund.
[
2023 c 51 s 12
;
2009 c 479 s 25
;
2005 c 195 s 2
.]
NOTES:
Effective date
—
2009 c 479:
See note following RCW 2.56.030
.
Effective date
—
2005 c 195:
See note following RCW 41.05.065
.
RCW 41.05.074
Public employees
—
Prior authorization standards and criteria
—
Health plan requirements
—
Definitions.
(1) A health plan offered to public employees and their covered dependents under this chapter that imposes different prior authorization standards and criteria for a covered service among tiers of contracting providers of the same licensed profession in the same health plan shall inform an enrollee which tier an individual provider or group of providers is in by posting the information on its website in a manner accessible to both enrollees and providers.
(2) The health plan may not require prior authorization for an evaluation and management visit or an initial treatment visit with a contracting provider in a new episode of chiropractic, physical therapy, occupational therapy, acupuncture and Eastern medicine, massage therapy, or speech and hearing therapies. Notwithstanding RCW 48.43.515
(5) this section may not be interpreted to limit the ability of a health plan to require a referral or prescription for the therapies listed in this section.
(3) The health care authority shall post on its website and provide upon the request of a covered person or contracting provider any prior authorization standards, criteria, or information the health plan uses for medical necessity decisions.
(4) A health care provider with whom the administrator of the health plan consults regarding a decision to deny, limit, or terminate a person's covered health care services must hold a license, certification, or registration, in good standing and must be in the same or related health field as the health care provider being reviewed or of a specialty whose practice entails the same or similar covered health care service.
(5) The health plan may not require a provider to provide a discount from usual and customary rates for health care services not covered under the health plan, policy, or other agreement, to which the provider is a party.
(6) For purposes of this section:
(a) "New episode of care" means treatment for a new or recurrent condition for which the enrollee has not been treated by the provider within the previous ninety days and is not currently undergoing any active treatment.
(b) "Contracting provider" does not include providers employed within an integrated delivery system operated by a carrier licensed under chapter
48.44
or
48.46
RCW.
[
2019 c 308 s 20
;
2015 c 251 s 1
.]
NOTES:
Findings
—
2019 c 308:
See note following RCW 18.06.010
.
Effective date
—
2015 c 251:
"This act takes effect January 1, 2017." [
2015 c 251 s 3
.]
RCW 41.05.075
Employee benefit plans
—
Contracts with insuring entities
—
Performance measures
—
Financial incentives
—
Health information technology.
(1) The director shall provide benefit plans designed by the board through a contract or contracts with insuring entities, through self-funding, self-insurance, or other methods of providing insurance coverage authorized by RCW 41.05.140
. The process of contracting for plans offered by the school employees' benefits board is subject to insight and direction by the school employees' benefits board.
(2) The director shall establish a contract bidding process that:
(a) Encourages competition among insuring entities;
(b) Maintains an equitable relationship between premiums charged for similar benefits and between risk pools including premiums charged for retired state and school district employees under the separate risk pools established by RCW 41.05.022
and
41.05.080
such that insuring entities may not avoid risk when establishing the premium rates for retirees eligible for medicare;
(c) Is timely to the state budgetary process; and
(d) Sets conditions for awarding contracts to any insuring entity.
(3) The entities described in RCW 28A.400.275
(2) shall provide the school employees' benefits board and authority specified data by April 1, 2018, in a format to be determined by the authority, to support an initial benefits plans procurement. At a minimum, the data must cover the period January 1, 2014, through December 31, 2017, and include:
(a) A summary of the benefit packages offered to each group of school employees, including covered benefits, point-of-service cost-sharing, member count, and the group policy number;
(b) Aggregated subscriber and member demographic information, including age band and gender, by insurance tier by month and by benefit packages;
(c) Monthly total by benefit package, including premiums paid, inpatient facility claims paid, outpatient facility claims paid, physician claims paid, pharmacy claims paid, capitation amounts paid, and other claims paid;
(d) A listing for calendar years 2014 through 2017 of large claims defined as annual amounts paid in excess of one hundred thousand dollars including the amount paid, the member enrollment status, and the primary diagnosis;
(e) A listing of calendar year 2017 allowed claims by provider entity; and
(f) All data needed for design, procurement, rate setting, and administration of all school employees' benefits board benefits.
Any data that may be confidential and contain personal health information may be protected in accordance with a data-sharing agreement.
(4) The director shall establish a requirement for review of utilization and financial data from participating insuring entities on a quarterly basis.
(5) The director shall centralize the enrollment files for all employee, school employee, and retired or disabled school employee health plans offered under chapter
41.05
RCW and develop enrollment demographics on a plan-specific basis.
(6) All claims data shall be the property of the state. The director may require of any insuring entity that submits a bid to contract for coverage all information deemed necessary including:
(a) Subscriber or member demographic and claims data necessary for risk assessment and adjustment calculations in order to fulfill the director's duties as set forth in this chapter; and
(b) Subscriber or member demographic and claims data necessary to implement performance measures or financial incentives related to performance under subsection (8) of this section.
(7) All contracts with insuring entities for the provision of health care benefits shall provide that the beneficiaries of such benefit plans may use on an equal participation basis the services of practitioners licensed pursuant to chapters
18.22, 18.25, 18.32, 18.53, 18.57, 18.71, 18.74, 18.83, and
18.79
RCW, as it applies to registered nurses and *advanced registered nurse practitioners. However, nothing in this subsection may preclude the director from establishing appropriate utilization controls approved pursuant to RCW 41.05.065
(2) (a), (b), and (d).
(8) The director shall, in collaboration with other state agencies that administer state purchased health care programs, private health care purchasers, health care facilities, providers, and carriers:
(a) Use evidence-based medicine principles to develop common performance measures and implement financial incentives in contracts with insuring entities, health care facilities, and providers that:
(i) Reward improvements in health outcomes for individuals with chronic diseases, increased utilization of appropriate preventive health services, and reductions in medical errors; and
(ii) Increase, through appropriate incentives to insuring entities, health care facilities, and providers, the adoption and use of information technology that contributes to improved health outcomes, better coordination of care, and decreased medical errors;
(b) Through state health purchasing, reimbursement, or pilot strategies, promote and increase the adoption of health information technology systems, including electronic medical records, by hospitals as defined in RCW 70.41.020, integrated delivery systems, and providers that:
(i) Facilitate diagnosis or treatment;
(ii) Reduce unnecessary duplication of medical tests;
(iii) Promote efficient electronic physician order entry;
(iv) Increase access to health information for consumers and their providers; and
(v) Improve health outcomes;
(c) Coordinate a strategy for the adoption of health information technology systems using the final health information technology report and recommendations developed under chapter 261, Laws of 2005.
(9) The director may permit the Washington state health insurance pool to contract to utilize any network maintained by the authority or any network under contract with the authority.
[
2018 c 260 s 14
;
2017 3rd sp.s. c 13 s 808
;
2007 c 259 s 34
;
2006 c 103 s 3
;
2005 c 446 s 2
;
2002 c 142 s 4
. Prior:
1994 sp.s. c 9 s 724
;
1994 c 309 s 3
;
1994 c 153 s 6
;
1993 c 386 s 10
;
1988 c 107 s 9
.]
NOTES:
*Reviser's note:
The term "advanced registered nurse practitioner" was changed to "advanced practice registered nurse" by 2024 c 239 s 1, effective June 30, 2027.
Effective date
—
2018 c 260 ss 14, 22, 23, 31, and 32:
"Sections 14, 22, 23, 31, and 32 of this act are necessary for the immediate preservation of the public peace, health, or safety, or support of the state government and its existing public institutions, and take effect immediately [March 23, 2018]." [
2018 c 260 s 35
.]
Intent
—
2017 3rd sp.s. c 13:
See note following RCW 28A.150.410
.
Collective bargaining agreements not impaired
—
2017 3rd sp.s. c 13:
See note following RCW 41.56.139
.
Subheadings not law
—
2007 c 259:
See note following RCW 7.70.060
.
Intent
—
2006 c 103:
See note following RCW 41.05.021
.
Severability
—
Headings and captions not law
—
Effective date
—
1994 sp.s. c 9:
See RCW 18.79.900
through
18.79.902
.
Intent
—
Effective dates
—
1994 c 153:
See notes following RCW 41.05.011
.
Intent
—
1993 c 386:
See note following RCW 28A.400.391
.
Effective date
—
1993 c 386 ss 1, 2, 4-6, 8-10, and 12-16:
See note following RCW 28A.400.391
.
RCW 41.05.080
Participation in insurance plans and contracts
—
Retired, disabled, or separated employees
—
Certain surviving spouses, state registered domestic partners, and dependent children.
(1) Under the qualifications, terms, conditions, and benefits set by the public employees' benefits board:
(a)(i) Retired or disabled state employees, retired or disabled school employees, or retired or disabled employees of employer groups covered by this chapter may continue their participation in insurance plans and contracts after retirement or disablement.
(ii) The retired or disabled employees of employer groups whose contractual agreement with the authority terminates may continue their participation in insurance plans and contracts after the contractual agreement is terminated. The retired or disabled employees of employer groups whose contractual agreement with the authority terminates are not eligible for any subsidy provided under RCW 41.05.085
;
(b) Separated employees may continue their participation in insurance plans and contracts if participation is selected immediately upon separation from employment;
(c) Surviving spouses, surviving state registered domestic partners, and dependent children of emergency service personnel killed in the line of duty may participate in insurance plans and contracts.
(2) Rates charged surviving spouses and surviving state registered domestic partners of emergency service personnel killed in the line of duty, retired or disabled employees, separated employees, spouses, or dependent children who are not eligible for parts A and B of medicare shall be based on the experience of the community-rated risk pool established under RCW 41.05.022
.
(3) Rates charged to surviving spouses and surviving state registered domestic partners of emergency service personnel killed in the line of duty, retired or disabled employees, separated employees, spouses, or children who are eligible for parts A and B of medicare shall be calculated from a separate experience risk pool comprised only of individuals eligible for parts A and B of medicare; however, the premiums charged to medicare-eligible retirees and disabled employees shall be reduced by the amount of the subsidy provided under RCW 41.05.085, except as provided in subsection (1)(a)(ii) of this section.
(4) Surviving spouses, surviving state registered domestic partners, and dependent children of emergency service personnel killed in the line of duty and retired or disabled and separated employees shall be responsible for payment of premium rates developed by the authority which shall include the cost to the authority of providing insurance coverage including any amounts necessary for reserves and administration in accordance with this chapter. These self pay rates will be established based on a separate rate for the employee, the spouse, state registered domestic partners, and the children.
(5) When a person described in subsection (1)(a)(i), (b), or (c) of this section dies, the authority shall waive the payment of the decedent's premiums and any applicable premium surcharges for the medical, dental, or vision plan for the month in which the death occurred. The authority shall enroll any eligible surviving dependents in the same medical, dental, or vision plan that they had been enrolled in, which shall be made effective on the first day of the month in which the death occurred, and the eligible surviving dependent shall be responsible for the payment of premiums and any applicable premium surcharges for themselves and any other eligible dependents.
(6) The term "retired state employees" for the purpose of this section shall include but not be limited to members of the legislature whether voluntarily or involuntarily leaving state office.
[
2024 c 185 s 1
. Prior:
2023 c 312 s 1
;
2023 c 13 s 5
;
2018 c 260 s 15
;
2015 c 116 s 5
; prior:
2009 c 523 s 1
;
2009 c 522 s 9
;
2007 c 114 s 6
;
2001 c 165 s 3
;
1996 c 39 s 22
;
1994 c 153 s 7
;
1993 c 386 s 11
;
1977 ex.s. c 136 s 6
; 1975-'76 2nd ex.s. c 106 s 6;
1973 1st ex.s. c 147 s 7
;
1970 ex.s. c 39 s 8
.]
NOTES:
Effective date
—
2023 c 312:
See note following RCW 41.05.083
.
Finding
—
Intent
—
2023 c 13:
See note following RCW 41.05.011
.
Intent
—
Effective date
—
2007 c 114:
See notes following RCW 41.05.011
.
Effective date
—
Application
—
2001 c 165:
See note following RCW 41.05.011
.
Effective dates
—
1996 c 39:
See note following RCW 41.32.010
.
Intent
—
Effective dates
—
1994 c 153:
See notes following RCW 41.05.011
.
Effective date
—
1993 c 386 ss 3, 7, and 11:
See note following RCW 41.04.205
.
Intent
—
1993 c 386:
See note following RCW 28A.400.391
.
Effective date
—
Conditions prerequisite to implementing sections
—
1977 ex.s. c 136:
See note following RCW 41.05.050
.
Effective date
—
Effect of veto
—
Savings
—
Severability
—
1973 1st ex.s. c 147:
See notes following RCW 41.05.050
.
Severability
—
1970 ex.s. c 39:
See note following RCW 41.05.050
.
RCW 41.05.083
Employer groups
—
Participation in insurance plans and contracts
—
Termination of agreement
—
Payment for retired or disabled employees.
(1) Employer groups that enter into a contractual agreement with the authority after May 4, 2023, and whose contractual agreement with the authority is subsequently terminated, shall make a one-time payment as calculated in subsection (2) of this section to the authority for each of the employer group's retired or disabled employees who continue their participation in insurance plans and contracts under RCW 41.05.080
(1)(a)(ii).
(2) For each of the employer group's retired or disabled employees who will be continuing their participation, the authority shall determine the one-time payment amount by calculating the difference in cost between the rate charged to retired or disabled employees under RCW 41.05.080
(2) and the actuarially determined value of the medical benefits for retired and disabled employees who are not eligible for parts A and B of medicare, and then multiplying that difference by the number of months until the retired or disabled employee would become eligible for medicare.
(3) Employer groups shall not be entitled to any refund of the amount paid to the authority under this section.
[
2023 c 312 s 2
.]
NOTES:
Effective date
—
2023 c 312:
"This act is necessary for the immediate preservation of the public peace, health, or safety, or support of the state government and its existing public institutions, and takes effect immediately [May 4, 2023]." [
2023 c 312 s 4
.]
RCW 41.05.085
Retired state employee and retired or disabled school employee health insurance subsidy.
(1) The legislature shall establish as part of both the state employees' and the school and educational service district employees' insurance benefit allocation the portion of the allocation to be used to provide a subsidy to reduce the medical and prescription drug insurance premium charged to retired or disabled school district and educational service district employees, or retired state employees, who are eligible for parts A and B of medicare.
(2) The amount of any premium reduction shall be established by the public employees' benefits board. The amount established shall not result in a premium reduction of more than fifty percent, except as provided in subsection (3) of this section. The public employees' benefits board may also determine the amount of any subsidy to be available to spouses and dependents.
(3) The amount of the premium reduction in subsection (2) of this section may exceed fifty percent, if the director, in consultation with the office of financial management, determines that it is necessary in order to meet eligibility requirements to participate in the federal employer incentive program as provided in RCW 41.05.068
.
[
2024 c 197 s 1
;
2018 c 260 s 16
;
2005 c 195 s 3
;
1994 c 153 s 8
.]
NOTES:
Effective date
—
2005 c 195:
See note following RCW 41.05.065
.
Intent
—
Effective dates
—
1994 c 153:
See notes following RCW 41.05.011
.
RCW 41.05.095
Coverage for dependents under the age of twenty-six.
(1) Any plan offered to employees under this chapter must offer each employee the option of covering any dependent of the employee under the age of twenty-six.
(2) Coverage must terminate upon attainment of age twenty-six except in the case of a child who is and continues to be both (a) incapable of self-sustaining employment by reason of a developmental or physical disability and (b) chiefly dependent upon the employee for support and maintenance, provided proof of such incapacity and dependency is furnished by the employee within sixty days of the child's attainment of age twenty-six and subsequently as may be required by the authority, but not more frequently than annually after the two-year period following the child's attainment of age twenty-six.
[
2020 c 274 s 20
;
2015 c 116 s 6
;
2010 c 94 s 11
;
2007 c 259 s 18
.]
NOTES:
Purpose
—
2010 c 94:
See note following RCW 44.04.280
.
Effective date
—
2007 c 259 ss 18-22:
"Sections 18 through 22 of this act take effect January 1, 2009." [
2007 c 259 s 72
.]
Subheadings not law
—
2007 c 259:
See note following RCW 7.70.060
.
RCW 41.05.100
Chapter not applicable to certain employees of Cooperative Extension Service.
The provisions of this chapter shall not be applicable to any employee of the Washington State University Cooperative Extension Service who holds a federal civil service appointment and is thereby eligible for insurance coverage under the regulations of the United States Department of Agriculture and the United States Civil Service Commission, and which employee elects participation in the federal programs in lieu of the programs established pursuant to this chapter. Such election may be made only once.
[
1979 ex.s. c 9 s 1
.]
RCW 41.05.120
Public employees' and retirees' insurance account
—
School employees' insurance account.
(1) The public employees' and retirees' insurance account is hereby established in the custody of the state treasurer, to be used by the director for the deposit of contributions, the remittance paid by school districts and educational service districts under RCW 28A.400.410, reserves, dividends, and refunds, for payment of premiums and claims for employee and retiree insurance benefit contracts and subsidy amounts provided under RCW 41.05.085, and transfers from the flexible spending administrative account as authorized in RCW 41.05.123
. Moneys from the account shall be disbursed by the state treasurer by warrants on vouchers duly authorized by the director. Moneys from the account may be transferred to the flexible spending administrative account to provide reserves and start-up costs for the operation of the flexible spending administrative account program. During the 2025-2027 fiscal biennium, the legislature may direct the state treasurer to transfer money in the public employees' and retirees' insurance account to the state general fund.
(2) The state treasurer and the state investment board may invest moneys in the public employees' and retirees' insurance account. All such investments shall be in accordance with RCW 43.84.080
or
43.84.150, whichever is applicable. The director shall determine whether the state treasurer or the state investment board or both shall invest moneys in the public employees' and retirees' insurance account.
(3) The school employees' insurance account is hereby established in the custody of the state treasurer, to be used by the director for the deposit of contributions, reserves, dividends, and refunds, for payment of premiums and claims for school employee insurance benefit contracts, and for transfers from the school employees' benefits board flexible spending and dependent care administrative account as authorized in this subsection. Moneys from the account shall be disbursed by the state treasurer by warrants on vouchers duly authorized by the director. Moneys from the account may be transferred to the school employees' benefits board flexible spending and dependent care administrative account to provide reserves and start-up costs for the operation of the school employees' benefits board flexible spending arrangement and dependent care assistance program. During the 2025-2027 fiscal biennium, the legislature may direct the state treasurer to transfer money in the school employees' insurance account to the state general fund.
(4) The state treasurer and the state investment board may invest moneys in the school employees' insurance account. These investments must be in accordance with RCW 43.84.080
or
43.84.150, whichever is applicable. The director shall determine whether the state treasurer or the state investment board or both shall invest moneys in the school employees' insurance account.
(5) Moneys may be transferred between the public employees' and retirees' insurance account and the school employees' insurance account for short-term cash management and cash balance purposes.
[
2025 c 424 s 937
;
2023 c 435 s 10
;
2018 c 260 s 25
;
2017 3rd sp.s. c 13 s 809
. Prior:
2005 c 518 s 921
;
2005 c 143 s 3
;
1994 c 153 s 9
;
1993 c 492 s 219
;
1991 sp.s. c 13 s 100
;
1988 c 107 s 10
.]
NOTES:
Effective date
—
2025 c 424:
See note following RCW 9.46.100
.
Effective date
—
2023 c 435:
See note following RCW 43.79.570
.
Intent
—
2017 3rd sp.s. c 13:
See note following RCW 28A.150.410
.
Collective bargaining agreements not impaired
—
2017 3rd sp.s. c 13:
See note following RCW 41.56.139
.
Effective date
—
2005 c 518:
See note following RCW 28A.600.110
.
Intent
—
Effective dates
—
1994 c 153:
See notes following RCW 41.05.011
.
Findings
—
Intent
—
1993 c 492:
See notes following RCW 43.20.050
.
Short title
—
Savings
—
Reservation of legislative power
—
Effective dates
—
1993 c 492:
See RCW 43.72.910
through
43.72.915
.
Effective dates
—
Severability
—
1991 sp.s. c 13:
See notes following RCW 18.08.240
.
RCW 41.05.123
Flexible spending administrative account
—
Salary reduction account
—
School employees' benefits board flexible spending and dependent care administrative account
—
School employees' benefits board salary reduction account.
(1) For the public employees' benefits board program, the flexible spending administrative account is created in the custody of the state treasurer.
(a) All receipts from the following must be deposited in the account:
(i) Revenues from employing agencies for costs associated with operating the *medical flexible spending arrangement program and the dependent care assistance program provided through the salary reduction plan authorized under this chapter; and
(ii) Unclaimed moneys at the end of the plan year after all timely submitted claims for that plan year have been processed. Expenditures from the account may be used only for administrative and other expenses related to operating the *medical flexible spending arrangement program and the dependent care assistance program provided through the salary reduction plan authorized under this chapter. Only the director or the director's designee may authorize expenditures from the account. The account is subject to allotment procedures under chapter
43.88
RCW, but an appropriation is not required for expenditures.
(b) The salary reduction account is created in the custody of the state treasurer. Employee salary reductions paid to reimburse participants or service providers for benefits provided by the *medical flexible spending arrangement program and the dependent care assistance program provided through the salary reduction plan authorized under this chapter shall be paid from the salary reduction account. The funds held by the state to pay for benefits provided by the *medical flexible spending arrangement program and the dependent care assistance program provided through the salary reduction plan authorized under this chapter shall be deposited in the salary reduction account. Unclaimed moneys remaining in the salary reduction account at the end of a plan year after all timely submitted claims for that plan year have been processed shall become a part of the flexible spending administrative account. Only the director or the director's designee may authorize expenditures from the account. The account is not subject to allotment procedures under chapter
43.88
RCW and an appropriation is not required for expenditures.
(c) Program claims reserves and money necessary for start-up costs transferred from the public employees' and retirees' insurance account established in RCW 41.05.120
may be deposited in the flexible spending administrative account. Moneys in excess of the amount necessary for administrative and operating expenses of the *medical flexible spending arrangement program may be transferred to the public employees' and retirees' insurance account.
(d) The authority may periodically bill employing agencies for costs associated with operating the *medical flexible spending arrangement program and the dependent care assistance program provided through the salary reduction plan authorized under this chapter.
(2) For the school employees' benefits board program, the school employees' benefits board flexible spending and dependent care administrative account is created in the custody of the state treasurer.
(a) All receipts from the following must be deposited in the account:
(i) Revenues from school employees' benefits board organizations for costs associated with operating the school employees' benefits board *medical flexible spending arrangement program and the school employees' benefits board dependent care assistance program provided through the salary reduction plan authorized under this chapter; and
(ii) Unclaimed moneys at the end of the plan year after all timely submitted claims for that plan year have been processed. Expenditures from the account may be used only for administrative and other expenses related to operating the school employees' benefits board *medical flexible spending arrangement program and the school employees' benefits board dependent care assistance program provided through the salary reduction plan authorized under this chapter. Only the director or the director's designee may authorize expenditures from the account. The account is subject to allotment procedures under chapter
43.88
RCW, but an appropriation is not required for expenditures.
(b) The school employees' benefits board salary reduction account is created in the custody of the state treasurer. School employee salary reductions paid to reimburse participants or service providers for benefits provided by the school employees' benefits board *medical flexible spending arrangement program and the school employees' benefits board dependent care assistance program provided through the salary reduction plan authorized under this chapter shall be paid from the school employees' benefits board salary reduction account. The funds held by the state to pay for benefits provided by the school employees' benefits board *medical flexible spending arrangement program and the school employees' benefits board dependent care assistance program provided through the salary reduction plan authorized under this chapter shall be deposited in the school employees' benefits board salary reduction account. Unclaimed moneys remaining in the school employees' benefits board salary reduction account at the end of a plan year after all timely submitted claims for that plan year have been processed shall become a part of the school employees' benefits board flexible spending and dependent care administrative account. Only the director or the director's designee may authorize expenditures from the account. The account is not subject to allotment procedures under chapter
43.88
RCW and an appropriation is not required for expenditures.
(c) Program claims reserves and money necessary for start-up costs transferred from the school employees' insurance account established in RCW 41.05.120
may be deposited in the school employees' benefits board flexible spending and dependent care administrative account. Moneys in excess of the amount necessary for administrative and operating expenses of the school employees' benefits board *medical flexible spending arrangement and the school employees' benefits board dependent care assistance program may be transferred to the school employees' insurance account.
(d) The authority may periodically bill school employees' benefits board organizations for costs associated with operating the school employees' benefits board *medical flexible spending arrangement program and the school employees' benefits board dependent care assistance program provided through the salary reduction plan authorized under this chapter.
[
2018 c 260 s 26
;
2008 c 229 s 6
;
2005 c 143 s 2
.]
NOTES:
*Reviser's note:
The term "medical flexible spending arrangement" was changed to "flexible spending arrangement" by
2023 c 51 s 3
.
Effective date
—
2008 c 229:
See note following RCW 41.05.295
.
RCW 41.05.130
State health care authority administrative account
—
School employees' insurance administrative account.
(1) The state health care authority administrative account is hereby created in the state treasury. Moneys in the account, including unanticipated revenues under RCW 43.79.270, may be spent only after appropriation by statute, and may be used only for operating expenses of the authority.
(2) The school employees' insurance administrative account is hereby created in the state treasury. Moneys in the account may be used for operating, contracting, and other administrative expenses of the authority in administration of the school employees insurance program, including reimbursement of the state health care authority administrative account for initial operating expenses of the authority associated with chapter 13, Laws of 2017 3rd sp. sess.
[
2023 c 51 s 13
;
2017 3rd sp.s. c 13 s 810
;
2014 c 221 s 914
;
1988 c 107 s 11
.]
NOTES:
Intent
—
2017 3rd sp.s. c 13:
See note following RCW 28A.150.410
.
Collective bargaining agreements not impaired
—
2017 3rd sp.s. c 13:
See note following RCW 41.56.139
.
Effective date
—
2014 c 221:
See note following RCW 28A.710.260
.
RCW 41.05.140
Payment of claims
—
Self-insurance
—
Insurance reserve fund created.
(1) Except for property and casualty insurance, the authority may self-fund, self-insure, or enter into other methods of providing insurance coverage for insurance programs under its jurisdiction, including the basic health plan as provided in chapter
70.47
RCW. The authority shall contract for payment of claims or other administrative services for programs under its jurisdiction. If a program does not require the prepayment of reserves, the authority shall establish such reserves within a reasonable period of time for the payment of claims as are normally required for that type of insurance under an insured program. The authority shall endeavor to reimburse basic health plan health care providers under this section at rates similar to the average reimbursement rates offered by the statewide benchmark plan determined through the request for proposal process.
(2) Reserves established by the authority for employee and retiree benefit programs shall be held in a separate account in the custody of the state treasurer and shall be known as the public employees' and retirees' insurance reserve fund. The state treasurer may invest the moneys in the reserve fund pursuant to RCW 43.79A.040
.
(3) Reserves established by the authority for school employee benefit programs shall be held in a separate account in the custody of the state treasurer and shall be known as the school employees' benefits board insurance reserve fund. The state treasurer may invest the moneys in the reserve fund pursuant to RCW 43.79A.040
.
(4) Any savings realized as a result of a program created for employees or school employees and retirees under this section shall not be used to increase benefits unless such use is authorized by statute.
(5) Any program created under this section shall be subject to the examination requirements of chapter
48.03
RCW as if the program were a domestic insurer. In conducting an examination, the commissioner shall determine the adequacy of the reserves established for the program.
(6) The authority shall keep full and adequate accounts and records of the assets, obligations, transactions, and affairs of any program created under this section.
(7) The authority shall file a quarterly statement of the financial condition, transactions, and affairs of any program created under this section in a form and manner prescribed by the insurance commissioner. The statement shall contain information as required by the commissioner for the type of insurance being offered under the program. A copy of the annual statement shall be filed with the speaker of the house of representatives and the president of the senate.
(8) The provisions of this section do not apply to the administration of chapter
74.09
RCW.
[
2018 c 260 s 17
;
2013 c 251 s 10
;
2012 c 187 s 10
;
2011 1st sp.s. c 15 s 59
;
2000 c 80 s 5
;
2000 c 79 s 44
;
1994 c 153 s 10
. Prior:
1993 c 492 s 220
;
1993 c 386 s 12
;
1988 c 107 s 12
.]
NOTES:
Residual balance of funds
—
Effective date
—
2013 c 251:
See notes following RCW 41.06.280
.
Effective date
—
Findings
—
Intent
—
Report
—
Agency transfer
—
References to head of health care authority
—
Draft legislation
—
2011 1st sp.s. c 15:
See notes following RCW 74.09.010
.
Effective date
—
Severability
—
2000 c 79:
See notes following RCW 48.04.010
.
Intent
—
Effective dates
—
1994 c 153:
See notes following RCW 41.05.011
.
Findings
—
Intent
—
1993 c 492:
See notes following RCW 43.20.050
.
Short title
—
Savings
—
Reservation of legislative power
—
Effective dates
—
1993 c 492:
See RCW 43.72.910
through
43.72.915
.
Intent
—
1993 c 386:
See note following RCW 28A.400.391
.
Effective date
—
1993 c 386 ss 1, 2, 4-6, 8-10, and 12-16:
See note following RCW 28A.400.391
.
RCW 41.05.143
Uniform medical plan benefits administration account
—
Uniform dental plan benefits administration account
—
School employees' benefits board medical benefits administrative account
—
School employees' benefits board dental benefits administration account.
(1) The uniform medical plan benefits administration account is created in the custody of the state treasurer. Only the director or the director's designee may authorize expenditures from the account. Moneys in the account shall be used exclusively for contracted expenditures for uniform medical plan claims administration, data analysis, utilization management, preferred provider administration, and activities related to benefits administration where the level of services provided pursuant to a contract fluctuate as a direct result of changes in uniform medical plan enrollment. Moneys in the account may also be used for administrative activities required to respond to new and unforeseen conditions that impact the uniform medical plan, but only when the authority and the office of financial management jointly agree that such activities must be initiated prior to the next legislative session.
(2) Receipts from amounts due from or on behalf of uniform medical plan enrollees for expenditures related to benefits administration, including moneys disbursed from the public employees' and retirees' insurance account, shall be deposited into the account. The account is subject to allotment procedures under chapter
43.88
RCW, but no appropriation is required for expenditures. All proposals for allotment increases shall be provided to the house of representatives appropriations committee and to the senate ways and means committee at the same time as they are provided to the office of financial management.
(3) The uniform dental plan benefits administration account is created in the custody of the state treasurer. Only the director or the director's designee may authorize expenditures from the account. Moneys in the account shall be used exclusively for contracted expenditures related to benefits administration for the uniform dental plan as established under RCW 41.05.140
. Receipts from amounts due from or on behalf of uniform dental plan enrollees for expenditures related to benefits administration, including moneys disbursed from the public employees' and retirees' insurance account, shall be deposited into the account. The account is subject to allotment procedures under chapter
43.88
RCW, but no appropriation is required for expenditures.
(4) The school employees' benefits board medical benefits administrative account is created in the custody of the state treasurer. Only the director or the director's designee may authorize expenditures from the account. Moneys in the account shall be used exclusively for school employees' benefits board contracted expenditures related to claims administration, data analysis, utilization management, preferred provider administration, and other activities related to benefits administration for self-insured medical plans. Receipts from amounts due from or on behalf of enrollees for expenditures related to benefits administration, including moneys disbursed from the school employees' insurance account, shall be deposited into the account. The account is subject to allotment procedures under chapter
43.88
RCW, but no appropriation is required for expenditures.
(5) The school employees' benefits board dental benefits administration account is created in the custody of the state treasurer. Only the director or the director's designee may authorize expenditures from the account. Moneys in the account shall be used exclusively for school employees' benefits board contracted expenditures related to benefits administration for the self-insured dental plan as established under RCW 41.05.140
. Receipts from amounts due from or on behalf of the self-insured dental plan enrollees for expenditures related to benefits administration, including moneys disbursed from the school employees' insurance account, shall be deposited into the account. The account is subject to allotment procedures under chapter
43.88
RCW, but no appropriation is required for expenditures.
[
2022 c 157 s 11
;
2018 c 260 s 27
;
2017 3rd sp.s. c 13 s 811
;
2007 c 507 s 1
;
2000 2nd sp.s. c 1 s 901
.]
NOTES:
Intent
—
2017 3rd sp.s. c 13:
See note following RCW 28A.150.410
.
Collective bargaining agreements not impaired
—
2017 3rd sp.s. c 13:
See note following RCW 41.56.139
.
Severability
—
2000 2nd sp.s. c 1:
"If any provision of this act or its application to any person or circumstance is held invalid, the remainder of the act or the application of the provision to other persons or circumstances is not affected." [
2000 2nd sp.s. c 1 s 1047
.]
Effective date
—
2000 2nd sp.s. c 1:
"This act is necessary for the immediate preservation of the public peace, health, or safety, or support of the state government and its existing public institutions, and takes effect immediately [May 2, 2000]." [
2000 2nd sp.s. c 1 s 1048
.]
RCW 41.05.155
Fern Lodge maintenance account.
The Fern Lodge maintenance account is created in the custody of the state treasurer. All receipts from the collection of rents for the Snohomish county long-term civil commitment facility known as Fern Lodge must be deposited into the account. Expenditures from the account may only be used for the ongoing maintenance and operational costs of Fern Lodge. Only the director or the director's designee may authorize expenses from the account. The account is subject to allotment procedures under chapter
43.88
RCW, but an appropriation is not required for expenditures.
[
2024 c 168 s 4
.]
NOTES:
Effective dates
—
2024 c 168 ss 4-13:
"(1) Sections 4 through 10 and 12 of this act take effect July 1, 2024.
(2) Section 11 of this act takes effect July 1, 2030.
(3) Section 13 of this act takes effect July 1, 2028." [
2024 c 168 s 17
.]
RCW 41.05.160
Rules.
The director may promulgate and adopt rules consistent with this chapter to carry out the purposes of this chapter. All rules shall be adopted in accordance with chapter
34.05
RCW.
[
2023 c 51 s 14
;
1988 c 107 s 15
.]
NOTES:
RCW 41.05.165
Rules
—
Insurance benefit reimbursement.
The authority shall adopt rules that provide for members of the legislature who choose reimbursement under RCW 44.04.230
in lieu of insurance benefits under this chapter.
[
1998 c 62 s 2
.]
NOTES:
Effective date
—
1998 c 62:
See note following RCW 44.04.230
.
RCW 41.05.170
Neurodevelopmental therapies
—
Employer-sponsored group contracts.
(1) Each health plan offered to public employees and their covered dependents under this chapter which is not subject to the provisions of Title
48
RCW and is established or renewed on or after twelve months after July 23, 1989, shall include coverage for neurodevelopmental therapies for covered individuals age six and under.
(2) Benefits provided under this section shall cover the services of those authorized to deliver occupational therapy, speech therapy, and physical therapy. Benefits shall be payable only where the services have been delivered pursuant to the referral and periodic review of a holder of a license issued pursuant to chapter
18.71
or
18.57
RCW or where covered services have been rendered by such licensee. Nothing in this section shall preclude a self-funded plan authorized under this chapter from negotiating rates with qualified providers.
(3) Benefits provided under this section shall be for medically necessary services as determined by the self-funded plan authorized under this chapter. Benefits shall be payable for services for the maintenance of a covered individual in cases where significant deterioration in the patient's condition would result without the service. Benefits shall be payable to restore and improve function.
(4) It is the intent of this section that the state, as an employer providing comprehensive health coverage including the benefits required by this section, retains the authority to design and employ utilization and cost controls. Therefore, benefits delivered under this section may be subject to contractual provisions regarding deductible amounts and/or copayments established by the self-funded plan authorized under this chapter. Benefits provided under this section may be subject to standard waiting periods for preexisting conditions, and may be subject to the submission of written treatment plans.
(5) In recognition of the intent expressed in subsection (4) of this section, benefits provided under this section may be subject to contractual provisions establishing annual and/or lifetime benefit limits. Such limits may define the total dollar benefits available, or may limit the number of services delivered as established by the self-funded plan authorized under this chapter.
[
1989 c 345 s 4
.]
RCW 41.05.175
Prescribed, self-administered anticancer medication.
(1) Each health plan offered to public employees and their covered dependents under this chapter, including those subject to the provision of Title
48
RCW, and is issued or renewed beginning January 1, 2012, and provides coverage for cancer chemotherapy treatment must provide coverage for prescribed, self-administered anticancer medication that is used to kill or slow the growth of cancerous cells on a basis at least comparable to cancer chemotherapy medications administered by a health care provider or facility as defined in *RCW 48.43.005
(25) and (26).
(2) Nothing in this section may be interpreted to prohibit a health plan from administering a formulary or preferred drug list, requiring prior authorization, or imposing other appropriate utilization controls in approving coverage for any chemotherapy.
[
2020 c 18 s 13
;
2011 c 159 s 2
.]
NOTES:
*Reviser's note:
RCW 48.43.005
was alphabetized pursuant to RCW 1.08.015
(2)(k), changing subsections (25) and (26) to subsections (27) and (28). RCW 48.43.005
was amended by 2024 c 218 s 1, changing subsections (27) and (28) to subsections (29) and (30).
Explanatory statement
—
2020 c 18:
See note following RCW 43.79A.040
.
Findings
—
2011 c 159:
"The Washington state legislature finds that for cancer patients, there is an inequity in how much they have to pay toward the cost of a self-administered oral medication and how much they have to pay for an intravenous product that is administered in a physician's office or clinic. The legislature further finds that when these inequities exist, patients' access to medically necessary, appropriate treatment is often unfairly restricted. The legislature also acknowledges that self-administered chemotherapy is the only treatment for some types of cancer where there is no intravenous alternative. The legislature declares that in order to reduce the out-of-pocket costs for cancer patients whose diagnosis requires treatment through self-administered anticancer medication, the cost-sharing responsibilities for these patients must be on a basis at least comparable to those of patients receiving intravenously administered anticancer medication." [
2011 c 159 s 1
.]
RCW 41.05.177
Prostate cancer screening
—
Required coverage.
(Effective until June 30, 2027.)
(1) Each plan offered to public employees and their covered dependents under this chapter that is not subject to the provisions of Title
48
RCW and is issued or renewed after December 31, 2006, shall provide coverage for prostate cancer screening, provided that the screening is delivered upon the recommendation of the patient's physician, *advanced registered nurse practitioner, or physician assistant.
(2) This section shall not be construed to prevent the application of standard policy provisions applicable to other benefits, such as deductible or copayment provisions. This section does not limit the authority of the health care authority to negotiate rates and contract with specific providers for the delivery of prostate cancer screening services. This section shall not apply to medicare supplemental policies or supplemental contracts covering a specified disease or other limited benefits.
[
2006 c 367 s 1
.]
NOTES:
*Reviser's note:
The term "advanced registered nurse practitioner" was changed to "advanced practice registered nurse" by 2024 c 239 s 1, effective June 30, 2027.
PDF
RCW 41.05.177
Prostate cancer screening
—
Required coverage.
(Effective June 30, 2027.)
(1) Each plan offered to public employees and their covered dependents under this chapter that is not subject to the provisions of Title
48
RCW and is issued or renewed after December 31, 2006, shall provide coverage for prostate cancer screening, provided that the screening is delivered upon the recommendation of the patient's physician, advanced practice registered nurse, or physician assistant.
(2) This section shall not be construed to prevent the application of standard policy provisions applicable to other benefits, such as deductible or copayment provisions. This section does not limit the authority of the health care authority to negotiate rates and contract with specific providers for the delivery of prostate cancer screening services. This section shall not apply to medicare supplemental policies or supplemental contracts covering a specified disease or other limited benefits.
[
2025 c 58 s 5091
;
2006 c 367 s 1
.]
NOTES:
Effective date
—
2025 c 58 ss 5058-5170:
See note following RCW 7.68.030
.
Explanatory note
—
2025 c 58:
See note following RCW 1.16.050
.
RCW 41.05.180
Mammograms
—
Insurance coverage.
(Effective until June 30, 2027.)
Each health plan offered to public employees and their covered dependents under this chapter that is not subject to the provisions of Title
48
RCW and is established or renewed after January 1, 1990, and that provides benefits for hospital or medical care shall provide benefits for screening or diagnostic mammography services, provided that such services are delivered upon the recommendation of the patient's physician or *advanced registered nurse practitioner as authorized by the state board of nursing pursuant to chapter
18.79
RCW or physician assistant pursuant to chapter
18.71A
RCW.
This section shall not be construed to prevent the application of standard health plan provisions applicable to other benefits such as deductible or copayment provisions. This section does not limit the authority of the state health care authority to negotiate rates and contract with specific providers for the delivery of mammography services. This section shall not apply to medicare supplement policies or supplemental contracts covering a specified disease or other limited benefits.
[
2025 c 58 s 5047
;
1994 sp.s. c 9 s 725
;
1989 c 338 s 5
.]
NOTES:
*Reviser's note:
The term "advanced registered nurse practitioner" was changed to "advanced practice registered nurse" by 2024 c 239 s 1, effective June 30, 2027.
Expiration date
—
2025 c 58 ss 5004, 5005, 5006, 5010, 5012, 5013, 5014, 5016, 5017, 5018, 5019, 5020, 5024, 5029, 5030, 5043, 5044, 5045, 5047, 5048, 5049, 5051, 5052, 5053, and 5055:
See note following RCW 18.79.040
.
Explanatory note
—
2025 c 58:
See note following RCW 1.16.050
.
Severability
—
Headings and captions not law
—
Effective date
—
1994 sp.s. c 9:
See RCW 18.79.900
through
18.79.902
.
PDF
RCW 41.05.180
Mammograms
—
Insurance coverage.
(Effective June 30, 2027.)
Each health plan offered to public employees and their covered dependents under this chapter that is not subject to the provisions of Title
48
RCW and is established or renewed after January 1, 1990, and that provides benefits for hospital or medical care shall provide benefits for screening or diagnostic mammography services, provided that such services are delivered upon the recommendation of the patient's physician or advanced practice registered nurse as authorized by the state board of nursing pursuant to chapter
18.79
RCW or physician assistant pursuant to chapter
18.71A
RCW.
This section shall not be construed to prevent the application of standard health plan provisions applicable to other benefits such as deductible or copayment provisions. This section does not limit the authority of the state health care authority to negotiate rates and contract with specific providers for the delivery of mammography services. This section shall not apply to medicare supplement policies or supplemental contracts covering a specified disease or other limited benefits.
[
2025 c 58 s 5092
;
1994 sp.s. c 9 s 725
;
1989 c 338 s 5
.]
NOTES:
Effective date
—
2025 c 58 ss 5058-5170:
See note following RCW 7.68.030
.
Explanatory note
—
2025 c 58:
See note following RCW 1.16.050
.
Severability
—
Headings and captions not law
—
Effective date
—
1994 sp.s. c 9:
See RCW 18.79.900
through
18.79.902
.
RCW 41.05.183
General anesthesia services for dental procedures
—
Public employee benefit plans.
(1) Each employee benefit plan offered to public employees that provides coverage for hospital, medical, or ambulatory surgery center services must cover general anesthesia services and related facility charges in conjunction with any dental procedure performed in a hospital or ambulatory surgical center if such anesthesia services and related facility charges are medically necessary because the covered person:
(a) Is under the age of seven, or physically or developmentally disabled, with a dental condition that cannot be safely and effectively treated in a dental office; or
(b) Has a medical condition that the person's physician determines would place the person at undue risk if the dental procedure were performed in a dental office. The procedure must be approved by the person's physician.
(2) Each employee benefit plan offered to public employees that provides coverage for dental services must cover general anesthesia services in conjunction with any covered dental procedure performed in a dental office if the general anesthesia services are medically necessary because the covered person is under the age of seven or physically or developmentally disabled.
(3) This section does not prohibit an employee benefit plan from:
(a) Applying cost-sharing requirements, maximum annual benefit limitations, and prior authorization requirements to the services required under this section; or
(b) Covering only those services performed by a health care provider, or in a health care facility, that is part of its provider network; nor does it limit the authority in negotiating rates and contracts with specific providers.
(4) This section does not apply to medicare supplement policies, or supplemental contracts covering a specified disease or other limited benefits.
(5) For the purpose of this section, "general anesthesia services" means services to induce a state of unconsciousness accompanied by a loss of protective reflexes, including the ability to maintain an airway independently and respond purposefully to physical stimulation or verbal command.
(6) This section applies to employee benefit plans issued or renewed on or after January 1, 2002.
[
2001 c 321 s 1
.]
RCW 41.05.185
Diabetes benefits
—
State purchased health care.
The legislature finds that diabetes imposes a significant health risk and tremendous financial burden on the citizens and government of the state of Washington, and that access to the medically accepted standards of care for diabetes, its treatment and supplies, and self-management training and education is crucial to prevent or delay the short and long-term complications of diabetes and its attendant costs.
(1) The definitions in this subsection apply throughout this section unless the context clearly requires otherwise.
(a) "Person with diabetes" means a person diagnosed by a health care provider as having insulin using diabetes, noninsulin using diabetes, or elevated blood glucose levels induced by pregnancy; and
(b) "Health care provider" means a health care provider as defined in RCW 48.43.005
.
(2) All state purchased health care purchased or renewed after January 1, 1998, except the basic health plan described in chapter
70.47
RCW, shall provide benefits for at least the following services and supplies for persons with diabetes:
(a) For state purchased health care that includes coverage for pharmacy services, appropriate and medically necessary equipment and supplies, as prescribed by a health care provider, that includes but is not limited to insulin, syringes, injection aids, blood glucose monitors, test strips for blood glucose monitors, visual reading and urine test strips, insulin pumps and accessories to the pumps, insulin infusion devices, prescriptive oral agents for controlling blood sugar levels, foot care appliances for prevention of complications associated with diabetes, and glucagon emergency kits; and
(b) For all state purchased health care, outpatient self-management training and education, including medical nutrition therapy, as ordered by the health care provider. Diabetes outpatient self-management training and education may be provided only by health care providers with expertise in diabetes. Nothing in this section prevents any state agency purchasing health care according to this section from restricting patients to seeing only health care providers who have signed participating provider agreements with that state agency or an insuring entity under contract with that state agency.
(3) Coverage required under this section may be subject to customary cost-sharing provisions established for all other similar services or supplies within a policy.
(4) Health care coverage may not be reduced or eliminated due to this section.
(5) Services required under this section shall be covered when deemed medically necessary by the medical director, or his or her designee, subject to any referral and formulary requirements.
[
1997 c 276 s 1
.]
NOTES:
Effective date
—
1997 c 276:
"This act takes effect January 1, 1998." [
1997 c 276 s 6
.]
RCW 41.05.188
Eosinophilic gastrointestinal associated disorder
—
Elemental formula.
(1) Each health benefit plan offered to public employees and their covered dependents under this chapter that is not subject to chapter
48.43
RCW and that is issued or renewed after December 31, 2015, must offer benefits or coverage for medically necessary elemental formula, regardless of delivery method, when a licensed physician or other health care provider with prescriptive authority:
(a) Diagnoses a patient with an eosinophilic gastrointestinal associated disorder; and
(b) Orders and supervises the use of the elemental formula.
(2) Nothing in this section prohibits a health benefit plan from requiring prior authorization or imposing other appropriate utilization controls in approving coverage for medically necessary elemental formula.
[
2014 c 115 s 1
.]
RCW 41.05.195
Medicare supplemental insurance policies.
Notwithstanding any other provisions of this chapter or rules or procedures adopted by the authority, the authority shall make available to retired or disabled employees who are enrolled in parts A and B of medicare one or more medicare supplemental insurance policies that conform to the requirements of chapter
48.66
RCW. The policies shall be chosen in consultation with the public employees' benefits board. These policies shall be made available to retired or disabled state employees; retired or disabled school district employees; retired employees of employer groups eligible for coverage available under the authority; or surviving spouses or surviving state registered domestic partners of emergency service personnel killed in the line of duty.
[
2023 c 13 s 6
;
2015 c 116 s 7
;
2009 c 523 s 2
;
2007 c 114 s 7
;
2005 c 47 s 1
;
1993 c 492 s 222
.]
NOTES:
Finding
—
Intent
—
2023 c 13:
See note following RCW 41.05.011
.
Intent
—
Effective date
—
2007 c 114:
See notes following RCW 41.05.011
.
Findings
—
Intent
—
1993 c 492:
See notes following RCW 43.20.050
.
Short title
—
Savings
—
Reservation of legislative power
—
Effective dates
—
1993 c 492:
See RCW 43.72.910
through
43.72.915
.
RCW 41.05.197
Medicare supplemental insurance policies.
The medicare supplemental insurance policies authorized under RCW 41.05.195
shall be made available to any resident of the state who:
(1) Is enrolled in parts A and B of medicare; and
(2) Is not eligible to purchase coverage as a retired or disabled employee under RCW 41.05.195
. State residents purchasing a medicare supplemental insurance policy under this section shall be required to pay the full cost of any such policy.
[
2005 c 47 s 2
;
1993 c 492 s 223
.]
NOTES:
Findings
—
Intent
—
1993 c 492:
See notes following RCW 43.20.050
.
Short title
—
Savings
—
Reservation of legislative power
—
Effective dates
—
1993 c 492:
See RCW 43.72.910
through
43.72.915
.
RCW 41.05.220
Community and migrant health centers
—
Maternity health care centers
—
People of color
—
Underserved populations.
(1) State general funds appropriated to the department of health for the purposes of funding community health centers to provide primary health and dental care services, migrant health services, and maternity health care services shall be transferred to the state health care authority. Any related administrative funds expended by the department of health for this purpose shall also be transferred to the health care authority. The health care authority shall exclusively expend these funds through contracts with community health centers to provide primary health and dental care services, migrant health services, and maternity health care services. The director of the health care authority shall establish requirements necessary to assure community health centers provide quality health care services that are appropriate and effective and are delivered in a cost-efficient manner. The director shall further assure that community health centers have appropriate referral arrangements for acute care and medical specialty services not provided by the community health centers.
(2) The authority, in consultation with the department of health, shall work with community and migrant health clinics and other providers of care to underserved populations, to ensure that the number of people of color and underserved people receiving access to managed care is expanded in proportion to need, based upon demographic data.
[
2023 c 51 s 15
;
1998 c 245 s 38
;
1993 c 492 s 232
.]
NOTES:
Findings
—
Intent
—
1993 c 492:
See notes following RCW 43.20.050
.
Short title
—
Savings
—
Reservation of legislative power
—
Effective dates
—
1993 c 492:
See RCW 43.72.910
through
43.72.915
.
RCW 41.05.225
Blind licensees in the business enterprises program
—
Plan of health insurance.
(1) The public employees' benefits board shall offer a plan of health insurance to blind licensees who are actively operating facilities and participating in the business enterprises program established in RCW 74.18.200
through
74.18.230, and maintained by the department of services for the blind. The plan of health insurance benefits must be the same or substantially similar to the plan of health insurance benefits offered to state employees under this chapter. Enrollment will be at the option of each individual licensee or vendor, under rules established by the public employees' benefits board.
(2) All costs incurred by the state or the public employees' benefits board for providing health insurance coverage to active blind vendors, excluding family participation, under subsection (1) of this section may be paid for from net proceeds from vending machine operations in public buildings under RCW 74.18.230
.
(3) Money from the business enterprises program under the federal Randolph-Sheppard Act may not be used for family participation in the health insurance benefits provided under this section. Family insurance benefits are the sole responsibility of the individual blind vendors.
[
2018 c 260 s 18
;
2002 c 71 s 1
.]
RCW 41.05.295
Dependent care assistance program
—
Health care authority
—
Powers, duties, and functions.
(1) All powers, duties, and functions of the department of retirement systems pertaining to the dependent care assistance program are transferred to the health care authority.
(2)(a) All reports, documents, surveys, books, records, files, papers, or written material in the possession of the department of retirement systems pertaining to the powers, functions, and duties transferred shall be delivered to the custody of the health care authority. All funds, credits, or other assets held in connection with the powers, functions, and duties transferred shall be assigned to the health care authority.
(b) Whenever any question arises as to the transfer of any funds, books, documents, records, papers, files, or other tangible property used or held in the exercise of the powers and the performance of the duties and functions transferred, the director of financial management shall make a determination as to the proper allocation and certify the same to the state agencies concerned.
(3) All rules and all pending business before the department of retirement systems pertaining to the powers, functions, and duties transferred shall be continued and acted upon by the health care authority. All existing contracts and obligations shall remain in full force and shall be performed by the health care authority.
(4) The transfer of the powers, duties, and functions of the department of retirement systems shall not affect the validity of any act performed before January 1, 2009.
(5) Nothing contained in this section may be construed to alter any existing collective bargaining unit or the provisions of any existing collective bargaining agreement until the agreement has expired or until the bargaining unit has been modified by action of the public employment relations commission as provided by law.
[
2008 c 229 s 1
.]
NOTES:
Effective date
—
2008 c 229:
"This act takes effect January 1, 2009." [
2008 c 229 s 15
.]
RCW 41.05.300
Salary reduction agreements
—
Authorized.
(1) The state of Washington may enter into salary reduction agreements with employees and school employees pursuant to the internal revenue code, for the purpose of making it possible for employees and school employees to select on a "before-tax basis" certain taxable and nontaxable benefits. The purpose of the salary reduction plan established in this chapter is to attract and retain individuals in governmental service by permitting them to enter into agreements with the state to provide for benefits pursuant to 26 U.S.C. Sec. 125, 26 U.S.C. Sec. 129, and other applicable sections of the internal revenue code.
(2) Nothing in the salary reduction plan constitutes an employment agreement between the participant and the state, and nothing contained in the participant's salary reduction agreement, the plan, this section, or RCW 41.05.123, 41.05.310
through
41.05.360, and
41.05.295
gives a participant any right to be retained in state employment.
[
2018 c 260 s 19
;
2008 c 229 s 3
;
1995 1st sp.s. c 6 s 11
.]
NOTES:
Effective date
—
2008 c 229:
See note following RCW 41.05.295
.
Effective date
—
1995 1st sp.s. c 6:
See note following RCW 28A.400.410
.
RCW 41.05.310
Salary reduction plan
—
Policies and procedures
—
Plan document.
The authority shall have responsibility for the formulation and adoption of a plan, policies, and procedures designed to guide, direct, and administer the salary reduction plan. For the plan year beginning January 1, 1996, the director may establish a premium only plan. Expansion of the salary reduction plan or cafeteria plan during subsequent plan years shall be subject to approval by the director of the office of financial management.
(1) A plan document describing the benefits offered under the salary reduction plan shall be adopted and administered by the authority. The authority shall represent the state in all matters concerning the administration of the plan. The state, through the authority, may engage the services of a professional consultant or administrator on a contractual basis to serve as an agent to assist the authority or perform the administrative functions necessary in carrying out the purposes of RCW 41.05.123, 41.05.300
through
41.05.350, and
41.05.295
.
(2) The authority shall formulate and establish policies and procedures for the administration of the salary reduction plan that are consistent with existing state law, the internal revenue code, and the regulations adopted by the internal revenue service as they may apply to the benefits offered to participants under the plan.
(3) Every action taken by the authority in administering RCW 41.05.123, 41.05.300
through
41.05.350, and
41.05.295
shall be presumed to be a fair and reasonable exercise of the authority vested in or the duties imposed upon it. The authority shall be presumed to have exercised reasonable care, diligence, and prudence and to have acted impartially as to all persons interested unless the contrary be proved by clear and convincing affirmative evidence.
[
2023 c 51 s 16
;
2008 c 229 s 4
;
1995 1st sp.s. c 6 s 12
.]
NOTES:
Effective date
—
2008 c 229:
See note following RCW 41.05.295
.
Effective date
—
1995 1st sp.s. c 6:
See note following RCW 28A.400.410
.
RCW 41.05.320
Salary reduction plan
—
Eligibility
—
Participation, withdrawal.
(1) Elected officials and permanent employees and school employees are eligible to participate in the salary reduction plan and reduce their salary by agreement with the authority. The authority may adopt rules to: (a) Limit the participation of employing agencies and their employees in the plan; and (b) permit participation in the plan by temporary employees and school employees.
(2) Persons eligible under subsection (1) of this section may enter into salary reduction agreements with the state.
(3)(a) An eligible person may become a participant of the salary reduction plan for a full plan year with annual benefit plan selection for each new plan year made before the beginning of the plan year, as determined by the authority, or upon becoming eligible.
(b) Once an eligible person elects to participate in the salary reduction plan and determines the amount his or her gross salary shall be reduced and the benefit plan for which the funds are to be used during the plan year, the agreement shall be irrevocable and may not be amended during the plan year except as provided in (c) of this subsection. Prior to making an election to participate in the salary reduction plan, the eligible person shall be informed in writing of all the benefits and reductions that will occur as a result of such election.
(c) The authority shall provide in the salary reduction plan that a participant may enroll, terminate, or change his or her election after the plan year has begun if there is a significant change in a participant's status, as provided by 26 U.S.C. Sec. 125 and the regulations adopted under that section and defined by the authority.
(4) The authority shall establish as part of the salary reduction plan the procedures for and effect of withdrawal from the plan by reason of retirement, death, leave of absence, or termination of employment. To the extent possible under federal law, the authority shall protect participants from forfeiture of rights under the plan.
(5) Any reduction of salary under the salary reduction plan shall not reduce the reportable compensation for the purpose of computing the state retirement and pension benefits earned by the public employee pursuant to chapters
41.26, 41.32, 41.35, 41.37, 41.40, and
43.43
RCW.
[
2023 c 51 s 17
;
2018 c 260 s 20
;
2008 c 229 s 5
;
2007 c 492 s 6
;
1995 1st sp.s. c 6 s 13
.]
NOTES:
Effective date
—
2008 c 229:
See note following RCW 41.05.295
.
Effective date
—
1995 1st sp.s. c 6:
See note following RCW 28A.400.410
.
RCW 41.05.330
Salary reduction plan
—
Accounts and records.
The authority shall keep or cause to be kept full and adequate accounts and records of the assets, obligations, transactions, and affairs of a salary reduction plan created under RCW 41.05.300
.
[
2008 c 229 s 7
;
1995 1st sp.s. c 6 s 14
.]
NOTES:
Effective date
—
2008 c 229:
See note following RCW 41.05.295
.
Effective date
—
1995 1st sp.s. c 6:
See note following RCW 28A.400.410
.
RCW 41.05.340
Salary reduction plan
—
Termination
—
Amendment.
(1) The state may terminate the salary reduction plan at the end of the plan year or upon notification of federal action affecting the status of the plan.
(2) The authority may amend the salary reduction plan at any time if the amendment does not affect the rights of the participants to receive eligible reimbursement from the participants' accounts.
[
2008 c 229 s 8
;
1995 1st sp.s. c 6 s 15
.]
NOTES:
Effective date
—
2008 c 229:
See note following RCW 41.05.295
.
Effective date
—
1995 1st sp.s. c 6:
See note following RCW 28A.400.410
.
RCW 41.05.350
Salary reduction plan
—
Rules.
The authority shall adopt rules necessary to implement RCW 41.05.123, 41.05.300
through
41.05.340, and
41.05.295
.
[
2008 c 229 s 9
;
1995 1st sp.s. c 6 s 16
.]
NOTES:
Effective date
—
2008 c 229:
See note following RCW 41.05.295
.
Effective date
—
1995 1st sp.s. c 6:
See note following RCW 28A.400.410
.
RCW 41.05.360
Salary reduction plan
—
Construction.
RCW 41.05.123, 41.05.300
through
41.05.350, and
41.05.295
shall be construed to effectuate the purposes of 26 U.S.C. Sec. 125 and other applicable sections of the internal revenue code as required.
[
2008 c 229 s 10
;
1995 1st sp.s. c 6 s 17
.]
NOTES:
Effective date
—
2008 c 229:
See note following RCW 41.05.295
.
Effective date
—
1995 1st sp.s. c 6:
See note following RCW 28A.400.410
.
RCW 41.05.400
Plan of health care coverage
—
Available funds
—
Components
—
Eligibility
—
Director's duties.
(1) The director shall design and offer a plan of health care coverage as described in subsection (2) of this section, for any person eligible under subsection (3) of this section. The health care coverage shall be designed and offered only to the extent that state funds are specifically appropriated for this purpose.
(2) The plan of health care coverage shall have the following components:
(a) Services covered more limited in scope than those contained in RCW 48.41.110
(3);
(b) Enrollee cost-sharing that may include but not be limited to point-of-service cost-sharing for covered services;
(c) Deductibles of three thousand dollars on a per person per calendar year basis, and four thousand dollars on a per family per calendar year basis. The deductible shall be applied to the first three thousand dollars, or four thousand dollars, of eligible expenses incurred by the covered person or family, respectively, except that the deductible shall not be applied to clinical preventive services as recommended by the United States public health service. Enrollee out-of-pocket expenses required to be paid under the plan for cost-sharing and deductibles shall not exceed five thousand dollars per person, or six thousand dollars per family;
(d) Payment methodologies for network providers may include but are not limited to resource-based relative value fee schedules, capitation payments, diagnostic related group fee schedules, and other similar strategies including risk-sharing arrangements; and
(e) Other appropriate care management and cost-containment measures determined appropriate by the director, including but not limited to care coordination, provider network limitations, preadmission certification, and utilization review.
(3) Any person is eligible for coverage in the plan who resides in a county of the state where no carrier, as defined in RCW 48.43.005, or insurer regulated under chapter
48.15
RCW offers to the public an individual health benefit plan as defined in RCW 48.43.005
other than a catastrophic health plan as defined in RCW 48.43.005
at the time of application to the director. Such eligibility may terminate pursuant to subsection (8) of this section.
(4) The director may not reject an individual for coverage based upon preexisting conditions of the individual or deny, exclude, or otherwise limit coverage for an individual's preexisting health conditions; except that it shall impose a nine-month benefit waiting period for preexisting conditions for which medical advice was given, or for which a health care provider recommended or provided treatment, or for which a prudent layperson would have sought advice or treatment, within six months before the effective date of coverage. The preexisting condition waiting period shall not apply to prenatal care services. Credit against the waiting period shall be provided pursuant to subsections (5) and (6) of this section.
(5) Except for persons to whom subsection (6) of this section applies, the director shall credit any preexisting condition waiting period in the plan for a person who was enrolled at any time during the sixty-three day period immediately preceding the date of application for the plan in a group health benefit plan or an individual health benefit plan other than a catastrophic health plan. The director must credit the period of coverage the person was continuously covered under the immediately preceding health plan toward the waiting period of the new health plan. For the purposes of this subsection, a preceding health plan includes an employer-provided self-funded health plan.
(6) The director shall waive any preexisting condition waiting period in the plan for a person who is an eligible individual as defined in section 2741(b) of the federal health insurance portability and accountability act of 1996 (42 U.S.C. 300gg-41(b)).
(7) The director shall set the rates to be charged plan enrollees.
(8) When a carrier, as defined in RCW 48.43.005, or an insurer regulated under chapter
48.15
RCW, begins to offer an individual health benefit plan as defined in RCW 48.43.005
in a county where no carrier or insurer had been offering an individual health benefit plan:
(a) If the health benefit plan offered is other than a catastrophic health plan as defined in RCW 48.43.005, any person enrolled in the plan under subsection (3) of this section in that county shall no longer be eligible;
(b) The director shall provide written notice to any person who is no longer eligible for coverage under the plan within thirty days of the director's determination that the person is no longer eligible. The notice shall: (i) Indicate that coverage under the plan will cease ninety days from the date that the notice is dated; (ii) describe any other coverage options available to the person; and (iii) describe the enrollment process for the available options.
[
2023 c 51 s 18
;
2000 c 80 s 7
;
2000 c 79 s 46
.]
NOTES:
Effective date
—
Severability
—
2000 c 79:
See notes following RCW 48.04.010
.
RCW 41.05.405
Public option plans
—
Availability
—
Hospital contracts
—
Recommendations.
(1) If a public option plan is not available in each county in the state during plan year 2022 or later, the following requirements apply for all subsequent plan years:
(a) Upon an offer from a public option plan, a hospital licensed under chapter
70.41
RCW that receives payment for services provided to enrollees in the public employees' benefits program or school employees' benefits program, or through a medical assistance program under chapter
74.09
RCW, must contract with at least one public option plan to provide in-network services to enrollees of that plan. This subsection (1)(a) does not apply to a hospital owned and operated by a health maintenance organization licensed under chapter
48.46
RCW; and
(b) The authority shall contract, under RCW 41.05.410, with one or more health carriers to offer at least one standardized bronze, one standardized silver, and one standardized gold qualified health plan in every county in the state or in each county within a region of the state.
(2) Health carriers and hospitals may not condition negotiations or participation of a hospital licensed under chapter
70.41
RCW in any health plan offered by the health carrier on the hospital's negotiations or participation in a public option plan.
(3) By December 1st of the plan year during which enrollment in public option plans statewide is greater than 10,000 covered lives:
(a) The health benefit exchange, in consultation with the insurance commissioner and the authority, shall analyze public option plan rates paid to hospitals for in-network services and whether they have impacted hospital financial sustainability. The analysis must include any impact on hospitals' operating margins during the years public option health plans have been offered in the state and the estimated impact on operating margins in future years if enrollment in public option plans increases. It must also examine the income levels of public option plan enrollees over time. The analysis may examine a sample of hospitals of various sizes and located in various counties. In conducting its analysis, the exchange must give substantial weight to any available reporting of health care provider and health system costs under RCW 70.390.050
;
(b) The health care cost transparency board established under chapter
70.390
RCW shall analyze the effect that enrollment in public option plans has had on consumers, including an analysis of the benefits provided to, and premiums and cost-sharing amounts paid by, consumers enrolled in public option plans compared to other standardized and nonstandardized qualified health plans; and
(c) The health benefit exchange, in consultation with the insurance commissioner, the authority, and interested stakeholders, including, but not limited to, statewide associations representing hospitals, health insurers, and physicians, shall review the analyses completed under (a) and (b) of this subsection and develop recommendations to the legislature to address financial or other issues identified in the analyses.
(4) The authority may adopt program rules, in consultation with the office of the insurance commissioner, to ensure compliance with this section, including levying fines and taking other contract actions it deems necessary to enforce compliance with this section.
(5) For the purposes of this section, "public option plan" means a qualified health plan contracted by the authority under RCW 41.05.410
.
[
2021 c 246 s 5
.]
RCW 41.05.410
Qualified health plans
—
Contract for
—
Requirements
—
Cost and quality data.
(1) The authority, in consultation with the health benefit exchange, must contract with one or more health carriers to offer qualified health plans on the Washington health benefit exchange for plan years beginning in 2021. A health carrier contracting with the authority under this section must offer at least one bronze, one silver, and one gold qualified health plan in a single county or in multiple counties. The goal of the procurement conducted under this section is to have a choice of qualified health plans under this section offered in every county in the state. The authority may not execute a contract with an apparently successful bidder under this section until after the insurance commissioner has given final approval of the health carrier's rates and forms pertaining to the health plan to be offered under this section and certification of the health plan under RCW 43.71.065
.
(2) A qualified health plan offered under this section must meet the following criteria:
(a) The qualified health plan must be a standardized health plan established under RCW 43.71.095
;
(b) The qualified health plan must meet all requirements for qualified health plan certification under RCW 43.71.065
including, but not limited to, requirements relating to rate review and network adequacy;
(c) The qualified health plan must incorporate recommendations of the Robert Bree collaborative and the health technology assessment program;
(d) The qualified health plan may use an integrated delivery system or a managed care model that includes care coordination or care management to enrollees as appropriate;
(e) The qualified health plan must meet additional participation requirements to reduce barriers to maintaining and improving health and align to state agency value-based purchasing. These requirements may include, but are not limited to, standards for population health management; high-value, proven care; health equity; primary care; care coordination and chronic disease management; wellness and prevention; prevention of wasteful and harmful care; and patient engagement;
(f) To reduce administrative burden and increase transparency, the qualified health plan's utilization review processes must:
(i) Be focused on care that has high variation, high cost, or low evidence of clinical effectiveness; and
(ii) Meet national accreditation standards;
(g) The total amount the qualified health plan reimburses providers and facilities for all covered benefits in the statewide aggregate, excluding pharmacy benefits, may not exceed one hundred sixty percent of the total amount medicare would have reimbursed providers and facilities for the same or similar services in the statewide aggregate;
(h) For services provided by rural hospitals certified by the centers for medicare and medicaid services as critical access hospitals or sole community hospitals, the rates may not be less than one hundred one percent of allowable costs as defined by the United States centers for medicare and medicaid services for purposes of medicare cost reporting;
(i) Reimbursement for primary care services, as defined by the authority, provided by a physician with a primary specialty designation of family medicine, general internal medicine, or pediatric medicine, may not be less than one hundred thirty-five percent of the amount that would have been reimbursed under the medicare program for the same or similar services; and
(j) The qualified health plan must comply with any requirements established by the authority to address amounts expended on pharmacy benefits including, but not limited to, increasing generic utilization and use of evidence-based formularies.
(3)(a) At the request of the authority for monitoring, enforcement, or program and quality improvement activities, a qualified health plan offered under this section must provide cost and quality of care information and data to the authority, and may not enter into an agreement with a provider or third party that would restrict the qualified health plan from providing this information or data.
(b) Pursuant to RCW 42.56.650, any cost or quality information or data submitted to the authority is exempt from public disclosure.
(4) Nothing in this section prohibits a health carrier offering qualified health plans under this section from offering other health plans in the individual market.
[
2021 c 246 s 6
;
2019 c 364 s 3
.]
RCW 41.05.413
Qualified health plans
—
Reimbursement limit
—
Waiver.
The director may, in his or her sole discretion, waive the requirements of RCW 41.05.410
(2)(g) if he or she finds that:
(1) A health carrier offering a qualified health plan under RCW 41.05.410
is unable to form a provider network that meets the network access standards adopted by the insurance commissioner due to the requirements of RCW 41.05.410
(2)(g); and
(2) The health carrier is able to achieve actuarially sound premiums that are ten percent lower than the previous plan year through other means.
[
2023 c 51 s 19
;
2019 c 364 s 4
.]
NOTES:
RCW 41.05.430
Plan of health care coverage
—
Immediate postpartum contraception devices.
(1) For births taking place in a licensed hospital or birthing center, a health plan offered to employees and their covered dependents must allow a provider to separately bill for devices, implants, professional services, or a combination thereof, associated with immediate postpartum contraception and may not consider such devices, implants, services, or combinations thereof to be part of any payments for general obstetric procedures.
(2) For purposes of this section, "immediate postpartum contraception" means the postpartum insertion of intrauterine devices or contraceptive implants performed before the patient is discharged from the hospital or birthing center and includes the devices or implants themselves.
(3) This section does not apply to facility services associated with immediate postpartum contraception.
(4) Nothing in this section affects an enrollee's right to directly access women's health care services, including contraceptive services.
(5) This section applies to health plans issued or renewed on or after January 1, 2023.
[
2022 c 122 s 2
.]
NOTES:
Findings
—
Intent
—
2022 c 122:
"The legislature finds that healthy birth spacing helps reduce adverse health outcomes for both parents and babies. The legislature further finds that increasing immediate postpartum access to contraception, before a patient is discharged from the hospital or birthing center, is critical to maternal and newborn health and that immediate postpartum contraception is associated with longer contraceptive coverage, fewer unintended pregnancies, and cost savings for payers and health care systems. To help achieve these outcomes, it is the intent of the legislature to increase access to immediate postpartum contraception by requiring commercial health insurers to pay for immediate postpartum contraception separately from the maternity bundle in a manner that mirrors the payment process for immediate postpartum contraception used by the state's medicaid program." [
2022 c 122 s 1
.]
RCW 41.05.520
Pharmacy connection program
—
Notice.
(1) The director shall establish and advertise a pharmacy connection program through which health care providers and members of the public can obtain information about manufacturer-sponsored prescription drug assistance programs. The director shall ensure that the program has staff available who can assist persons in procuring free or discounted medications from manufacturer-sponsored prescription drug assistance programs by:
(a) Determining whether an assistance program is offered for the needed drug or drugs;
(b) Evaluating the likelihood of a person obtaining drugs from an assistance program under the guidelines formulated;
(c) Assisting persons with the application and enrollment in an assistance program;
(d) Coordinating and assisting physicians and others authorized to prescribe medications with communications, including applications, made on behalf of a person to a participating manufacturer to obtain approval of the person in an assistance program; and
(e) Working with participating manufacturers to simplify the system whereby eligible persons access drug assistance programs, including development of a single application form and uniform enrollment process.
(2) Notice regarding the pharmacy connection program shall initially target senior citizens, but the program shall be available to anyone, and shall include a toll-free telephone number, available during regular business hours, that may be used to obtain information.
(3) The director may apply for and accept grants or gifts and may enter into interagency agreements or contracts with other state agencies or private organizations to assist with the implementation of this program including, but not limited to, contracts, gifts, or grants from pharmaceutical manufacturers to assist with the direct costs of the program.
(4) The director shall notify pharmaceutical companies doing business in Washington of the pharmacy connection program. Any pharmaceutical company that does business in this state and that offers a pharmaceutical assistance program shall notify the director of the existence of the program, the drugs covered by the program, and all information necessary to apply for assistance under the program.
(5) For purposes of this section, "manufacturer-sponsored prescription drug assistance program" means a program offered by a pharmaceutical company through which the company provides a drug or drugs to eligible persons at no charge or at a reduced cost. The term does not include the provision of a drug as part of a clinical trial.
[
2023 c 51 s 20
;
2003 1st sp.s. c 29 s 7
.]
NOTES:
Finding
—
Intent
—
Severability
—
Conflict with federal requirements
—
Effective date
—
2003 1st sp.s. c 29:
See notes following RCW 74.09.650
.
RCW 41.05.525
Treatment of opioid use disorder
—
Prior authorization.
A health plan offered to employees, school employees, and their covered dependents under this chapter issued or renewed on or after January 1, 2020, shall provide coverage without prior authorization of at least one federal food and drug administration approved product for the treatment of opioid use disorder in the drug classes opioid agonists, opioid antagonists, and opioid partial agonists.
[
2019 c 314 s 36
.]
NOTES:
Declaration
—
2019 c 314:
See note following RCW 18.22.810
.