RCW 48.43.310
Company action level event
—
Required RBC plan
—
Commissioner's review
—
Notification
—
Challenge by carrier.
(1) "Company action level event" means any of the following events:
(a) The filing of an RBC report by a carrier which indicates that:
(i) The carrier's total adjusted capital is greater than or equal to its regulatory action level RBC but less than its company action level RBC; or
(ii) The carrier has total adjusted capital which is greater than or equal to its company action level RBC but less than the product of its authorized control level RBC and 3 and has a negative trend;
(b) The notification by the commissioner to the carrier of an adjusted RBC report that indicates an event in (a) of this subsection, provided the carrier does not challenge the adjusted RBC report under RCW 48.43.330
; or
(c) If, under RCW 48.43.330, a carrier challenges an adjusted RBC report that indicates the event in (a) of this subsection, the notification by the commissioner to the carrier that the commissioner has, after a hearing, rejected the carrier's challenge.
(2) In the event of a company action level event, the carrier shall prepare and submit to the commissioner an RBC plan that:
(a) Identifies the conditions that contribute to the company action level event;
(b) Contains proposals of corrective actions that the carrier intends to take and would be expected to result in the elimination of the company action level event;
(c) Provides projections of the carrier's financial results in the current year and at least the four succeeding years, both in the absence of proposed corrective actions and giving effect to the proposed corrective actions, including projections of statutory operating income, net income, capital, surplus, capital and surplus, and net worth. The projections for both new and renewal business might include separate projections for each major line of business and separately identify each significant income, expense, and benefit component;
(d) Identifies the key assumptions impacting the carrier's projections and the sensitivity of the projections to the assumptions; and
(e) Identifies the quality of, and problems associated with, the carrier's business, including but not limited to its assets, anticipated business growth and associated surplus strain, extraordinary exposure to risk, mix of business, and use of reinsurance, if any, in each case.
(3) The RBC plan shall be submitted:
(a) Within forty-five days of the company action level event; or
(b) If the carrier challenges an adjusted RBC report under RCW 48.43.330, within forty-five days after notification to the carrier that the commissioner has, after a hearing, rejected the carrier's challenge.
(4) Within sixty days after the submission by a carrier of an RBC plan to the commissioner, the commissioner shall notify the carrier whether the RBC plan may be implemented or is, in the judgment of the commissioner, unsatisfactory. If the commissioner determines the RBC plan is unsatisfactory, the notification to the carrier shall set forth the reasons for the determination, and may set forth proposed revisions that will render the RBC plan satisfactory. Upon notification from the commissioner, the carrier shall prepare a revised RBC plan, that may incorporate by reference any revisions proposed by the commissioner, and shall submit the revised RBC plan to the commissioner:
(a) Within forty-five days after the notification from the commissioner; or
(b) If the carrier challenges the notification from the commissioner under RCW 48.43.330, within forty-five days after a notification to the carrier that the commissioner has, after a hearing, rejected the carrier's challenge.
(5) In the event of a notification by the commissioner to a carrier that the carrier's RBC plan or revised RBC plan is unsatisfactory, the commissioner may, subject to the carrier's rights to a hearing under RCW 48.43.330, specify in the notification that the notification constitutes a regulatory action level event.
(6) Every domestic carrier that files an RBC plan or revised RBC plan with the commissioner shall file a copy of the RBC plan or revised RBC plan with the insurance commissioner in any state in which the carrier is authorized to do business if:
(a) Such state has an RBC provision substantially similar to RCW 48.43.335
(1); and
(b) The insurance commissioner of that state has notified the carrier of its request for the filing in writing, in which case the carrier shall file a copy of the RBC plan or revised RBC plan in that state no later than the later of:
(i) Fifteen days after the receipt of notice to file a copy of its RBC plan or revised plan with the state; or
(ii) The date on which the RBC plan or revised RBC plan is filed under subsections (3) and (4) of this section.
[
2012 c 211 s 8
;
1998 c 241 s 3
.]
RCW 48.43.315
Regulatory action level event
—
Required RBC plan
—
Commissioner's review
—
Notification
—
Challenge by carrier.
(1) "Regulatory action level event" means, with respect to any carrier, any of the following events:
(a) The filing of an RBC report by the carrier which indicates that the carrier's total adjusted capital is greater than or equal to its authorized control level RBC but less than its regulatory action level RBC;
(b) The notification by the commissioner to a carrier of an adjusted RBC report that indicates the event in (a) of this subsection, provided the carrier does not challenge the adjusted RBC report under RCW 48.43.330
;
(c) If, under RCW 48.43.330, the carrier challenges an adjusted RBC report that indicates the event in (a) of this subsection, the notification by the commissioner to the carrier that the commissioner has, after a hearing, rejected the carrier's challenge;
(d) The failure of the carrier to file an RBC report by the filing date, unless the carrier has provided an explanation for such failure that is satisfactory to the commissioner and has cured the failure within ten days after the filing date;
(e) The failure of the carrier to submit an RBC plan to the commissioner within the time period set forth in RCW 48.43.310
(3);
(f) Notification by the commissioner to the carrier that:
(i) The RBC plan or revised RBC plan submitted by the carrier is, in the judgment of the commissioner, unsatisfactory; and
(ii) The notification constitutes a regulatory action level event with respect to the carrier, provided the carrier has not challenged the determination under RCW 48.43.330
;
(g) If, under RCW 48.43.330, the carrier challenges a determination by the commissioner under (f) of this subsection, the notification by the commissioner to the carrier that the commissioner has, after a hearing, rejected the challenge;
(h) Notification by the commissioner to the carrier that the carrier has failed to adhere to its RBC plan or revised RBC plan, but only if such failure has a substantial adverse effect on the ability of the carrier to eliminate the company action level event in accordance with its RBC plan or revised RBC plan and the commissioner has so stated in the notification, provided the carrier has not challenged the determination under RCW 48.43.330
; or
(i) If, under RCW 48.43.330, the carrier challenges a determination by the commissioner under (h) of this subsection, the notification by the commissioner to the carrier that the commissioner has, after a hearing, rejected the challenge.
(2) In the event of a regulatory action level event the commissioner shall:
(a) Require the carrier to prepare and submit an RBC plan or, if applicable, a revised RBC plan;
(b) Perform the examination or analysis the commissioner deems necessary of the assets, liabilities, and operations of the carrier including a review of its RBC plan or revised RBC plan; and
(c) Subsequent to the examination or analysis, issue an order specifying those corrective actions the commissioner determines are required.
(3) In determining corrective actions, the commissioner may take into account those factors deemed relevant with respect to the carrier based upon the commissioner's examination or analysis of the assets, liabilities, and operations of the carrier, including, but not limited to, the results of any sensitivity tests undertaken pursuant to the RBC instructions. The RBC plan or revised RBC plan shall be submitted:
(a) Within forty-five days after the occurrence of the regulatory action level event;
(b) If the carrier challenges an adjusted RBC report under RCW 48.43.330
and the challenge is not frivolous in the judgment of the commissioner within forty-five days after the notification to the carrier that the commissioner has, after a hearing, rejected the carrier's challenge; or
(c) If the carrier challenges a revised RBC plan under RCW 48.43.330
and the challenge is not frivolous in the judgment of the commissioner, within forty-five days after the notification to the carrier that the commissioner has, after a hearing, rejected the carrier's challenge.
(4) The commissioner may retain actuaries and investment experts and other consultants as may be necessary in the judgment of the commissioner to review the carrier's RBC plan or revised RBC plan, examine or analyze the assets, liabilities, and operations of the carrier and formulate the corrective order with respect to the carrier. The fees, costs, and expenses relating to consultants shall be borne by the affected carrier or other party as directed by the commissioner.
[
1998 c 241 s 4
.]
RCW 48.43.320
Authorized control level event
—
Commissioner's options.
(1) "Authorized control level event" means any of the following events:
(a) The filing of an RBC report by the carrier which indicates that the carrier's total adjusted capital is greater than or equal to its mandatory control level RBC but less than its authorized control level RBC;
(b) The notification by the commissioner to the carrier of an adjusted RBC report that indicates the event in (a) of this subsection, provided the carrier does not challenge the adjusted RBC report under RCW 48.43.330
;
(c) If, under RCW 48.43.330, the carrier challenges an adjusted RBC report that indicates the event in (a) of this subsection, notification by the commissioner to the carrier that the commissioner has, after a hearing, rejected the carrier's challenge;
(d) The failure of the carrier to respond, in a manner satisfactory to the commissioner, to a corrective order, provided the carrier has not challenged the corrective order under RCW 48.43.330
; or
(e) If the carrier has challenged a corrective order under RCW 48.43.330
and the commissioner has, after a hearing, rejected the challenge or modified the corrective order, the failure of the carrier to respond, in a manner satisfactory to the commissioner, to the corrective order subsequent to rejection or modification by the commissioner.
(2) In the event of an authorized control level event with respect to a carrier, the commissioner shall:
(a) Take those actions required under RCW 48.43.315
regarding a carrier with respect to which a regulatory action level event has occurred; or
(b) If the commissioner deems it to be in the best interests of either the policyholders or subscribers, or both, and creditors of the carrier and of the public, take those actions necessary to cause the carrier to be placed under regulatory control under chapter
48.31
RCW. In the event the commissioner takes such actions, the authorized control level event is sufficient grounds for the commissioner to take action under chapter
48.31
RCW, and the commissioner shall have the rights, powers, and duties with respect to the carrier as are set forth in chapter
48.31
RCW. In the event the commissioner takes actions under this subsection (2)(b) pursuant to an adjusted RBC report, the carrier is entitled to those protections afforded to carriers under the provisions of RCW 48.31.121
pertaining to summary proceedings.
[
1998 c 241 s 5
.]
RCW 48.43.325
Mandatory control level event
—
Commissioner's duty
—
Regulatory control.
(1) "Mandatory control level event" means any of the following events:
(a) The filing of an RBC report which indicates that the carrier's total adjusted capital is less than its mandatory control level RBC;
(b) Notification by the commissioner to the carrier of an adjusted RBC report that indicates the event in (a) of this subsection, provided the carrier does not challenge the adjusted RBC report under RCW 48.43.330
; or
(c) If, under RCW 48.43.330, the carrier challenges an adjusted RBC report that indicates the event in (a) of this subsection, notification by the commissioner to the carrier that the commissioner has, after a hearing, rejected the carrier's challenge.
(2) In the event of a mandatory control level event, with respect to a carrier, the commissioner shall take those actions necessary to place the carrier under regulatory control under chapter
48.31
RCW. In that event, the mandatory control level event is sufficient grounds for the commissioner to take action under chapter
48.31
RCW, and the commissioner shall have the rights, powers, and duties with respect to the carrier as are set forth in chapter
48.31
RCW. If the commissioner takes actions pursuant to an adjusted RBC report, the carrier is entitled to the protections of RCW 48.31.121
pertaining to summary proceedings. However, the commissioner may forego action for up to ninety days after the mandatory control level event if the commissioner finds there is a reasonable expectation that the mandatory control level event may be eliminated within the ninety-day period.
[
1998 c 241 s 6
.]
RCW 48.43.330
Carrier's right to hearing
—
Request by carrier
—
Date set by commissioner.
(1) Upon notification to a carrier by the commissioner of any of the following, the carrier shall have the right to a hearing, in accordance with chapters
48.04
and
34.05
RCW, at which the carrier may challenge any determination or action by the commissioner:
(a) Of an adjusted RBC report; or
(b)(i) That the carrier's RBC plan or revised RBC plan is unsatisfactory; and
(ii) The notification constitutes a regulatory action level event with respect to such carrier; or
(c) That the carrier has failed to adhere to its RBC plan or revised RBC plan and that such failure has a substantial adverse effect on the ability of the carrier to eliminate the company action level event with respect to the carrier in accordance with its RBC plan or revised RBC plan; or
(d) Of a corrective order with respect to the carrier.
(2) The carrier shall notify the commissioner of its request for a hearing within five days after the notification by the commissioner under this section. Upon receipt of the carrier's request for a hearing, the commissioner shall set a date for the hearing. The date shall be no less than ten nor more than thirty days after the date of the carrier's request.
[
1998 c 241 s 7
.]
RCW 48.43.335
Confidentiality of RBC reports and plans
—
Use of certain comparisons prohibited
—
Certain information intended solely for use by commissioner.
(1) All RBC reports, to the extent the information therein is not required to be set forth in a publicly available annual statement schedule, and RBC plans, including the results or report of any examination or analysis of a carrier and any corrective order issued by the commissioner, with respect to any domestic carrier or foreign carrier that are filed with the commissioner constitute information that might be damaging to the carrier if made available to its competitors, and therefore shall be kept confidential by the commissioner. This information shall not be made public or be subject to subpoena, other than by the commissioner and then only for the purpose of enforcement actions taken by the commissioner.
(2) The comparison of a carrier's total adjusted capital to any of its RBC levels is a regulatory tool that may indicate the need for possible corrective action with respect to the carrier, and is not a means to rank carriers generally. Therefore, except as otherwise required under the provisions of RCW 48.43.300
through
48.43.370, the making, publishing, disseminating, circulating, or placing before the public, or causing, directly or indirectly, to be made, published, disseminated, circulated, or placed before the public, in a newspaper, magazine, or other publication, or in the form of a notice, circular, pamphlet, letter, or poster, or over any radio or television station, or in any other way, an advertisement, announcement, or statement containing an assertion, representation, or statement with regard to the RBC levels of any carrier, or of any component derived in the calculation, by any carrier, insurance producer, or other person engaged in any manner in the insurance business would be misleading and is therefore prohibited. However, if any materially false statement with respect to the comparison regarding a carrier's total adjusted capital to its RBC levels (or any of them) or an inappropriate comparison of any other amount to the carrier's RBC levels is published in any written publication and the carrier is able to demonstrate to the commissioner with substantial proof the falsity of such statement, or the inappropriateness, as the case may be, then the carrier may publish an announcement in a written publication if the sole purpose of the announcement is to rebut the materially false statement.
(3) The RBC instructions, RBC reports, adjusted RBC reports, RBC plans, and revised RBC plans are intended solely for use by the commissioner in monitoring the solvency of carriers and the need for possible corrective action with respect to carriers and shall not be used by the commissioner for ratemaking nor considered or introduced as evidence in any rate proceeding nor used by the commissioner to calculate or derive any elements of an appropriate premium level or rate of return for any line of insurance that a carrier or any affiliate is authorized to write.
[
2008 c 217 s 49
;
1998 c 241 s 8
.]
NOTES:
Severability
—
Effective date
—
2008 c 217:
See notes following RCW 48.03.020
.
RCW 48.43.340
Powers or duties of commissioner not limited
—
Rules.
(1) The provisions of RCW 48.43.300
through
48.43.370
are supplemental to any other provisions of the laws and rules of this state, and shall not preclude or limit any other powers or duties of the commissioner under such laws and rules, including, but not limited to, chapter
48.31
RCW.
(2) The commissioner may adopt reasonable rules necessary for the implementation of RCW 48.43.300
through
48.43.370
.
[
1998 c 241 s 9
.]
RCW 48.43.345
Foreign or alien carriers
—
Required RBC report
—
Commissioner may require RBC plan
—
Mandatory control level event.
(1) Any foreign or alien carrier shall, upon the written request of the commissioner, submit to the commissioner an RBC report as of the end of the calendar year just ended by the later of:
(a) The date an RBC report would be required to be filed by a domestic carrier under RCW 48.43.300
through
48.43.370
; or
(b) Fifteen days after the request is received by the foreign or alien carrier. Any foreign or alien carrier shall, at the written request of the commissioner, promptly submit to the commissioner a copy of any RBC plan that is filed with the insurance commissioner of any other state.
(2) In the event of a company action level event, regulatory action level event, or authorized control level event with respect to any foreign or alien carrier as determined under the RBC statute applicable in the state of domicile of the carrier or, if no RBC statute is in force in that state, under the provisions of RCW 48.43.300
through
48.43.370, if the insurance commissioner of the state of domicile of the foreign or alien carrier fails to require the foreign or alien carrier to file an RBC plan in the manner specified under that state's RBC statute or, if no RBC statute is in force in that state, under RCW 48.43.310, the commissioner may require the foreign or alien carrier to file an RBC plan with the commissioner. In this event, the failure of the foreign or alien carrier to file an RBC plan with the commissioner is grounds to order the carrier to cease and desist from writing new insurance business in this state.
(3) In the event of a mandatory control level event with respect to any foreign or alien carrier, if no domiciliary receiver has been appointed with respect to the foreign or alien carrier under the rehabilitation and liquidation statute applicable in the state of domicile of the foreign or alien carrier, the commissioner may apply for an order under RCW 48.31.080
or
48.31.090
to conserve the assets within this state of foreign or alien carriers, and the occurrence of the mandatory control level event is considered adequate grounds for the application.
[
1998 c 241 s 10
.]
RCW 48.43.350
No liability or cause of action against commissioner or department.
There is no liability on the part of, and no cause of action shall arise against, the commissioner or insurance department or its employees or agents for any action taken by them in the performance of their powers and duties under RCW 48.43.300
through
48.43.370
.
[
1998 c 241 s 11
.]
RCW 48.43.355
Notice by commissioner to carrier
—
When effective.
All notices by the commissioner to a carrier that may result in regulatory action are effective upon dispatch if transmitted by registered or certified mail, or in the case of any other transmission, are effective upon the carrier's receipt of such notice.
[
1998 c 241 s 12
.]
RCW 48.43.360
Initial RBC reports
—
Calculation of initial RBC levels
—
Subsequent reports.
For RBC reports to be filed by carriers commencing operations after June 11, 1998, those carriers shall calculate the initial RBC levels using financial projections, considering managed care arrangements, for its first full year in operation. Such projections, including the risk-based capital requirement, must be included as part of a comprehensive business plan that is submitted as part of the application for registration under RCW 48.44.040
and
48.46.030
. The resulting RBC requirement shall be reported in the first RBC report submitted under RCW 48.43.305
. For subsequent reports, the RBC results using actual financial data shall be included.
[
1998 c 241 s 13
.]
RCW 48.43.366
Self-funded multiple employer welfare arrangements.
A self-funded multiple employer welfare arrangement, as defined in RCW 48.125.010, is subject to the same RBC reporting requirements as a domestic carrier under RCW 48.43.300
through
48.43.370
.
[
2004 c 260 s 19
.]
NOTES:
Effective date
—
2004 c 260:
See RCW 48.125.901
.
RCW 48.43.370
RBC standards not applicable to certain carriers.
RCW 48.43.300
through
48.43.370
shall not apply to a carrier which is subject to the provisions of RCW 48.05.430
through *
48.05.490
.
[
1998 c 241 s 15
.]
NOTES:
*Reviser's note:
RCW 48.05.490
was repealed by
2006 c 25 s 11
.
RCW 48.43.400
Prescription drug utilization management
—
Definitions.
The definitions in this section apply throughout this section and RCW 48.43.410
and
48.43.420
unless the context clearly requires otherwise.
(1) "Clinical practice guidelines" means a systemically developed statement to assist decision making by health care providers and patients about appropriate health care for specific clinical circumstances and conditions.
(2) "Clinical review criteria" means the written screening procedures, decision rules, medical protocols, and clinical practice guidelines used by a health carrier or prescription drug utilization management entity as an element in the evaluation of medical necessity and appropriateness of requested prescription drugs under a health plan.
(3) "Emergency fill" means a limited dispensed amount of medication that allows time for the processing of prescription drug utilization management.
(4) "Medically appropriate" means prescription drugs that under the applicable standard of care are appropriate: (a) To improve or preserve health, life, or function; (b) to slow the deterioration of health, life, or function; or (c) for the early screening, prevention, evaluation, diagnosis, or treatment of a disease, condition, illness, or injury.
(5) "Prescription drug utilization management" means a set of formal techniques used by a health carrier or prescription drug utilization management entity, that are designed to monitor the use of or evaluate the medical necessity, appropriateness, efficacy, or efficiency of prescription drugs including, but not limited to, prior authorization and step therapy protocols.
(6) "Prescription drug utilization management entity" means an entity affiliated with, under contract with, or acting on behalf of a health carrier to perform prescription drug utilization management.
(7) "Prior authorization" means a mandatory process that a carrier or prescription drug utilization management entity requires a provider or facility to follow to determine if a service is a benefit and meets the requirements for medical necessity, clinical appropriateness, level of care, or effectiveness in relation to the applicable plan.
(8) "Step therapy protocol" means a protocol or program that establishes the specific sequence in which prescription drugs for a specified medical condition will be covered by a health carrier.
[
2019 c 171 s 1
.]
NOTES:
Rules
—
2019 c 171:
See note following RCW 48.43.420
.
RCW 48.43.410
Prescription drug utilization management
—
Clinical review criteria
—
Requirement to be evidence-based and updated regularly.
(Effective until January 1, 2027.)
For health plans delivered, issued for delivery, or renewed on or after January 1, 2021, clinical review criteria used to establish a prescription drug utilization management protocol must be evidence-based and updated on a regular basis through review of new evidence, research, and newly developed treatments.
[
2019 c 171 s 2
.]
NOTES:
Rules
—
2019 c 171:
See note following RCW 48.43.420
.
PDF
RCW 48.43.410
Prescription drug utilization management
—
Clinical review criteria
—
Requirement to be evidence-based and updated regularly.
(Effective January 1, 2027.)
For health plans delivered, issued for delivery, or renewed on or after January 1, 2021, clinical review criteria used to establish a prescription drug utilization management protocol must be evidence-based and updated on a regular basis through review of new evidence, research, and newly developed treatments. For prescription drugs prescribed to treat mental health or substance use disorder conditions, clinical review criteria must meet the requirements of RCW 48.43.766
.
[
2025 c 227 s 4
;
2019 c 171 s 2
.]
NOTES:
Effective date
—
2025 c 227 ss 1-8:
See note following RCW 48.43.766
.
Findings
—
Intent
—
Rules
—
2025 c 227:
See notes following RCW 48.43.766
.
Rules
—
2019 c 171:
See note following RCW 48.43.420
.
RCW 48.43.420
Prescription drug utilization management
—
Exception request process
—
Conditions, requirements, and time frames for approval or denial of requests
—
Emergency fill coverage
—
Notice of new policies and procedures.
For health plans delivered, issued for delivery, or renewed on or after January 1, 2021:
(1) When coverage of a prescription drug for the treatment of any medical condition is subject to prescription drug utilization management, the patient and prescribing practitioner must have access to a clear, readily accessible, and convenient process to request an exception through which the prescription drug utilization management can be overridden in favor of coverage of a prescription drug prescribed by a treating health care provider. A health carrier or prescription drug utilization management entity may use its existing medical exceptions process to satisfy this requirement. The process must be easily accessible on the health carrier and prescription drug utilization management entity's website. Approval criteria must be clearly posted on the health carrier and prescription drug utilization management entity's website. This information must be in plain language and understandable to providers and patients.
(2) Health carriers must disclose all rules and criteria related to the prescription drug utilization management process to all participating providers, including the specific information and documentation that must be submitted by a health care provider or patient to be considered a complete exception request.
(3) An exception request must be granted if the health carrier or prescription drug utilization management entity determines that the evidence submitted by the provider or patient is sufficient to establish that:
(a) The required prescription drug is contraindicated or will likely cause a clinically predictable adverse reaction by the patient;
(b) The required prescription drug is expected to be ineffective based on the known clinical characteristics of the patient and the known characteristics of the prescription drug regimen;
(c) The patient has tried the required prescription drug or another prescription drug in the same pharmacologic class or a drug with the same mechanism of action while under his or her current or a previous health plan, and such prescription drug was discontinued due to lack of efficacy or effectiveness, diminished effect, or an adverse event;
(d) The patient is currently experiencing a positive therapeutic outcome on a prescription drug recommended by the patient's provider for the medical condition under consideration while on his or her current or immediately preceding health plan, and changing to the required prescription drug may cause clinically predictable adverse reactions, or physical or mental harm to, the patient; or
(e) The required prescription drug is not in the best interest of the patient, based on documentation of medical appropriateness, because the patient's use of the prescription drug is expected to:
(i) Create a barrier to the patient's adherence to or compliance with the patient's plan of care;
(ii) Negatively impact a comorbid condition of the patient;
(iii) Cause a clinically predictable negative drug interaction; or
(iv) Decrease the patient's ability to achieve or maintain reasonable functional ability in performing daily activities.
(4) Upon the granting of an exception, the health carrier or prescription drug utilization management entity shall authorize coverage for the prescription drug prescribed by the patient's treating health care provider.
(5)(a) For nonurgent exception requests, the health carrier or prescription drug utilization management entity must:
(i) Within three business days notify the treating health care provider that additional information, as disclosed under subsection (2) of this section, is required in order to approve or deny the exception request, if the information provided is not sufficient to approve or deny the request; and
(ii) Within three business days of receipt of sufficient information from the treating health care provider as disclosed under subsection (2) of this section, approve a request if the information provided meets at least one of the conditions referenced in subsection (3) of this section or if deemed medically appropriate, or deny a request if the requested service does not meet at least one of the conditions referenced in subsection (3) of this section.
(b) For urgent exception requests, the health carrier or prescription drug utilization management entity must:
(i) Within one business day notify the treating health care provider that additional information, as disclosed under subsection (2) of this section, is required in order to approve or deny the exception request, if the information provided is not sufficient to approve or deny the request; and
(ii) Within one business day of receipt of sufficient information from the treating health care provider as disclosed under subsection (2) of this section, approve a request if the information provided meets at least one of the conditions referenced in subsection (3) of this section or if deemed medically appropriate, or deny a request if the requested service does not meet at least one of the conditions referenced in subsection (3) of this section.
(c) If a response by a health carrier or prescription drug utilization management entity is not received within the time frames established under this section, the exception request is deemed granted.
(d) For purposes of this subsection, exception requests are considered urgent when an enrollee is experiencing a health condition that may seriously jeopardize the enrollee's life, health, or ability to regain maximum function, or when an enrollee is undergoing a current course of treatment using a nonformulary drug.
(6) Health carriers must cover an emergency supply fill if a treating health care provider determines an emergency fill is necessary to keep the patient stable while the exception request is being processed. This exception shall not be used to solely justify any further exemption.
(7) When responding to a prescription drug utilization management exception request, a health carrier or prescription drug utilization management entity shall clearly state in their response if the exception request was approved or denied. The health carrier must use clinical review criteria as referenced in RCW 48.43.410
for the basis of any denial. Any denial must be based upon and include the specific clinical review criteria relied upon for the denial and include information regarding how to appeal denial of the exception request. If the exception request from a treating health care provider is denied for administrative reasons, or for not including all the necessary information, the health carrier or prescription drug utilization management entity must inform the provider what additional information is needed and the deadline for its submission.
(8) The health carrier or prescription drug utilization management entity must permit a stabilized patient to remain on a drug during an exception request process.
(9) A health carrier must provide sixty days' notice to providers and patients for any new policies or procedures applicable to prescription drug utilization management protocols. New health carrier policies or procedures may not be applied retroactively.
(10) This section does not prevent:
(a) A health carrier or prescription drug utilization management entity from requiring a patient to try an AB-rated generic equivalent or a biological product that is an interchangeable biological product prior to providing coverage for the equivalent branded prescription drug;
(b) A health carrier or prescription drug utilization management entity from denying an exception for a drug that has been removed from the market due to safety concerns from the federal food and drug administration; or
(c) A health care provider from prescribing a prescription drug that is determined to be medically appropriate.
[
2019 c 171 s 3
.]
NOTES:
Rules
—
2019 c 171:
"The insurance commissioner shall adopt rules necessary for the implementation of this act." [
2019 c 171 s 4
.]
RCW 48.43.430
Prescription medication
—
Maximum charge at point of sale
—
Requirements.
(1) Beginning January 1, 2021, the maximum amount a health carrier or pharmacy benefit manager may require a person to pay at the point of sale for a covered prescription medication is the lesser of:
(a) The applicable cost sharing for the prescription medication; or
(b) The amount the person would pay for the prescription medication if the person purchased the prescription medication without using a health plan.
(2) A health carrier or pharmacy benefit manager may not require a pharmacist to dispense a brand name prescription medication when a less expensive therapeutically equivalent generic prescription medication is available.
(3) For purposes of this section, "pharmacy benefit manager" has the same meaning as in *RCW 19.340.010
.
[
2020 c 116 s 1
.]
NOTES:
*Reviser's note:
RCW 19.340.010
was repealed by 2020 c 240 s 19, effective January 1, 2022. For later enactment, see RCW 48.200.020
.
RCW 48.43.435
Prescription medication
—
Cost-sharing calculation
—
Application
—
Rules.
(1)(a) Except as provided in (b) of this subsection, when calculating an enrollee's contribution to any applicable cost-sharing or out-of-pocket maximum, a health carrier offering a nongrandfathered health plan with a pharmacy benefit, or a health care benefit manager administering benefits for the health carrier, shall include any cost-sharing amounts paid by the enrollee directly or on behalf of the enrollee by another person for a covered prescription drug that is:
(i) Without a generic equivalent or a therapeutic equivalent preferred under the health plan's formulary;
(ii) With a generic equivalent or a therapeutic equivalent preferred under the health plan's formulary where the enrollee has obtained access to the drug through:
(A) Prior authorization;
(B) Step therapy; or
(C) The prescription drug exception request process under RCW 48.43.420
; or
(iii) With a generic equivalent or therapeutic equivalent preferred under the health plan's formulary, throughout an exception request process under RCW 48.43.420, including any appeal of a denial of an exception request. If the health carrier utilizes a health care benefit manager to approve or deny exception requests, the exception request process for the purposes of this subsection (1)(a)(iii) also includes any time between the completion of the exception request process, including any appeal of a denial, and when the health care benefit manager communicates the status of the request to the health carrier.
(b) When calculating an enrollee's contribution to any applicable deductible, any amount paid on behalf of the enrollee by another person for a prescription drug that is not subject to payment of a deductible need not be included in the calculation, unless the terms of the enrollee's health plan require inclusion.
(2) Any cost-sharing amounts paid directly by or on behalf of the enrollee by another person for a covered prescription drug under subsection (1) of this section shall be applied towards the enrollee's applicable cost-sharing or out-of-pocket maximum in full at the time it is rendered.
(3) The commissioner may adopt any rules necessary to implement this section.
(4) This section applies to nongrandfathered health plans issued or renewed on or after January 1, 2023.
(5) This section does not apply to a qualifying health plan for a health savings account to the extent necessary to preserve the enrollee's ability to claim tax exempt contributions and withdrawals from the enrollee's health savings account under internal revenue service laws, regulations, and guidance.
(6) For purposes of this section:
(a) "Health care benefit manager" has the same meaning as in RCW 48.200.020
.
(b) "Person" has the same meaning as in RCW 48.01.070
.
[
2022 c 228 s 1
.]
RCW 48.43.440
Human immunodeficiency virus postexposure prophylaxis drugs
—
Cost sharing and prior authorization.
(1) Except as provided in subsection (2) of this section, for nongrandfathered health plans issued or renewed on or after January 1, 2025, a health carrier may not impose cost sharing or require prior authorization for the drugs that comprise at least one regimen recommended by the centers for disease control and prevention for human immunodeficiency virus postexposure prophylaxis.
(2) For a health plan that is offered as a qualifying health plan for a health savings account, the health carrier must establish the plan's cost sharing for the coverage required by this section at the minimum level necessary to preserve the enrollee's ability to claim tax exempt contributions and withdrawals from the enrollee's health savings account under the internal revenue service laws and regulations.
(3) Notwithstanding the coverage requirements of this section, a health plan shall reimburse a hospital that bills for a 28-day supply of any human immunodeficiency virus postexposure prophylaxis drugs or therapies dispensed or delivered to a patient in the emergency department for take-home use, pursuant to RCW 70.41.495, as a separate reimbursable expense. This reimbursable expense is separate from any bundled payment for emergency department services.
[
2024 c 251 s 3
.]
NOTES:
Effective date
—
2024 c 251:
See note following RCW 70.41.495
.
RCW 48.43.500
Intent
—
Purpose
—
2000 c 5.
It is the intent of the legislature that enrollees covered by health plans receive quality health care designed to maintain and improve their health. The purpose of chapter 5, Laws of 2000 is to ensure that health plan enrollees:
(1) Have improved access to information regarding their health plans;
(2) Have sufficient and timely access to appropriate health care services, and choice among health care providers;
(3) Are assured that health care decisions are made by appropriate medical personnel;
(4) Have access to a quick and impartial process for appealing plan decisions;
(5) Are protected from unnecessary invasions of health care privacy; and
(6) Are assured that personal health care information will be used only as necessary to obtain and pay for health care or to improve the quality of care.
[
2000 c 5 s 1
.]
NOTES:
Application
—
2000 c 5:
"This act applies to: Health plans as defined in RCW 48.43.005
offered, renewed, or issued by a carrier; medical assistance provided under RCW 74.09.522
; the basic health plan offered under chapter
70.47
RCW; and health benefits provided under chapter
41.05
RCW." [
2000 c 5 s 19
.]
Short title
—
2000 c 5:
"This act may be known and cited as the health care patient bill of rights." [
2000 c 5 s 22
.]
Captions not law
—
2000 c 5:
"Captions used in this act are not any part of the law." [
2000 c 5 s 24
.]
Construction
—
2000 c 5:
"To the extent permitted by law, if any provision of this act conflicts with state or federal law, such provision must be construed in a manner most favorable to the enrollee." [
2000 c 5 s 26
.]
Severability
—
2000 c 5:
"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 c 5 s 27
.]
Application to contracts
—
Effective dates
—
2000 c 5:
"(1) Except as provided in subsections (2) and (3) of this section, this act applies to contracts entered into or renewing after June 30, 2001.
(2) Sections 13, 14, 15, and 16 of this act take effect January 1, 2001.
(3) Section 29 of this act takes effect July 1, 2001." [
2000 c 5 s 28
.]
RCW 48.43.505
Enrollee's and protected individual's right to privacy and confidential services
—
Health carrier or insurer duties
—
Requests for confidential communications
—
Rules.
(1) Health carriers and insurers shall adopt policies and procedures that conform administrative, business, and operational practices to protect an enrollee's and protected individual's right to privacy or right to confidential health care services granted under state or federal laws.
(2) A health carrier may not require protected individuals to obtain the policyholder, primary subscriber, or other covered person's authorization to receive health care services or to submit a claim if the protected individual has the right to consent to care.
(3) A health carrier must recognize the right of a protected individual or enrollee to exclusively exercise rights granted under this section regarding health information related to care that the enrollee or protected individual has received.
(4) A health carrier or insurer must direct all communication regarding a protected individual's receipt of sensitive health care services directly to the protected individual receiving care, or to a physical or email address or telephone number specified by the protected individual. A carrier or insurer may not disclose nonpublic personal health information concerning sensitive health care services provided to a protected individual to any person, including the policyholder, the primary subscriber, or any plan enrollees other than the protected individual receiving care, without the express written consent or verbal authorization on a recorded telephone line of the protected individual receiving care. Communications subject to this limitation include the following written, verbal, or electronic communications:
(a) Bills and attempts to collect payment;
(b) A notice of adverse benefits determinations;
(c) An explanations of benefits notice;
(d) A carrier's request for additional information regarding a claim;
(e) A notice of a contested claim;
(f) The name and address of a provider, a description of services provided, and other visit information; and
(g) Any written, oral, or electronic communication from a carrier that contains protected health information.
(5) Protected individuals may request that health carrier communications regarding the receipt of sensitive health care services be sent to another individual, including the policyholder, primary subscriber, or a health care provider, for the purposes of appealing adverse benefits determinations.
(6) Health carriers shall:
(a) Limit disclosure of any information, including personal health information, about a protected individual who is the subject of the information and shall direct communications containing such information directly to the protected individual, or to a physical or email address or telephone number specified by the protected individual, if he or she requests such a limitation, regardless of whether the information pertains to sensitive services;
(b) Permit protected individuals to use the form described in RCW 48.43.5051
(2) and must also allow enrollees and protected individuals to make the request by telephone, email, or the internet;
(c) Ensure that requests for nondisclosure remain in effect until the protected individual revokes or modifies the request in writing;
(d) Limit disclosure of information under this subsection consistent with the protected individual's request; and
(e) Ensure that requests for nondisclosure are implemented no later than three business days after receipt of a request.
(7) Health carriers may not require a protected individual to waive any right to limit disclosure under this section as a condition of eligibility for or coverage under a health benefit plan.
(8) For the protection of patient confidentiality, any communication from a health carrier relating to the provision of health care services, if the communications disclose protected health information, including medical information or provider name and address, relating to receipt of sensitive services, must be provided in the form and format requested by the individual patient receiving care.
(9) The commissioner may adopt rules to implement this section after considering relevant standards adopted by national managed care accreditation organizations and the national association of insurance commissioners, and after considering the effect of those standards on the ability of carriers to undertake enrollee care management and disease management programs.
[
2019 c 56 s 3
;
2000 c 5 s 5
.]
NOTES:
Findings
—
Declarations
—
Effective date
—
2019 c 56:
See notes following RCW 48.43.5051
.
Application
—
Short title
—
Captions not law
—
Construction
—
Severability
—
Application to contracts
—
Effective dates
—
2000 c 5:
See notes following RCW 48.43.500
.
RCW 48.43.5051
Requests for confidential communications
—
Monitoring and ensuring compliance
—
Standardized form for submission of requests
—
Rules.
(1) The commissioner shall:
(a) Develop a process for the regular collection of information from carriers on requests for confidential communications pursuant to RCW 48.43.505
for the purposes of monitoring compliance, including monitoring:
(i) The effectiveness of the process described in RCW 48.43.505
in allowing protected individuals to redirect insurance communications, the extent to which protected individuals are using the process, and whether the process is working properly; and
(ii) The education and outreach activities conducted by carriers to inform enrollees about their right to confidential communications;
(b) Establish a process for ensuring compliance; and
(c) Develop rules necessary to implement chapter 56, Laws of 2019.
(2) The commissioner shall work with stakeholders to develop and make available to the public a standardized form that a protected individual may submit to a carrier to make a confidential communications request. At minimum, this form must:
(a) Inform a protected individual about the protected individual's right to confidential communications;
(b) Allow a protected individual to indicate where to redirect communications, including a specified physical or email address or specified telephone number; and
(c) Include a disclaimer that it may take up to three business days from the date of receipt for a carrier to process the form.
[
2019 c 56 s 4
.]
NOTES:
Findings
—
Declarations
—
2019 c 56:
"The legislature finds and declares:
(1) All people deserve the right to choose the health services that are right for them, and the right to confidential access to those health services.
(2) When people are assured of the ability to confidentially access health care services, they are more likely to seek health services, disclose health risk behaviors to a clinician, and return for follow-up care.
(3) When denied confidential access to needed care, people may delay or forgo care, leading to higher rates of unprotected sex, unintended pregnancy, untreated sexually transmitted infections, and mental health issues, or they may turn to public health safety net funds or free clinics to receive confidential care—important resources that should be reserved for people who do not have insurance coverage." [
2019 c 56 s 1
.]
Effective date
—
2019 c 56:
"This act takes effect January 1, 2020." [
2019 c 56 s 8
.]
RCW 48.43.510
Carrier required to disclose health plan information
—
Marketing and advertising restrictions
—
Rules.
(1) A carrier that offers a health plan may not offer to sell a health plan to an enrollee or to any group representative, agent, employer, or enrollee representative without first offering to provide, and providing upon request, the following information before purchase or selection:
(a) A listing of covered benefits, including prescription drug benefits, if any, a copy of the current formulary, if any is used, definitions of terms such as generic versus brand name, and policies regarding coverage of drugs, such as how they become approved or taken off the formulary, and how consumers may be involved in decisions about benefits;
(b) A listing of exclusions, reductions, and limitations to covered benefits, and any definition of medical necessity or other coverage criteria upon which they may be based;
(c) A statement of the carrier's policies for protecting the confidentiality of health information;
(d) A statement of the cost of premiums and any enrollee cost-sharing requirements;
(e) A summary explanation of the carrier's review of adverse benefit determinations and grievance processes;
(f) A statement regarding the availability of a point-of-service option, if any, and how the option operates; and
(g) A convenient means of obtaining lists of participating primary care and specialty care providers, including disclosure of network arrangements that restrict access to providers within any plan network. The offer to provide the information referenced in this subsection (1) must be clearly and prominently displayed on any information provided to any prospective enrollee or to any prospective group representative, agent, employer, or enrollee representative.
(2) Upon the request of any person, including a current enrollee, prospective enrollee, or the insurance commissioner, a carrier must provide written information regarding any health care plan it offers, that includes the following written information:
(a) Any documents, instruments, or other information referred to in the medical coverage agreement;
(b) A full description of the procedures to be followed by an enrollee for consulting a provider other than the primary care provider and whether the enrollee's primary care provider, the carrier's medical director, or another entity must authorize the referral;
(c) Procedures, if any, that an enrollee must first follow for obtaining prior authorization for health care services;
(d) A written description of any reimbursement or payment arrangements, including, but not limited to, capitation provisions, fee-for-service provisions, and health care delivery efficiency provisions, between a carrier and a provider or network;
(e) Descriptions and justifications for provider compensation programs, including any incentives or penalties that are intended to encourage providers to withhold services or minimize or avoid referrals to specialists;
(f) An annual accounting of all payments made by the carrier which have been counted against any payment limitations, visit limitations, or other overall limitations on a person's coverage under a plan; however, the individual requesting an annual accounting may only receive information about that individual's own care, and may not receive information pertaining to protected individuals who have requested confidential communications pursuant to RCW 48.43.505
;
(g) A copy of the carrier's review of adverse benefit determinations grievance process for claim or service denial and its grievance process for dissatisfaction with care; and
(h) Accreditation status with one or more national managed care accreditation organizations, and whether the carrier tracks its health care effectiveness performance using the health employer data information set (HEDIS), whether it publicly reports its HEDIS data, and how interested persons can access its HEDIS data.
(3) Each carrier shall provide to all enrollees and prospective enrollees a list of available disclosure items.
(4) Nothing in this section requires a carrier or a health care provider to divulge proprietary information to an enrollee, including the specific contractual terms and conditions between a carrier and a provider.
(5) No carrier may advertise or market any health plan to the public as a plan that covers services that help prevent illness or promote the health of enrollees unless it:
(a) Provides all clinical preventive health services provided by the basic health plan, authorized by chapter
70.47
RCW;
(b) Monitors and reports annually to enrollees on standardized measures of health care and satisfaction of all enrollees in the health plan. The state department of health shall recommend appropriate standardized measures for this purpose, after consideration of national standardized measurement systems adopted by national managed care accreditation organizations and state agencies that purchase managed health care services; and
(c) Makes available upon request to enrollees its integrated plan to identify and manage the most prevalent diseases within its enrolled population, including cancer, heart disease, and stroke.
(6) No carrier may preclude or discourage its providers from informing an enrollee of the care he or she requires, including various treatment options, and whether in the providers' view such care is consistent with the plan's health coverage criteria, or otherwise covered by the enrollee's medical coverage agreement with the carrier. No carrier may prohibit, discourage, or penalize a provider otherwise practicing in compliance with the law from advocating on behalf of an enrollee with a carrier. Nothing in this section shall be construed to authorize a provider to bind a carrier to pay for any service.
(7) No carrier may preclude or discourage enrollees or those paying for their coverage from discussing the comparative merits of different carriers with their providers. This prohibition specifically includes prohibiting or limiting providers participating in those discussions even if critical of a carrier.
(8) Each carrier must communicate enrollee information required in chapter 5, Laws of 2000 by means that ensure that a substantial portion of the enrollee population can make use of the information. Carriers may implement alternative, efficient methods of communication to ensure enrollees have access to information including, but not limited to, website alerts, postcard mailings, and electronic communication in lieu of printed materials.
(9) The commissioner may adopt rules to implement this section. In developing rules to implement this section, the commissioner shall consider relevant standards adopted by national managed care accreditation organizations and state agencies that purchase managed health care services, as well as opportunities to reduce administrative costs included in health plans.
[
2019 c 56 s 5
;
2012 c 211 s 26
;
2009 c 304 s 1
;
2000 c 5 s 6
.]
NOTES:
Findings
—
Declarations
—
Effective date
—
2019 c 56:
See notes following RCW 48.43.5051
.
Application
—
Short title
—
Captions not law
—
Construction
—
Severability
—
Application to contracts
—
Effective dates
—
2000 c 5:
See notes following RCW 48.43.500
.
RCW 48.43.515
Access to appropriate health services
—
Enrollee options
—
Rules.
(1) Each enrollee in a health plan must have adequate choice among health care providers.
(2) Each carrier must allow an enrollee to choose a primary care provider who is accepting new enrollees from a list of participating providers. Enrollees also must be permitted to change primary care providers at any time with the change becoming effective no later than the beginning of the month following the enrollee's request for the change.
(3) Each carrier must have a process whereby an enrollee with a complex or serious medical or psychiatric condition may receive a standing referral to a participating specialist for an extended period of time.
(4) Each carrier must provide for appropriate and timely referral of enrollees to a choice of specialists within the plan if specialty care is warranted. If the type of medical specialist needed for a specific condition is not represented on the specialty panel, enrollees must have access to nonparticipating specialty health care providers.
(5) Each carrier shall provide enrollees with direct access to the participating chiropractor of the enrollee's choice for covered chiropractic health care without the necessity of prior referral. Nothing in this subsection shall prevent carriers from restricting enrollees to seeing only providers who have signed participating provider agreements or from utilizing other managed care and cost containment techniques and processes. For purposes of this subsection, "covered chiropractic health care" means covered benefits and limitations related to chiropractic health services as stated in the plan's medical coverage agreement, with the exception of any provisions related to prior referral for services.
(6) Each carrier must provide, upon the request of an enrollee, access by the enrollee to a second opinion regarding any medical diagnosis or treatment plan from a qualified participating provider of the enrollee's choice.
(7) Each carrier must cover services of a primary care provider whose contract with the plan or whose contract with a subcontractor is being terminated by the plan or subcontractor without cause under the terms of that contract for at least sixty days following notice of termination to the enrollees or, in group coverage arrangements involving periods of open enrollment, only until the end of the next open enrollment period. The provider's relationship with the carrier or subcontractor must be continued on the same terms and conditions as those of the contract the plan or subcontractor is terminating, except for any provision requiring that the carrier assign new enrollees to the terminated provider.
(8) Every carrier shall meet the standards set forth in this section and any rules adopted by the commissioner to implement this section. In developing rules to implement this section, the commissioner shall consider relevant standards adopted by national managed care accreditation organizations and state agencies that purchase managed health care services.
[
2000 c 5 s 7
.]
NOTES:
Application
—
Short title
—
Captions not law
—
Construction
—
Severability
—
Application to contracts
—
Effective dates
—
2000 c 5:
See notes following RCW 48.43.500
.
RCW 48.43.517
Enrollment of child participating in medical assistance program
—
Employer-sponsored health plan.
When the health care authority has determined that it is cost-effective to enroll a child participating in a medical assistance program under chapter
74.09
RCW in an employer-sponsored health plan, the carrier shall permit the enrollment of the participant who is otherwise eligible for coverage in the health plan without regard to any open enrollment restrictions. The request for special enrollment shall be made by the authority or participant within sixty days of the authority's determination that the enrollment would be cost-effective.
[
2011 1st sp.s. c 15 s 78
;
2007 c 5 s 7
.]
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
.
RCW 48.43.520
Requirement to maintain a documented utilization review program description and written utilization review criteria
—
Rules.
(Effective until January 1, 2027.)
(1) Carriers that offer a health plan shall maintain a documented utilization review program description and written utilization review criteria based on reasonable medical evidence. The program must include a method for reviewing and updating criteria. Carriers shall make clinical protocols, medical management standards, and other review criteria available upon request to participating providers.
(2) The commissioner shall adopt, in rule, standards for this section after considering relevant standards adopted by national managed care accreditation organizations and state agencies that purchase managed health care services.
(3) A carrier shall not be required to use medical evidence or standards in its utilization review of religious nonmedical treatment or religious nonmedical nursing care.
[
2000 c 5 s 8
.]
NOTES:
Application
—
Short title
—
Captions not law
—
Construction
—
Severability
—
Application to contracts
—
Effective dates
—
2000 c 5:
See notes following RCW 48.43.500
.
PDF
RCW 48.43.520
Requirement to maintain a documented utilization review program description and written utilization review and clinical review criteria
—
Rules.
(Effective January 1, 2027.)
(1) Carriers that offer a health plan shall maintain a documented utilization review program description and written utilization review and clinical review criteria based on reasonable medical evidence. For mental health and substance use disorder services, as defined in RCW 48.43.766, clinical review criteria must meet the requirements of RCW 48.43.766
. The program must include a method for reviewing and updating criteria. Carriers shall make clinical protocols, medical management standards, clinical review criteria as defined in RCW 48.43.766, and other review criteria available upon request to participating providers.
(2) The commissioner shall adopt, in rule, standards for this section after considering relevant standards adopted by national managed care accreditation organizations and state agencies that purchase managed health care services.
(3) A carrier shall not be required to use medical evidence or standards in its utilization review of religious nonmedical treatment or religious nonmedical nursing care.
[
2025 c 227 s 5
;
2000 c 5 s 8
.]
NOTES:
Effective date
—
2025 c 227 ss 1-8:
See note following RCW 48.43.766
.
Findings
—
Intent
—
Rules
—
2025 c 227:
See notes following RCW 48.43.766
.
Application
—
Short title
—
Captions not law
—
Construction
—
Severability
—
Application to contracts
—
Effective dates
—
2000 c 5:
See notes following RCW 48.43.500
.
RCW 48.43.525
Prohibition against retrospective denial of health plan coverage
—
Rules.
(1) A health carrier that offers a health plan shall not retrospectively deny coverage for emergency and nonemergency care that had prior authorization under the plan's written policies at the time the care was rendered.
(2) The commissioner shall adopt, in rule, standards for this section after considering relevant standards adopted by national managed care accreditation organizations and state agencies that purchase managed health care services.
[
2000 c 5 s 9
.]
NOTES:
Application
—
Short title
—
Captions not law
—
Construction
—
Severability
—
Application to contracts
—
Effective dates
—
2000 c 5:
See notes following RCW 48.43.500
.
RCW 48.43.530
Requirement for carriers to have comprehensive grievance and appeal processes
—
Carrier's duties
—
Procedures
—
Appeals
—
Rules.
(1) Each carrier and health plan must have fully operational, comprehensive grievance and appeal processes, and for plans that are not grandfathered, fully operational, comprehensive, and effective grievance and review of adverse benefit determination processes that comply with the requirements of this section and any rules adopted by the commissioner to implement this section. For the purposes of this section, the commissioner must consider applicable grievance and appeal or review of adverse benefit determination process standards adopted by national managed care accreditation organizations and state agencies that purchase managed health care services, and for health plans that are not grandfathered health plans as approved by the United States department of health and human services or the United States department of labor. In the case of coverage offered in connection with a group health plan, if either the carrier or the health plan complies with the requirements of this section and RCW 48.43.535, then the obligation to comply is satisfied for both the carrier and the plan with respect to the health insurance coverage.
(2) Each carrier and health plan must process as a grievance an enrollee's expression of dissatisfaction about customer service or the quality or availability of a health service. Each carrier must implement procedures for registering and responding to oral and written grievances in a timely and thorough manner.
(3) Each carrier and health plan must provide written notice to an enrollee or the enrollee's designated representative, and the enrollee's provider, of its decision to deny, modify, reduce, or terminate payment, coverage, authorization, or provision of health care services or benefits, including the admission to or continued stay in a health care facility. Such notice must be sent directly to a protected individual receiving care when accessing sensitive health care services or when a protected individual has requested confidential communication pursuant to RCW 48.43.505
(5).
(4) An enrollee's written or oral request that a carrier reconsider its decision to deny, modify, reduce, or terminate payment, coverage, authorization, or provision of health care services or benefits, including the admission to, or continued stay in, a health care facility must be processed as follows:
(a) When the request is made under a grandfathered health plan, the plan and the carrier must process it as an appeal;
(b) When the request is made under a health plan that is not grandfathered, the plan and the carrier must process it as a review of an adverse benefit determination; and
(c) Neither a carrier nor a health plan, whether grandfathered or not, may require that an enrollee file a complaint or grievance prior to seeking appeal of a decision or review of an adverse benefit determination under this subsection.
(5) To process an appeal, each plan that is not grandfathered and each carrier offering that plan must:
(a) Provide written notice to the enrollee when the appeal is received;
(b) Assist the enrollee with the appeal process;
(c) Make its decision regarding the appeal within thirty days of the date the appeal is received. An appeal must be expedited if the enrollee's provider or the carrier's medical director reasonably determines that following the appeal process response timelines could seriously jeopardize the enrollee's life, health, or ability to regain maximum function. The decision regarding an expedited appeal must be made within seventy-two hours of the date the appeal is received;
(d) Cooperate with a representative authorized in writing by the enrollee;
(e) Consider information submitted by the enrollee;
(f) Investigate and resolve the appeal; and
(g) Provide written notice of its resolution of the appeal to the enrollee and, with the permission of the enrollee, to the enrollee's providers. The written notice must explain the carrier's and health plan's decision and the supporting coverage or clinical reasons and the enrollee's right to request independent review of the carrier's decision under RCW 48.43.535
.
(6) Written notice required by subsection (3) of this section must explain:
(a) The carrier's and health plan's decision and the supporting coverage or clinical reasons; and
(b) The carrier's and grandfathered plan's appeal or for plans that are not grandfathered, adverse benefit determination review process, including information, as appropriate, about how to exercise the enrollee's rights to obtain a second opinion, and how to continue receiving services as provided in this section.
(7) When an enrollee requests that the carrier or health plan reconsider its decision to modify, reduce, or terminate an otherwise covered health service that an enrollee is receiving through the health plan and the carrier's or health plan's decision is based upon a finding that the health service, or level of health service, is no longer medically necessary or appropriate, the carrier and health plan must continue to provide that health service until the appeal, or for health plans that are not grandfathered, the review of an adverse benefit determination, is resolved. If the resolution of the appeal, review of an adverse benefit determination, or any review sought by the enrollee under RCW 48.43.535
affirms the carrier's or health plan's decision, the enrollee may be responsible for the cost of this continued health service.
(8) Each carrier and health plan must provide a clear explanation of the grievance and appeal, or for plans that are not grandfathered, the process for review of an adverse benefit determination process upon request, upon enrollment to new enrollees, and annually to enrollees and subcontractors.
(9) Each carrier and health plan must ensure that each grievance, appeal, and for plans that are not grandfathered, grievance and review of adverse benefit determinations, process is accessible to enrollees who are limited English speakers, who have literacy problems, or who have physical or mental disabilities that impede their ability to file a grievance, appeal or review of an adverse benefit determination.
(10)(a) Each plan that is not grandfathered and the carrier that offers it must: Track each appeal until final resolution; maintain, and make accessible to the commissioner for a period of three years, a log of all appeals; and identify and evaluate trends in appeals.
(b) Each grandfathered plan and the carrier that offers it must: Track each review of an adverse benefit determination until final resolution; maintain and make accessible to the commissioner, for a period of six years, a log of all such determinations; and identify and evaluate trends in requests for and resolution of review of adverse benefit determinations.
(11) In complying with this section, plans that are not grandfathered and the carriers offering them must treat a rescission of coverage, whether or not the rescission has an adverse effect on any particular benefit at that time, and any decision to deny coverage in an initial eligibility determination as an adverse benefit determination.
[
2019 c 56 s 6
;
2012 c 211 s 20
;
2011 c 314 s 4
;
2000 c 5 s 10
.]
NOTES:
Findings
—
Declarations
—
Effective date
—
2019 c 56:
See notes following RCW 48.43.5051
.
Application
—
Short title
—
Captions not law
—
Construction
—
Severability
—
Application to contracts
—
Effective dates
—
2000 c 5:
See notes following RCW 48.43.500
.
RCW 48.43.535
Independent review of health care disputes
—
System for using certified independent review organizations
—
Rules.
(Effective until January 1, 2027.)
(1) There is a need for a process for the fair consideration of disputes relating to decisions by carriers that offer a health plan to deny, modify, reduce, or terminate coverage of or payment for health care services for an enrollee. For purposes of this section, "carrier" also applies to a health plan if the health plan administers the appeal process directly or through a third party.
(2) An enrollee may seek review by a certified independent review organization of a carrier's decision to deny, modify, reduce, or terminate coverage of or payment for a health care service or of any adverse determination made by a carrier under RCW 48.49.020, 48.49.030, or sections 2799A-1 or 2799A-2 of the public health service act (42 U.S.C. Secs. 300gg-111 or 300gg-112) and implementing federal regulations in effect as of March 31, 2022, after exhausting the carrier's grievance process and receiving a decision that is unfavorable to the enrollee, or after the carrier has exceeded the timelines for grievances provided in RCW 48.43.530, without good cause and without reaching a decision.
(3) The commissioner must establish and use a rotational registry system for the assignment of a certified independent review organization to each dispute. The system should be flexible enough to ensure that an independent review organization has the expertise necessary to review the particular medical condition or service at issue in the dispute, and that any approved independent review organization does not have a conflict of interest that will influence its independence.
(4) Carriers must provide to the appropriate certified independent review organization, not later than the third business day after the date the carrier receives a request for review, a copy of:
(a) Any medical records of the enrollee that are relevant to the review;
(b) Any documents used by the carrier in making the determination to be reviewed by the certified independent review organization;
(c) Any documentation and written information submitted to the carrier in support of the appeal; and
(d) A list of each physician or health care provider who has provided care to the enrollee and who may have medical records relevant to the appeal. Health information or other confidential or proprietary information in the custody of a carrier may be provided to an independent review organization, subject to rules adopted by the commissioner.
(5) Enrollees must be provided with at least five business days to submit to the independent review organization in writing additional information that the independent review organization must consider when conducting the external review. The independent review organization must forward any additional information submitted by an enrollee to the plan or carrier within one business day of receipt by the independent review organization.
(6) The medical reviewers from a certified independent review organization will make determinations regarding the medical necessity or appropriateness of, and the application of health plan coverage provisions to, health care services for an enrollee. The medical reviewers' determinations must be based upon their expert medical judgment, after consideration of relevant medical, scientific, and cost-effectiveness evidence, and medical standards of practice in the state of Washington. Except as provided in this subsection, the certified independent review organization must ensure that determinations are consistent with the scope of covered benefits as outlined in the medical coverage agreement. Medical reviewers may override the health plan's medical necessity or appropriateness standards if the standards are determined upon review to be unreasonable or inconsistent with sound, evidence-based medical practice.
(7) Once a request for an independent review determination has been made, the independent review organization must proceed to a final determination, unless requested otherwise by both the carrier and the enrollee or the enrollee's representative.
(a) An enrollee or carrier may request an expedited external review if the adverse benefit determination or internal adverse benefit determination concerns an admission, availability of care, continued stay, or health care service for which the claimant received emergency services but has not been discharged from a facility; or involves a medical condition for which the standard external review time frame would seriously jeopardize the life or health of the enrollee or jeopardize the enrollee's ability to regain maximum function. The independent review organization must make its decision to uphold or reverse the adverse benefit determination or final internal adverse benefit determination and notify the enrollee and the carrier or health plan of the determination as expeditiously as possible but within not more than seventy-two hours after the receipt of the request for expedited external review. If the notice is not in writing, the independent review organization must provide written confirmation of the decision within forty-eight hours after the date of the notice of the decision.
(b) For claims involving experimental or investigational treatments, the independent review organization must ensure that adequate clinical and scientific experience and protocols are taken into account as part of the external review process.
(8) Carriers must timely implement the certified independent review organization's determination, and must pay the certified independent review organization's charges.
(9) When an enrollee requests independent review of a dispute under this section, and the dispute involves a carrier's decision to modify, reduce, or terminate an otherwise covered health service that an enrollee is receiving at the time the request for review is submitted and the carrier's decision is based upon a finding that the health service, or level of health service, is no longer medically necessary or appropriate, the carrier must continue to provide the health service if requested by the enrollee until a determination is made under this section. If the determination affirms the carrier's decision, the enrollee may be responsible for the cost of the continued health service.
(10) Each certified independent review organization must maintain written records and make them available upon request to the commissioner.
(11) A certified independent review organization may notify the office of the insurance commissioner if, based upon its review of disputes under this section, it finds a pattern of substandard or egregious conduct by a carrier.
(12)(a) The commissioner shall adopt rules to implement this section after considering relevant standards adopted by national managed care accreditation organizations and the national association of insurance commissioners.
(b) This section is not intended to supplant any existing authority of the office of the insurance commissioner under this title to oversee and enforce carrier compliance with applicable statutes and rules.
[
2022 c 263 s 4
;
2012 c 211 s 21
;
2011 c 314 s 5
;
2000 c 5 s 11
.]
NOTES:
Effective date
—
2022 c 263:
See note following RCW 43.371.100
.
Application
—
Short title
—
Captions not law
—
Construction
—
Severability
—
Application to contracts
—
Effective dates
—
2000 c 5:
See notes following RCW 48.43.500
.
PDF
RCW 48.43.535
Independent review of health care disputes
—
System for using certified independent review organizations
—
Rules.
(Effective January 1, 2027.)
(1) There is a need for a process for the fair consideration of disputes relating to decisions by carriers that offer a health plan to deny, modify, reduce, or terminate coverage of or payment for health care services for an enrollee. For purposes of this section, "carrier" also applies to a health plan if the health plan administers the appeal process directly or through a third party.
(2) An enrollee may seek review by a certified independent review organization of a carrier's decision to deny, modify, reduce, or terminate coverage of or payment for a health care service or of any adverse determination made by a carrier under RCW 48.49.020, 48.49.030, or sections 2799A-1 or 2799A-2 of the public health service act (42 U.S.C. Secs. 300gg-111 or 300gg-112) and implementing federal regulations in effect as of March 31, 2022, after exhausting the carrier's grievance process and receiving a decision that is unfavorable to the enrollee, or after the carrier has exceeded the timelines for grievances provided in RCW 48.43.530, without good cause and without reaching a decision.
(3) The commissioner must establish and use a rotational registry system for the assignment of a certified independent review organization to each dispute. The system should be flexible enough to ensure that an independent review organization has the expertise necessary to review the particular medical condition or service at issue in the dispute, and that any approved independent review organization does not have a conflict of interest that will influence its independence.
(4) Carriers must provide to the appropriate certified independent review organization, not later than the third business day after the date the carrier receives a request for review, a copy of:
(a) Any medical records of the enrollee that are relevant to the review;
(b) Any documents used by the carrier in making the determination to be reviewed by the certified independent review organization;
(c) Any documentation and written information submitted to the carrier in support of the appeal; and
(d) A list of each physician or health care provider who has provided care to the enrollee and who may have medical records relevant to the appeal. Health information or other confidential or proprietary information in the custody of a carrier may be provided to an independent review organization, subject to rules adopted by the commissioner.
(5) Enrollees must be provided with at least five business days to submit to the independent review organization in writing additional information that the independent review organization must consider when conducting the external review. The independent review organization must forward any additional information submitted by an enrollee to the plan or carrier within one business day of receipt by the independent review organization.
(6) The medical reviewers from a certified independent review organization will make determinations regarding the medical necessity or appropriateness of, and the application of health plan coverage provisions to, health care services for an enrollee. The medical reviewers' determinations must be based upon their expert medical judgment, after consideration of relevant medical, scientific, and cost-effectiveness evidence, and medical standards of practice in the state of Washington. Except as provided in this subsection, the certified independent review organization must ensure that determinations are consistent with the scope of covered benefits as outlined in the medical coverage agreement. Medical reviewers may override the health plan's medical necessity or appropriateness standards if the standards are determined upon review to be unreasonable or inconsistent with sound, evidence-based medical practice. For reviews of mental health and substance use disorder services, as defined in RCW 48.43.766, the medical reviewers must conduct reviews and make determinations in a manner consistent with the requirements of RCW 48.43.766
.
(7) Once a request for an independent review determination has been made, the independent review organization must proceed to a final determination, unless requested otherwise by both the carrier and the enrollee or the enrollee's representative.
(a) An enrollee or carrier may request an expedited external review if the adverse benefit determination or internal adverse benefit determination concerns an admission, availability of care, continued stay, or health care service for which the claimant received emergency services but has not been discharged from a facility; or involves a medical condition for which the standard external review time frame would seriously jeopardize the life or health of the enrollee or jeopardize the enrollee's ability to regain maximum function. The independent review organization must make its decision to uphold or reverse the adverse benefit determination or final internal adverse benefit determination and notify the enrollee and the carrier or health plan of the determination as expeditiously as possible but within not more than seventy-two hours after the receipt of the request for expedited external review. If the notice is not in writing, the independent review organization must provide written confirmation of the decision within forty-eight hours after the date of the notice of the decision.
(b) For claims involving experimental or investigational treatments, the independent review organization must ensure that adequate clinical and scientific experience and protocols are taken into account as part of the external review process.
(8) Carriers must timely implement the certified independent review organization's determination, and must pay the certified independent review organization's charges.
(9) When an enrollee requests independent review of a dispute under this section, and the dispute involves a carrier's decision to modify, reduce, or terminate an otherwise covered health service that an enrollee is receiving at the time the request for review is submitted and the carrier's decision is based upon a finding that the health service, or level of health service, is no longer medically necessary or appropriate, the carrier must continue to provide the health service if requested by the enrollee until a determination is made under this section. If the determination affirms the carrier's decision, the enrollee may be responsible for the cost of the continued health service.
(10) Each certified independent review organization must maintain written records and make them available upon request to the commissioner.
(11) A certified independent review organization may notify the office of the insurance commissioner if, based upon its review of disputes under this section, it finds a pattern of substandard or egregious conduct by a carrier.
(12)(a) The commissioner shall adopt rules to implement this section after considering relevant standards adopted by national managed care accreditation organizations and the national association of insurance commissioners.
(b) This section is not intended to supplant any existing authority of the office of the insurance commissioner under this title to oversee and enforce carrier compliance with applicable statutes and rules.
[
2025 c 227 s 6
;
2022 c 263 s 4
;
2012 c 211 s 21
;
2011 c 314 s 5
;
2000 c 5 s 11
.]
NOTES:
Effective date
—
2025 c 227 ss 1-8:
See note following RCW 48.43.766
.
Findings
—
Intent
—
Rules
—
2025 c 227:
See notes following RCW 48.43.766
.
Effective date
—
2022 c 263:
See note following RCW 43.371.100
.
Application
—
Short title
—
Captions not law
—
Construction
—
Severability
—
Application to contracts
—
Effective dates
—
2000 c 5:
See notes following RCW 48.43.500
.
RCW 48.43.537
Health care disputes
—
Certifying independent review organizations
—
Application
—
Restrictions
—
Maximum fee schedule for conducting reviews
—
Rules.
(1) No later than January 1, 2017, the insurance commissioner shall adopt rules providing a procedure and criteria for certifying one or more organizations to perform independent review of health care disputes described in RCW 48.43.535
.
(2) The rules must require that the organization ensure:
(a) The confidentiality of medical records transmitted to an independent review organization for use in independent reviews;
(b) That each health care provider, physician, or contract specialist making review determinations for an independent review organization is qualified. Physicians, other health care providers, and, if applicable, contract specialists must be appropriately licensed, certified, or registered as required in Washington state or in at least one state with standards substantially comparable to Washington state. Reviewers may be drawn from nationally recognized centers of excellence, academic institutions, and recognized leading practice sites. Expert medical reviewers should have substantial, recent clinical experience dealing with the same or similar health conditions. The organization must have demonstrated expertise and a history of reviewing health care in terms of medical necessity, appropriateness, and the application of other health plan coverage provisions;
(c) That any physician, health care provider, or contract specialist making a review determination in a specific review is free of any actual or potential conflict of interest or bias. Neither the expert reviewer, nor the independent review organization, nor any officer, director, or management employee of the independent review organization may have any material professional, familial, or financial affiliation with any of the following: The health carrier; professional associations of carriers and providers; the provider; the provider's medical or practice group; the health facility at which the service would be provided; the developer or manufacturer of a drug or device under review; or the enrollee;
(d) The fairness of the procedures used by the independent review organization in making the determinations;
(e) That each independent review organization make its determination:
(i) Not later than the earlier of:
(A) The fifteenth day after the date the independent review organization receives the information necessary to make the determination; or
(B) The twentieth day after the date the independent review organization receives the request that the determination be made. In exceptional circumstances, when the independent review organization has not obtained information necessary to make a determination, a determination may be made by the twenty-fifth day after the date the organization received the request for the determination; and
(ii) In requests for expedited review under RCW 48.43.535
(7)(a), as expeditiously as possible but within not more than seventy-two hours after the date the independent review organization receives the request for expedited review;
(f) That timely notice is provided to enrollees of the results of the independent review, including the clinical basis for the determination;
(g) That the independent review organization has a quality assurance mechanism in place that ensures the timeliness and quality of review and communication of determinations to enrollees and carriers, and the qualifications, impartiality, and freedom from conflict of interest of the organization, its staff, and expert reviewers; and
(h) That the independent review organization meets any other reasonable requirements of the insurance commissioner directly related to the functions the organization is to perform under this section and RCW 48.43.535, and related to assessing fees to carriers in a manner consistent with the maximum fee schedule developed under this section.
(3) To be certified as an independent review organization under this chapter, an organization must submit to the insurance commissioner an application in the form required by the insurance commissioner. The application must include:
(a) For an applicant that is publicly held, the name of each stockholder or owner of more than five percent of any stock or options;
(b) The name of any holder of bonds or notes of the applicant that exceed one hundred thousand dollars;
(c) The name and type of business of each corporation or other organization that the applicant controls or is affiliated with and the nature and extent of the affiliation or control;
(d) The name and a biographical sketch of each director, officer, and executive of the applicant and any entity listed under (c) of this subsection and a description of any relationship the named individual has with:
(i) A carrier;
(ii) A utilization review agent;
(iii) A nonprofit or for-profit health corporation;
(iv) A health care provider;
(v) A drug or device manufacturer; or
(vi) A group representing any of the entities described by (d)(i) through (v) of this subsection;
(e) The percentage of the applicant's revenues that are anticipated to be derived from reviews conducted under RCW 48.43.535
;
(f) A description of the areas of expertise of the health care professionals and contract specialists making review determinations for the applicant; and
(g) The procedures to be used by the independent review organization in making review determinations regarding reviews conducted under RCW 48.43.535
.
(4) If at any time there is a material change in the information included in the application under subsection (3) of this section, the independent review organization shall submit updated information to the insurance commissioner.
(5) An independent review organization may not be a subsidiary of, or in any way owned or controlled by, a carrier or a trade or professional association of health care providers or carriers.
(6) An independent review organization, and individuals acting on its behalf, are immune from suit in a civil action when performing functions under chapter 5, Laws of 2000. However, this immunity does not apply to an act or omission made in bad faith or that involves gross negligence.
(7) Independent review organizations must be free from interference by state government in its functioning except as provided in subsection (8) of this section.
(8) The rules adopted under this section shall include provisions for terminating the certification of an independent review organization for failure to comply with the requirements for certification. The insurance commissioner may review the operation and performance of an independent review organization in response to complaints or other concerns about compliance. The rules adopted under this section must include a reasonable maximum fee schedule that independent review organizations shall use to assess carriers for conducting reviews authorized under RCW 48.43.535
.
(9) In adopting rules for this section, the insurance commissioner shall take into consideration rules adopted by the department of health that regulate independent review organizations and standards for independent review organizations adopted by national accreditation organizations. The insurance commissioner may accept national accreditation or certification by another state as evidence that an organization satisfies some or all of the requirements for certification by the insurance commissioner as an independent review organization.
(10) The rules adopted under this section must require independent review organizations to report decisions and associated information directly to the insurance commissioner.
[
2016 c 139 s 1
;
2012 c 211 s 14
;
2005 c 54 s 1
;
2000 c 5 s 12
. Formerly RCW 43.70.235
.]
NOTES:
Savings clause
—
Automatic certification
—
2016 c 139:
"(1) Independent review organizations remain subject to RCW 48.43.537, as it existed on January 1, 2016, and the rules adopted by the department of health under that section through December 31, 2016. Beginning on January 1, 2017, the insurance commissioner is the sole certifying authority for independent review organizations under RCW 48.43.537
.
(2) On January 1, 2017, the insurance commissioner shall automatically certify each independent review organization that was certified in good standing by the department of health on December 31, 2016." [
2016 c 139 s 2
.]
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 48.43.540
Requirement to designate a licensed medical director
—
Exemption.
Any carrier that offers a health plan and any self-insured health plan subject to the jurisdiction of Washington state shall designate a medical director who is licensed under chapter
18.57
or
18.71
RCW. However, a naturopathic or complementary alternative health plan, which provides solely complementary alternative health care to individuals, groups, or health plans, may have a medical director licensed under chapter
18.36A
RCW. A carrier that offers dental only coverage shall designate a dental director who is licensed under chapter
18.32
RCW, or licensed in a state that has been determined by the dental quality assurance commission to have substantially equivalent licensing standards to those of Washington. A health plan or self-insured health plan that offers only religious nonmedical treatment or religious nonmedical nursing care shall not be required to have a medical director.
[
2002 c 103 s 1
;
2000 c 5 s 13
.]
NOTES:
Application
—
Short title
—
Captions not law
—
Construction
—
Severability
—
Application to contracts
—
Effective dates
—
2000 c 5:
See notes following RCW 48.43.500
.
RCW 48.43.545
Standard of care
—
Liability
—
Causes of action
—
Defense
—
Exception.
(1)(a) A health carrier shall adhere to the accepted standard of care for health care providers under chapter
7.70
RCW when arranging for the provision of medically necessary health care services to its enrollees. A health carrier shall be liable for any and all harm proximately caused by its failure to follow that standard of care when the failure resulted in the denial, delay, or modification of the health care service recommended for, or furnished to, an enrollee.
(b) A health carrier is also liable for damages under (a) of this subsection for harm to an enrollee proximately caused by health care treatment decisions that result from a failure to follow the accepted standard of care made by its:
(i) Employees;
(ii) Agents; or
(iii) Ostensible agents who are acting on its behalf and over whom it has the right to exercise influence or control or has actually exercised influence or control.
(2) The provisions of this section may not be waived, shifted, or modified by contract or agreement and responsibility for the provisions shall be a duty that cannot be delegated. Any effort to waive, modify, delegate, or shift liability for a breach of the duty established by this section, through a contract for indemnification or otherwise, is invalid.
(3) This section does not create any new cause of action, or eliminate any presently existing cause of action, with respect to health care providers and health care facilities that are included in and subject to the provisions of chapter
7.70
RCW.
(4) It is a defense to any action or liability asserted under this section against a health carrier that:
(a) The health care service in question is not a benefit provided under the plan or the service is subject to limitations under the plan that have been exhausted;
(b) Neither the health carrier, nor any employee, agent, or ostensible agent for whose conduct the health carrier is liable under subsection (1)(b) of this section, controlled, influenced, or participated in the health care decision; or
(c) The health carrier did not deny or unreasonably delay payment for treatment prescribed or recommended by a participating health care provider for the enrollee.
(5) This section does not create any liability on the part of an employer, an employer group purchasing organization that purchases coverage or assumes risk on behalf of its employers, or a governmental agency that purchases coverage on behalf of individuals and families. The governmental entity established to offer and provide health insurance to public employees, public retirees, and their covered dependents under RCW 41.05.140
is subject to liability under this section.
(6) Nothing in any law of this state prohibiting a health carrier from practicing medicine or being licensed to practice medicine may be asserted as a defense by the health carrier in an action brought against it under this section.
(7)(a) A person may not maintain a cause of action under this section against a health carrier unless:
(i) The affected enrollee has suffered substantial harm. As used in this subsection, "substantial harm" means loss of life, loss or significant impairment of limb, bodily or cognitive function, significant disfigurement, or severe or chronic physical pain; and
(ii) The affected enrollee or the enrollee's representative has exercised the opportunity established in RCW 48.43.535
to seek independent review of the health care treatment decision.
(b) This subsection (7) does not prohibit an enrollee from pursuing other appropriate remedies, including injunctive relief, a declaratory judgment, or other relief available under law, if its requirements place the enrollee's health in serious jeopardy.
(8) In an action against a health carrier, a finding that a health care provider is an employee, agent, or ostensible agent of such a health carrier shall not be based solely on proof that the person's name appears in a listing of approved physicians or health care providers made available to enrollees under a health plan.
(9) Any action under this section shall be commenced within three years of the completion of the independent review process.
(10) This section does not apply to workers' compensation insurance under Title
51
RCW.
[
2000 c 5 s 17
.]
NOTES:
Application
—
Short title
—
Captions not law
—
Construction
—
Severability
—
Application to contracts
—
Effective dates
—
2000 c 5:
See notes following RCW 48.43.500
.
RCW 48.43.550
Delegation of duties
—
Carrier accountability.
Each carrier is accountable for and must oversee any activities required by chapter 5, Laws of 2000 that it delegates to any subcontractor. No contract with a subcontractor executed by the health carrier or the subcontractor may relieve the health carrier of its obligations to any enrollee for the provision of health care services or of its responsibility for compliance with statutes or rules.
[
2000 c 5 s 18
.]
NOTES:
Application
—
Short title
—
Captions not law
—
Construction
—
Severability
—
Application to contracts
—
Effective dates
—
2000 c 5:
See notes following RCW 48.43.500
.
RCW 48.43.600
Overpayment recovery
—
Carrier.
(Effective until January 1, 2027.)
(1) Except in the case of fraud, or as provided in subsections (2) and (3) of this section, a carrier may not: (a) Request a refund from a health care provider of a payment previously made to satisfy a claim unless it does so in writing to the provider within twenty-four months after the date that the payment was made; or (b) request that a contested refund be paid any sooner than six months after receipt of the request. Any such request must specify why the carrier believes the provider owes the refund. If a provider fails to contest the request in writing to the carrier within thirty days of its receipt, the request is deemed accepted and the refund must be paid.
(2) A carrier may not, if doing so for reasons related to coordination of benefits with another carrier or entity responsible for payment of a claim: (a) Request a refund from a health care provider of a payment previously made to satisfy a claim unless it does so in writing to the provider within thirty months after the date that the payment was made; or (b) request that a contested refund be paid any sooner than six months after receipt of the request. Any such request must specify why the carrier believes the provider owes the refund, and include the name and mailing address of the entity that has primary responsibility for payment of the claim. If a provider fails to contest the request in writing to the carrier within thirty days of its receipt, the request is deemed accepted and the refund must be paid.
(3) A carrier may at any time request a refund from a health care provider of a payment previously made to satisfy a claim if: (a) A third party, including a government entity, is found responsible for satisfaction of the claim as a consequence of liability imposed by law, such as tort liability; and (b) the carrier is unable to recover directly from the third party because the third party has either already paid or will pay the provider for the health services covered by the claim.
(4) If a contract between a carrier and a health care provider conflicts with this section, this section shall prevail. However, nothing in this section prohibits a health care provider from choosing at any time to refund to a carrier any payment previously made to satisfy a claim.
(5) For purposes of this section, "refund" means the return, either directly or through an offset to a future claim, of some or all of a payment already received by a health care provider.
(6) This section neither permits nor precludes a carrier from recovering from a subscriber, enrollee, or beneficiary any amounts paid to a health care provider for benefits to which the subscriber, enrollee, or beneficiary was not entitled under the terms and conditions of the health plan, insurance policy, or other benefit agreement.
(7) This section does not apply to claims for health care services provided through dental only health carriers, health care services provided under Title XVIII (medicare) of the social security act, or medicare supplemental plans regulated under chapter
48.66
RCW.
[
2005 c 278 s 1
.]
NOTES:
Application
—
2005 c 278:
"This act applies to contracts issued or renewed on or after January 1, 2006." [
2005 c 278 s 3
.]
PDF
RCW 48.43.600
Overpayment recovery
—
Carrier.
(Effective January 1, 2027.)
(1) Except in the case of fraud, or as provided in subsections (2) and (3) of this section, a carrier may not: (a) Request a refund from a health care provider of a payment previously made to satisfy a claim unless it does so in writing to the provider within twenty-four months after the date that the payment was made or, in the case of mental health and substance use disorder services as defined in RCW 48.43.766, within six months after the date the payment was made; or (b) request that a contested refund be paid any sooner than six months after receipt of the request. Any such request must specify why the carrier believes the provider owes the refund. If a provider fails to contest the request in writing to the carrier within thirty days of its receipt, the request is deemed accepted and the refund must be paid.
(2) A carrier may not, if doing so for reasons related to coordination of benefits with another carrier or entity responsible for payment of a claim: (a) Request a refund from a health care provider of a payment previously made to satisfy a claim unless it does so in writing to the provider within thirty months after the date that the payment was made or, in the case of mental health and substance use disorder services as defined in RCW 48.43.766, within nine months after the date the payment was made; or (b) request that a contested refund be paid any sooner than six months after receipt of the request. Any such request must specify why the carrier believes the provider owes the refund, and include the name and mailing address of the entity that has primary responsibility for payment of the claim. If a provider fails to contest the request in writing to the carrier within thirty days of its receipt, the request is deemed accepted and the refund must be paid.
(3) A carrier may at any time request a refund from a health care provider of a payment previously made to satisfy a claim if: (a) A third party, including a government entity, is found responsible for satisfaction of the claim as a consequence of liability imposed by law, such as tort liability; and (b) the carrier is unable to recover directly from the third party because the third party has either already paid or will pay the provider for the health services covered by the claim.
(4) If a contract between a carrier and a health care provider conflicts with this section, this section shall prevail. However, nothing in this section prohibits a health care provider from choosing at any time to refund to a carrier any payment previously made to satisfy a claim.
(5) For purposes of this section, "refund" means the return, either directly or through an offset to a future claim, of some or all of a payment already received by a health care provider.
(6) This section neither permits nor precludes a carrier from recovering from a subscriber, enrollee, or beneficiary any amounts paid to a health care provider for benefits to which the subscriber, enrollee, or beneficiary was not entitled under the terms and conditions of the health plan, insurance policy, or other benefit agreement.
(7) This section does not apply to claims for health care services provided through dental only health carriers, health care services provided under Title XVIII (medicare) of the social security act, or medicare supplemental plans regulated under chapter
48.66
RCW.
[
2025 c 227 s 7
;
2005 c 278 s 1
.]
NOTES:
Effective date
—
2025 c 227 ss 1-8:
See note following RCW 48.43.766
.
Findings
—
Intent
—
Rules
—
2025 c 227:
See notes following RCW 48.43.766
.
Application
—
2005 c 278:
"This act applies to contracts issued or renewed on or after January 1, 2006." [
2005 c 278 s 3
.]
RCW 48.43.605
Overpayment recovery
—
Health care provider.
(1) Except in the case of fraud, or as provided in subsection (2) of this section, a health care provider may not: (a) Request additional payment from a carrier to satisfy a claim unless he or she does so in writing to the carrier within twenty-four months after the date that the claim was denied or payment intended to satisfy the claim was made; or (b) request that the additional payment be made any sooner than six months after receipt of the request. Any such request must specify why the provider believes the carrier owes the additional payment.
(2) A health care provider may not, if doing so for reasons related to coordination of benefits with another carrier or entity responsible for payment of a claim: (a) Request additional payment from a carrier to satisfy a claim unless he or she does so in writing to the carrier within thirty months after the date the claim was denied or payment intended to satisfy the claim was made; or (b) request that the additional payment be made any sooner than six months after receipt of the request. Any such request must specify why the provider believes the carrier owes the additional payment, and include the name and mailing address of any entity that has disclaimed responsibility for payment of the claim.
(3) If a contract between a carrier and a health care provider conflicts with this section, this section shall prevail. However, nothing in this section prohibits a carrier from choosing at any time to make additional payments to a provider to satisfy a claim.
(4) This section does not apply to claims for health care services provided through dental only health carriers, health care services provided under Title XVIII (medicare) of the social security act, or medicare supplemental plans regulated under chapter
48.66
RCW.
[
2005 c 278 s 2
.]
NOTES:
Application
—
2005 c 278:
See note following RCW 48.43.600
.
RCW 48.43.670
Plan or contract renewal
—
Modification of wellness program.
Upon the renewal date of an individual or group health benefit plan or contract containing health benefits, the modification of a wellness program, as defined in 45 C.F.R. 146.121(f), included in such a plan or contract shall not be considered a cancellation or nonrenewal of such plan or contract.
[
2009 c 329 s 3
.]
RCW 48.43.680
Lifetime limit on transplants
—
Definition.
(1) A health benefit plan that is issued or renewed on or after January 1, 2010, and that provides coverage for organ and tissue transplants, may not permit a separate lifetime limit on transplants of any less than three hundred fifty thousand dollars. The lifetime limit on transplants shall apply from one day prior to the date of the transplant or the date of hospital admission, for a patient who receives a transplant during the course of a longer hospital stay, through one hundred days after the transplant. Donor-related services may apply to the lifetime limit on transplants any time. The major medical lifetime limit shall apply to health care services provided before and after this time period. Benefits provided are subject to all other terms and conditions of the health benefit plan, including but not limited to any applicable coinsurances, deductibles, and copayments.
(2) "Organ and tissue transplant" means the same as defined under the applicable health benefit plan.
[
2009 c 487 s 1
.]
RCW 48.43.690
Assessments under RCW 70.290.040
considered medical expenses.
Assessments paid by carriers under RCW 70.290.040
may be considered medical expenses for purposes of rate setting and regulatory filings.
[
2010 c 174 s 15
.]
NOTES:
Effective date
—
2010 c 174:
See RCW 70.290.900
.
RCW 48.43.700
Exchange
—
Plans that a carrier must offer
—
Review
—
Rules.
(1) For plan or policy years beginning January 1, 2014, a carrier offering a health benefit plan that meets the definition of bronze level in section 1302 of P.L. 111-148 of 2010, as amended, in the individual market outside of the exchange must also offer plans that meet the definition of silver and gold level plans in section 1302 of P.L. 111-148 of 2010, as amended, in the individual market outside of the exchange.
(2) For plan or policy years beginning January 1, 2014, a carrier offering a health benefit plan that meets the definition of bronze level in section 1302 of P.L. 111-148 of 2010, as amended, in the small group market outside of the exchange must also offer plans that meet the definition of silver and gold level plans in section 1302 of P.L. 111-148 of 2010, as amended, in the small group market outside of the exchange.
(3) A health benefit plan meeting the definition of a catastrophic plan in *RCW 48.43.005
(8)(c)(i) may only be sold through the exchange.
(4) By December 1, 2016, the exchange board, in consultation with the commissioner, must complete a review of the impact of this section on the health and viability of the markets inside and outside the exchange and submit the recommendations to the legislature on whether to maintain the market rules or let them expire.
(5) The commissioner shall evaluate plans offered at each actuarial value defined in section 1302 of P.L. 111-148 of 2010, as amended, and determine whether variation in prescription drug benefit cost-sharing, both inside and outside the exchange in both the individual and small group markets results in adverse selection. If so, the commissioner may adopt rules to assure substantial equivalence of prescription drug cost-sharing.
[
2014 c 31 s 1
;
2012 c 87 s 6
.]
NOTES:
*Reviser's note:
RCW 48.43.005
was alphabetized pursuant to RCW 1.08.015
(2)(k), changing subsection (8) to subsection (10). RCW 48.43.005
was alphabetized pursuant to RCW 1.08.015
(2)(k), changing subsection (10) to subsection (12).
Spiritual care services
—
2012 c 87:
See RCW 43.71.901
.
RCW 48.43.705
Plans offered outside of exchange.
All nongrandfathered individual and small group health plans, other than catastrophic health plans, offered outside of the exchange must conform with the actuarial value tiers specified in section 1302 of P.L. 111-148 of 2010, as amended, as bronze, silver, gold, or platinum.
[
2014 c 31 s 2
;
2012 c 87 s 7
.]
NOTES:
Spiritual care services
—
2012 c 87:
See RCW 43.71.901
.
RCW 48.43.710
Certification as qualified health plan not an exemption.
Certification by the Washington health benefit exchange of a plan as a qualified health plan, or of a carrier as a qualified issuer, does not exempt the plan or carrier from any of the requirements of this title or rules adopted by the commissioner pursuant to chapter
34.05
RCW to implement this title.
[
2012 c 87 s 12
.]
NOTES:
Spiritual care services
—
2012 c 87:
See RCW 43.71.901
.
RCW 48.43.715
Individual and small group market
—
Selection of benchmark plan
—
Minimum requirements
—
Criteria
—
List of state-mandated health benefits.
(1) Until the effective date of an updated essential health benefits benchmark plan submitted under section 1, chapter 87, Laws of 2023, the commissioner, in consultation with the board and the health care authority, shall, by rule, select the largest small group plan in the state by enrollment as the benchmark plan for the individual and small group market for purposes of establishing the essential health benefits in Washington state.
(2) If the essential health benefits benchmark plan for the individual and small group market does not include all of the 10 essential health benefits categories, the commissioner, in consultation with the board and the health care authority, shall, by rule, supplement the benchmark plan benefits as needed.
(3) All individual and small group health plans must cover the 10 essential health benefits categories, other than a health plan offered through the federal basic health program, a grandfathered health plan, or medicaid. Such a health plan may not be offered in the state unless the commissioner finds that it is substantially equal to the benchmark plan. When making this determination, the commissioner:
(a) Must ensure that the plan covers the 10 essential health benefits categories;
(b) May consider whether the health plan has a benefit design that would create a risk of biased selection based on health status and whether the health plan contains meaningful scope and level of benefits in each of the ten essential health benefits categories;
(c) Notwithstanding (a) and (b) of this subsection, for benefit years beginning January 1, 2015, must establish by rule the review and approval requirements and procedures for pediatric oral services when offered in stand-alone dental plans in the nongrandfathered individual and small group markets outside of the exchange; and
(d) Must allow health carriers to also offer pediatric oral services within the health benefit plan in the nongrandfathered individual and small group markets outside of the exchange.
(4) Beginning December 15, 2012, and every year thereafter, the commissioner shall submit to the legislature a list of state-mandated health benefits, the enforcement of which will result in federally imposed costs to the state related to the plans sold through the exchange because the benefits are not included in the essential health benefits designated under federal law. The list must include the anticipated costs to the state of each state-mandated health benefit on the list and any statutory changes needed if funds are not appropriated to defray the state costs for the listed mandate. The commissioner may enforce a mandate on the list for the entire market only if funds are appropriated in an omnibus appropriations act specifically to pay the state portion of the identified costs.
(5) The commissioner shall include coverage for donor human milk as provided in RCW 48.43.815
and hearing instruments and associated services as described in RCW 48.43.135, in any update of the state's essential health benefits benchmark plan submitted to the centers for medicare and medicaid services under section 1, chapter 87, Laws of 2023.
[
2023 c 87 s 2
;
2022 c 236 s 2
;
2019 c 33 s 9
;
2013 c 325 s 1
;
2012 c 87 s 13
.]
NOTES:
Effective date
—
2023 c 87:
"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 [April 13, 2023]." [
2023 c 87 s 3
.]
Effective date
—
2019 c 33:
See note following RCW 48.43.005
.
Spiritual care services
—
2012 c 87:
See RCW 43.71.901
.
RCW 48.43.720
Reinsurance and risk adjustment programs
—
Affordable care act
—
Rules.
(1)(a) The commissioner, in consultation with the board, shall adopt rules establishing the reinsurance and risk adjustment programs required by P.L. 111-148 of 2010, as amended.
(b) The commissioner must include in deliberations related to reinsurance rule making an analysis of an invisible high risk pool option, in which the full premium and risk associated with certain high-risk or high-cost enrollees would be ceded to the transitional reinsurance program. The analysis must include a determination as to whether that option is authorized under the federal reinsurance program regulations, whether the option would provide sufficiently comprehensive coverage for current nonmedicare high risk pool enrollees, and how an invisible high risk pool option could be designed to ensure that carriers ceding risk provide effective care management to high-risk or high-cost enrollees.
(2) Consistent with federal law, the rules for the reinsurance program must, at a minimum, establish:
(a) A mechanism to collect reinsurance contribution funds;
(b) A reinsurance payment formula; and
(c) A mechanism to disburse reinsurance payments.
(3)(a) The commissioner may adjust the rules adopted under this section as needed to preserve a healthy market both inside and outside of the exchange.
(b) The rules adopted under this section must identify and may require submission of the data needed to support operation of the reinsurance and risk adjustment programs established under this section. The commissioner must identify by rule the sources of the data, and other requirements related to the collection, validation, correction, interpretation, transmission or exchange, and retention of the data.
(4) The commissioner shall contract with one or more nonprofit entities to administer the risk adjustment and reinsurance programs.
(5) Contribution amounts for the transitional reinsurance program under section 1341 of P.L. 111-148 of 2010, as amended, may be increased to include amounts sufficient to cover the costs of administration of the reinsurance program including reasonable costs incurred for preoperational and planning activities related to the reinsurance program.
[
2012 c 87 s 16
.]
NOTES:
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
.
RCW 48.43.725
Exclusion of mandated benefits from health plan
—
Carrier requirements
—
Notice
—
Fees
—
Commissioner's duties.
(1) A health carrier that excludes, under state or federal law, any benefit required or mandated by this title or rules adopted by the commissioner from any health plan or student health plan shall:
(a) Notify each enrollee in writing of the following:
(i) Which benefits the health plan or student health plan does not cover; and
(ii) Alternate ways in which the enrollees may access excluded benefits in a timely manner;
(b) Ensure that enrollees have prompt access to the information required under this subsection; and
(c) Clearly and legibly include the information specified in (a)(i) and (ii) of this subsection in any of its marketing materials that include a list of benefits covered under the plan. The information must also be listed in the benefit booklet and posted on the carrier's health plan or student health plan website.
(2) For the purpose of mitigating inequity in the health insurance market, unless waived by the commissioner pursuant to (c) of this subsection, the commissioner must assess a fee on any health carrier offering a health plan or student health plan if the health plan or student health plan excludes, under state or federal law, any essential health benefit or coverage that is otherwise required or mandated by this title or rules adopted by the commissioner.
(a) The commissioner shall set the fee in an amount that is the actuarial equivalent of costs attributed to the provision and administration of the excluded benefit. As part of its rate filing, a health carrier subject to this subsection (2) must submit to the commissioner an estimate of the amount of the fee, including supporting documentation of its methods for estimating the fee. The carrier must include in its supporting documentation a certification by a member of the American academy of actuaries that the estimated fee is the actuarial equivalent of costs attributed to the provision and administration of the excluded benefit.
(b) Fees paid under this section must be deposited into the general fund.
(c) The commissioner may waive the fee assessed under this subsection (2) if he or she finds that the carrier excluding a mandated benefit for a health plan or student health plan provides health plan enrollees or student health plan enrollees alternative access to all excluded mandated benefits.
(3) Beginning July 1, 2021, the commissioner shall provide on its website written notice of the carrier requirements in this section and information on alternate ways in which enrollees may access excluded benefits in a timely manner.
(4) Nothing in this section limits the authority of the commissioner to take enforcement action if a health carrier unlawfully fails to comply with the provisions of this title.
(5) The commissioner shall adopt any rules necessary to implement this section.
[
2020 c 283 s 1
.]
RCW 48.43.730
Carrier must file provider contracts and compensation agreements with commissioner
—
Approval or disapproval
—
Confidentiality
—
Hearings
—
Rules
—
Definitions.
(1) For the purposes of this section:
(a) "Carrier" means a:
(i) Health carrier as defined in RCW 48.43.005
; and
(ii) Limited health care service contractor that offers limited health care service as defined in RCW 48.44.035
.
(b) "Provider" means:
(i) A health care provider as defined in RCW 48.43.005
;
(ii) A participating provider as defined in RCW 48.44.010
;
(iii) A health care facility, as defined in RCW 48.43.005
; and
(iv) Intermediaries that have agreed in writing with a carrier to provide access to providers under this subsection (1)(b) who render covered services to enrollees of a carrier.
(c) "Provider compensation agreement" means any written agreement that includes specific information about payment methodology, payment rates, and other terms that determine the remuneration a carrier will pay to a provider.
(d) "Provider contract" means a written contract between a carrier and a provider for any health care services rendered to an enrollee.
(2) A carrier must file all provider contracts and provider compensation agreements with the commissioner thirty calendar days before use. When a carrier and provider negotiate a provider contract or provider compensation agreement that deviates from a filed agreement, the carrier must also file that specific contract or agreement with the commissioner thirty calendar days before use.
(a) Any provider contract and related provider compensation agreements not affirmatively disapproved by the commissioner are deemed approved, except the commissioner may extend the approval date an additional fifteen calendar days upon giving notice before the expiration of the initial thirty-day period.
(b) Changes to previously filed and approved provider compensation agreements modifying the compensation amount or related terms that help determine the compensation amount must be filed and are deemed approved upon filing if no other changes are made to the previously approved provider contract or compensation agreement.
(3) The commissioner may not base a disapproval of a provider compensation agreement on the amount of compensation or other financial arrangements between the carrier and the provider, unless that compensation amount causes the underlying health benefit plan to otherwise be in violation of state or federal law. This subsection does not grant the commissioner the authority to regulate provider reimbursement amounts.
(4) The commissioner may withdraw approval of a provider contract or provider compensation agreement at any time for cause.
(5) Provider compensation agreements are confidential and not subject to public inspection under RCW 48.02.120
(2), or public disclosure under chapter
42.56
RCW, if filed in accordance with the procedures for submitting confidential filings through the system for electronic rate and form filings and the general filing instructions as set forth by the commissioner. In the event the referenced filing fails to comply with the filing instructions setting forth the process to withhold the compensation agreement from public inspection, and the carrier indicates that the compensation agreement is to be withheld from public inspection, the commissioner shall reject the filing and notify the carrier through the system for electronic rate and form filings to amend its filing to comply with the confidentiality filing instructions.
(6) In the event a provider contract or provider compensation agreement is disapproved or withdrawn from use by the commissioner, the carrier has the right to demand and receive a hearing under chapters
48.04
and
34.05
RCW.
(7) Provider contracts filed pursuant to subsection (2) of this section shall identify the network or networks to which the contract applies.
(8) The commissioner may adopt rules to implement this section.
[
2019 c 427 s 30
;
2013 c 277 s 1
.]
NOTES:
Findings
—
Intent
—
Effective date
—
2019 c 427:
See RCW 48.49.003
and
48.49.900
.
RCW 48.43.731
Health care benefit management contracts
—
Carrier filing requirements
—
Notice to enrollees
—
Confidentiality of filings.
(1) A carrier must file with the commissioner in the form and manner prescribed by the commissioner every contract and contract amendment between the carrier and any health care benefit manager registered under RCW 48.200.030, within thirty days following the effective date of the contract or contract amendment.
(2) For health plans issued or renewed on or after January 1, 2022, carriers must notify health plan enrollees in writing of each health care benefit manager contracted with the carrier to provide any benefit management services in the administration of the health plan.
(3) Contracts filed under this section are confidential and not subject to public inspection under RCW 48.02.120
(2), or public disclosure under chapter
42.56
RCW, if filed in accordance with the procedures for submitting confidential filings through the system for electronic rate and form filings and the general filing instructions as set forth by the commissioner. In the event the referenced filing fails to comply with the filing instructions setting forth the process to withhold the contract from public inspection, and the carrier indicates that the contract is to be withheld from public inspection, the commissioner must reject the filing and notify the carrier through the system for electronic rate and form filings to amend its filing to comply with the confidentiality filing instructions.
(4) For purposes of this section, "health care benefit manager" has the same meaning as in RCW 48.200.020
.
[
2020 c 240 s 6
.]
NOTES:
Rule making
—
Effective date
—
2020 c 240:
See RCW 48.200.900
and
48.200.901
.
RCW 48.43.732
Provider contracts
—
Public statements
—
Language.
(1) In the case of a provider contract that is expiring by its own terms or for which one party has given notice to the other party of an intended termination without cause in accordance with the terms of the provider contract, neither the health care provider, the health care facility, any health care provider employed by, contracted with, or otherwise affiliated with the facility, nor the carrier may make or cause to be made public statements, including by directly communicating with impacted health plan enrollees and patients, regarding such expiration or termination until 45 days prior to the termination date, unless: (a) The disclosure is required to satisfy a specific legal obligation; or (b) the expiration or termination has already been disclosed publicly because of a legal obligation. Communications exclusively with the governor, legislators, or state agency staff regarding a potential or intended contract termination do not constitute a public statement.
(2) Nothing in this section requires a carrier, health care facility, or health care provider to provide notice of a potential termination to enrollees, unless required to do so as a regulatory or legal requirement.
(3) Public statements or communication with health plan enrollees or patients by a carrier, health care facility, or health care provider may not occur prior to the date the carrier, health care facility, or health care provider has given written notice of the termination to the other party, unless agreed upon by both parties.
(4)(a) By December 1, 2025, the commissioner, in consultation with health carriers, health care providers, health care facilities, and consumers, must develop standard template language for notices sent to health plan enrollees and patients by health carriers, health care providers, or health care facilities pursuant to this section. The standard template language must be posted on the commissioner's website.
(b) Notices developed pursuant to this section must include, at a minimum:
(i) A reference to the specific facility or facilities by name that would be affected by the potential contract termination or expiration and an indication of whether the potential termination or expiration would apply to hospital-based providers;
(ii) Direction to enrollees related to appointments that are scheduled past the date of the potential contract termination or expiration date; and
(iii) Information concerning the enrollee's continuity of care rights pursuant to the federal no surprises act, 42 U.S.C. Sec. 300gg-111.
(c) Notices sent to enrollees or patients that solely utilize the template language developed pursuant to this section are not subject to review or approval. Notices to enrollees or patients that do not utilize the template language in full, or add to or revise the language of the template developed pursuant to this section, must be reviewed and approved by the commissioner before being used in any manner.
(5) By January 1, 2027, the requirements of this section must be included in all provider contracts. The commissioner must develop template language for inclusion in provider contracts by rule.
(6)(a) The commissioner is authorized to enforce the provisions of chapter 389, Laws of 2025 related to carriers on or after January 1, 2026. In addition to the enforcement actions authorized under RCW 48.02.080, the commissioner may impose a civil monetary penalty in an amount not to exceed $100 for each day that a notice has been sent to enrollees in advance of the 45-day period established in subsection (1) of this section for each enrollee to whom the notice has been sent.
(b) If the commissioner has cause to believe that any health care provider or health care facility has violated this section, the commissioner may submit information to the department of health, another appropriate health care facility licensing entity, or the appropriate health profession disciplining authority for action. The commissioner may provide the health care provider or health care facility with an opportunity to explain why the actions in question did not violate this section.
(c) If any health care provider or health care facility violates this section, the department of health, other appropriate health care facility licensing entity, or the appropriate health profession disciplining authority may levy a fine or cost recovery upon the health care provider or health care facility in an amount not to exceed the applicable statutory amount per violation and take other action as permitted under the authority of the department of health or disciplining authority. Upon completion of its review of any potential violation submitted by the commissioner, the department of health or the disciplining authority shall notify the commissioner of the results of the review, including whether the violation was substantiated and any enforcement action taken as a result of a finding of a substantiated violation.
(7) For the purposes of this section, "provider contract" means a written contract between a carrier and a health care provider or health care facility, as they are defined in RCW 48.43.005, for any health care services rendered to an enrollee.
(8) This section does not apply to a provider contract that is expiring or being terminated by an independent individual provider or an independent single-specialty or multispecialty group practice of five or fewer providers, whether due to a provider's retirement or some other reason. For purposes of this subsection, "independent" means a provider that is not employed by or affiliated with a hospital or multihospital health system.
[
2025 c 389 s 2
.]
NOTES:
Finding
—
Intent
—
2025 c 389:
"The legislature finds that public communications and notices to health plan members by carriers, health care providers, or health care facilities during contract negotiations have created concerns for enrollees, patients, and affected communities. Therefore, the legislature intends to provide consistent policies for communication with enrollees and affected communities regarding potential contract terminations." [
2025 c 389 s 1
.]
RCW 48.43.733
Rates and forms of group health benefit plans
—
Timing of filings
—
Exceptions
—
Rules.
(1) All rates and forms of group health benefit plans other than small group plans, and all stand-alone dental and all stand-alone vision plans offered by a health carrier or limited health care service contractor as defined in RCW 48.44.035
and modification of a contract form or rate must be filed before the contract form is offered for sale to the public and before the rate schedule is used.
(2) Filings of negotiated health benefit plans, stand-alone dental, and stand-alone vision contract forms for groups other than small groups, and applicable rate schedules, that are placed into effect at time of negotiation or that have a retroactive effective date are not required to be filed in accordance with subsection (1) of this section, but must be filed within thirty working days after the earlier of:
(a) The date group contract negotiations are completed; or
(b) The date renewal premiums are implemented.
(3) For purposes of this section, a negotiated contract form is a health benefit plan, stand-alone dental plan, or stand-alone vision plan where benefits, and other terms and conditions, including the applicable rate schedules are negotiated and agreed to by the carrier or limited health care service contractor and the policy or contract holder. The negotiated policy form and associated rate schedule must otherwise comply with state and federal laws governing the content and schedule of rates for the negotiated plans.
(4) Stand-alone dental and stand-alone vision plans offered by a disability insurer to out-of-state groups specified by RCW 48.21.010
(2) may be negotiated, but may not be offered in this state before the commissioner finds that the stand-alone dental or stand-alone vision plan otherwise meets the standards set forth in RCW 48.21.010
(2) (a) and (b).
(5) The commissioner may, subject to a carrier's or limited health care service contractor's right to demand and receive a hearing under chapters
48.04
and
34.05
RCW, disapprove filings submitted under this section, as permitted under RCW 48.18.110, 48.44.020, and
48.46.060
.
(6) The commissioner shall amend existing rules to standardize the rate and form filing process as well as regulatory review standards for the rates and forms of the plans submitted under this section. The commissioner may amend the rules previously adopted under RCW 48.43.733
and shall amend any additional rating requirements established by existing rule, that are not applied to health care service contractors and health maintenance organizations.
(7) The requirements of this section apply to all group health benefit plans other than small group plans, all stand-alone dental plans, and all stand-alone vision plans issued or renewed on or after March 31, 2016.
[
2016 c 156 s 2
;
2015 c 19 s 3
.]
NOTES:
Effective date
—
2016 c 156:
"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 [March 31, 2016]." [
2016 c 156 s 3
.]
Intent
—
2016 c 156:
"It is the intent of the legislature to enhance competition among all health carriers and limited health care service contractors by having the office of the insurance commissioner establish regulatory uniformity for the rate and form filing process and the rate and form filing content and regulatory review standards for group health benefit plans other than small group health benefit plans, as well as all stand-alone dental plans and all stand-alone vision plans." [
2016 c 156 s 1
.]
Intent
—
2015 c 19:
See note following RCW 48.18.100
.
RCW 48.43.734
Health carrier rate filings
—
Review of surplus, capital, and profit levels.
(1) For individual and small group rate filings with an effective date on or after January 1, 2021, submitted by a health carrier for either the individual or small group markets, the commissioner may review the carrier's surplus, capital, or profit levels as an element in determining the reasonableness of the proposed rate.
(2) In reviewing the surplus, capital, or profit levels, the commissioner must take into consideration the current capital facility needs for carriers, including those maintaining and operating hospital and clinical facilities.
(3) Except as provided in subsection (1) of this section, this section does not affect the rate review authority granted to the commissioner by chapter
48.19, 48.44, or
48.46
RCW.
(4) Nothing in this section affects the requirement that all approved individual and small group rates be actuarially sound according to chapter
48.19, 48.44, or
48.46
RCW.
(5) The commissioner may adopt rules to implement this section.
[
2020 c 247 s 1
.]
RCW 48.43.735
Reimbursement of health care services provided through telemedicine or store and forward technology
—
Audio-only telemedicine.
(1)(a) For health plans issued or renewed on or after January 1, 2017, a health carrier shall reimburse a provider for a health care service provided to a covered person through telemedicine or store and forward technology if:
(i) The plan provides coverage of the health care service when provided in person by the provider;
(ii) The health care service is medically necessary;
(iii) The health care service is a service recognized as an essential health benefit under section 1302(b) of the federal patient protection and affordable care act in effect on January 1, 2015;
(iv) The health care service is determined to be safely and effectively provided through telemedicine or store and forward technology according to generally accepted health care practices and standards, and the technology used to provide the health care service meets the standards required by state and federal laws governing the privacy and security of protected health information; and
(v) Beginning January 1, 2023, for audio-only telemedicine, the covered person has an established relationship with the provider.
(b)(i) Except as provided in (b)(ii) of this subsection, for health plans issued or renewed on or after January 1, 2021, a health carrier shall reimburse a provider for a health care service provided to a covered person through telemedicine the same amount of compensation the carrier would pay the provider if the health care service was provided in person by the provider.
(ii) Hospitals, hospital systems, telemedicine companies, and provider groups consisting of eleven or more providers may elect to negotiate an amount of compensation for telemedicine services that differs from the amount of compensation for in-person services.
(iii) For purposes of this subsection (1)(b), the number of providers in a provider group refers to all providers within the group, regardless of a provider's location.
(2) For purposes of this section, reimbursement of store and forward technology is available only for those covered services specified in the negotiated agreement between the health carrier and the health care provider.
(3) An originating site for a telemedicine health care service subject to subsection (1) of this section includes a:
(a) Hospital;
(b) Rural health clinic;
(c) Federally qualified health center;
(d) Physician's or other health care provider's office;
(e) Licensed or certified behavioral health agency;
(f) Skilled nursing facility;
(g) Home or any location determined by the individual receiving the service; or
(h) Renal dialysis center, except an independent renal dialysis center.
(4) Except for subsection (3)(g) of this section, any originating site under subsection (3) of this section may charge a facility fee for infrastructure and preparation of the patient. Reimbursement for a facility fee must be subject to a negotiated agreement between the originating site and the health carrier. A distant site, a hospital that is an originating site for audio-only telemedicine, or any other site not identified in subsection (3) of this section may not charge a facility fee.
(5) A health carrier may not distinguish between originating sites that are rural and urban in providing the coverage required in subsection (1) of this section.
(6) A health carrier may subject coverage of a telemedicine or store and forward technology health service under subsection (1) of this section to all terms and conditions of the plan in which the covered person is enrolled including, but not limited to, utilization review, prior authorization, deductible, copayment, or coinsurance requirements that are applicable to coverage of a comparable health care service provided in person.
(7) This section does not require a health carrier to reimburse:
(a) An originating site for professional fees;
(b) A provider for a health care service that is not a covered benefit under the plan; or
(c) An originating site or health care provider when the site or provider is not a contracted provider under the plan.
(8)(a) If a provider intends to bill a patient or the patient's health plan for an audio-only telemedicine service, the provider must obtain patient consent for the billing in advance of the service being delivered.
(b) If the commissioner has cause to believe that a provider has engaged in a pattern of unresolved violations of this subsection (8), the commissioner may submit information to the appropriate disciplining authority, as defined in RCW 18.130.020, for action. Prior to submitting information to the appropriate disciplining authority, the commissioner may provide the provider with an opportunity to cure the alleged violations or explain why the actions in question did not violate this subsection (8).
(c) If the provider has engaged in a pattern of unresolved violations of this subsection (8), the appropriate disciplining authority may levy a fine or cost recovery upon the provider in an amount not to exceed the applicable statutory amount per violation and take other action as permitted under the authority of the disciplining authority. Upon completion of its review of any potential violation submitted by the commissioner or initiated directly by an enrollee, the disciplining authority shall notify the commissioner of the results of the review, including whether the violation was substantiated and any enforcement action taken as a result of a finding of a substantiated violation.
(9) For purposes of this section:
(a)(i) "Audio-only telemedicine" means the delivery of health care services through the use of audio-only technology, permitting real-time communication between the patient at the originating site and the provider, for the purpose of diagnosis, consultation, or treatment.
(ii) For purposes of this section only, "audio-only telemedicine" does not include:
(A) The use of facsimile or email; or
(B) The delivery of health care services that are customarily delivered by audio-only technology and customarily not billed as separate services by the provider, such as the sharing of laboratory results;
(b) "Disciplining authority" has the same meaning as in RCW 18.130.020
;
(c) "Distant site" means the site at which a physician or other licensed provider, delivering a professional service, is physically located at the time the service is provided through telemedicine;
(d) "Established relationship" means the provider providing audio-only telemedicine has access to sufficient health records to ensure safe, effective, and appropriate care services and:
(i) The covered person has had, within the past three years, at least one in-person appointment, or at least one real-time interactive appointment using both audio and video technology, with the provider providing audio-only telemedicine or with a provider employed at the same medical group, at the same clinic, or by the same integrated delivery system operated by a carrier licensed under chapter
48.44
or
48.46
RCW as the provider providing audio-only telemedicine; or
(ii) The covered person was referred to the provider providing audio-only telemedicine by another provider who has had, within the past three years, at least one in-person appointment, or at least one real-time interactive appointment using both audio and video technology, with the covered person and has provided relevant medical information to the provider providing audio-only telemedicine;
(e) "Health care service" has the same meaning as in RCW 48.43.005
;
(f) "Hospital" means a facility licensed under chapter
70.41, 71.12, or
72.23
RCW;
(g) "Originating site" means the physical location of a patient receiving health care services through telemedicine;
(h) "Provider" has the same meaning as in RCW 48.43.005
;
(i) "Store and forward technology" means use of an asynchronous transmission of a covered person's medical information from an originating site to the health care provider at a distant site which results in medical diagnosis and management of the covered person, and does not include the use of audio-only telephone, facsimile, or email; and
(j) "Telemedicine" means the delivery of health care services through the use of interactive audio and video technology, permitting real-time communication between the patient at the originating site and the provider, for the purpose of diagnosis, consultation, or treatment. For purposes of this section only, "telemedicine" includes audio-only telemedicine, but does not include facsimile or email.
(10) The commissioner may adopt any rules necessary to implement this section.
[
2024 c 215 s 2
;
2023 c 8 s 2
;
2022 c 213 s 2
;
2021 c 157 s 2
;
2020 c 92 s 1
;
2017 c 219 s 1
;
2016 c 68 s 3
;
2015 c 23 s 3
.]
NOTES:
Conflict with federal requirements
—
2022 c 213:
See note following RCW 41.05.700
.
Conflict with federal requirements
—
2021 c 157:
See note following RCW 74.09.327
.
Effective date
—
2020 c 92:
"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 [March 19, 2020]." [
2020 c 92 s 5
.]
Effective date
—
2017 c 219:
"Sections 1 through 3 of this act take effect January 1, 2018." [
2017 c 219 s 4
.]
Effective date
—
2016 c 68:
"Sections 3 through 5 of this act take effect January 1, 2018." [
2016 c 68 s 7
.]
Intent
—
2016 c 68:
"The legislature recognizes telemedicine will play an increasingly important role in the health care system. Telemedicine is a meaningful and efficient way to treat patients and control costs while improving access to care. The expansion of the use of telemedicine should be thoughtfully and systematically considered in Washington state in order to maximize its application and expand access to care. Therefore, it is the intent of the legislature to broaden the reimbursement opportunities for health care services and establish a collaborative for the advancement of telemedicine to provide guidance, research, and recommendations for the benefit of professionals providing care through telemedicine." [
2016 c 68 s 1
.]
Effective date
—
Adoption of sections
—
2015 c 23 ss 2-4:
See notes following RCW 41.05.700
.
Intent
—
2015 c 23:
See note following RCW 41.05.700
.
RCW 48.43.740
Dental only plan
—
Emergency dental conditions
—
Definitions.
(1) A health carrier offering a dental only plan may not deny coverage for treatment of emergency dental conditions that would otherwise be considered a covered service of an existing benefit contract on the basis that the services were provided on the same day the covered person was examined and diagnosed for the emergency dental condition.
(2) For purposes of this section:
(a) "Emergency dental condition" means a dental condition manifesting itself by acute symptoms of sufficient severity, including severe pain or infection such that a prudent layperson, who possesses an average knowledge of health and dentistry, could reasonably expect the absence of immediate dental attention to result in:
(i) Placing the health of the individual, or with respect to a pregnant woman the health of the woman or her unborn child, in serious jeopardy;
(ii) Serious impairment to bodily functions; or
(iii) Serious dysfunction of any bodily organ or part.
(b) "Health carrier," in addition to the definition in RCW 48.43.005, also includes health care service contractors, limited health care service contractors, and disability insurers offering dental only coverage.
[
2015 c 9 s 1
.]
NOTES:
Effective date
—
2015 c 9:
"This act takes effect January 1, 2017." [
2015 c 9 s 3
.]
RCW 48.43.743
Dental only plan
—
Annual data statement
—
Contents
—
Public use
—
Definition.
(1) Each health carrier offering a dental only plan in Washington shall submit to the commissioner on or before April 1st of each year as part of the additional data statement, or as a supplemental data statement, Washington specific data for the preceding year that is derived from the carrier's annual statement, including the exhibit of premiums, enrollments, and utilization for the company at an aggregate level and the additional data to the annual statement, which must be based on Washington data and may not include data from other states:
(a) The total number of dental members;
(b) The total amount of dental revenue;
(c) The total amount of dental payments;
(d) The dental loss ratio that is computed by dividing the total amount of dental payments by the total amount of dental revenues;
(e) The average amount of premiums per member per month; and
(f) The percentage change in the average premium per member per month, measured from the previous year.
(2) A carrier shall electronically submit the information described in subsection (1) of this section in a format and according to instructions prescribed by the commissioner.
(3) The commissioner shall make the information reported under this section available to the public on the commissioner's public website on the internet.
(4) For the purposes of licensed disability insurers and health care service contractors, the commissioner shall work collaboratively with insurers to develop an additional or supplemental data statement that utilizes to the maximum extent possible information from the annual statement forms that are currently filed by these entities.
(5) For purposes of this section, "health carrier," in addition to the definition in RCW 48.43.005, also includes health care service contractors, limited health care service contractors, and disability insurers offering dental only coverage.
(6) Nothing in this section is intended to establish a minimum dental loss ratio.
[
2025 c 243 s 10
;
2025 c 219 s 5
;
2015 c 9 s 2
.]
NOTES:
Reviser's note:
This section was amended by 2025 c 219 s 5 and by 2025 c 243 s 10, 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
—
2015 c 9:
See note following RCW 48.43.740
.
RCW 48.43.745
Dental only plan
—
Denturist services.
(1) Every health carrier offering dental only coverage and every health carrier offering dental only coverage in addition to a health plan delivered, issued for delivery, or renewed by a health carrier on and after January 1, 2024, shall permit denturists licensed under chapter
18.30
RCW to provide dental services or care included in their benefits package, to the extent that:
(a) The provision of such dental services or care is within the health care providers' permitted scope of practice; and
(b) The providers agree to abide by standards related to:
(i) Provision, utilization review, and cost containment of dental services;
(ii) Management and administrative procedures; and
(iii) Provision of cost-effective and clinically efficacious dental services.
(2) The requirements of subsection (1) of this section do not apply to a licensed health care profession regulated under Title
18
RCW when the licensing statute for the profession states that such requirements do not apply.
(3) For purposes of this section, "health carrier," in addition to the definition in RCW 48.43.005, also includes health care service contractors, limited health care service contractors, and disability insurers offering dental only coverage.
(4) Chapter 216, Laws of 2023 does not apply to a plan that offers dental only coverage when the plan relies solely on employees of the health carrier for provision of the benefits.
[
2023 c 216 s 1
.]
RCW 48.43.747
Dental only plan
—
Coverage for same day procedures.
(1) A dental only plan offered by a carrier or limited health care service contractor, as defined in RCW 48.44.035, may not deny coverage for procedures solely on the basis that the procedures were performed on the same day.
(2) Nothing in this section shall prevent a dental only plan offered by a carrier or limited health care service contractor from denying a claim for coverage where such denial relates in whole or in part to any of the following:
(a) Limitations intended to prevent fraud, waste, and abuse;
(b) A claim indicating unbundling of procedure elements where payment for a service bundles multiple procedure elements;
(c) Clinical appropriateness;
(d) Medical necessity;
(e) A final benefit decision that has been pended due to the need for further documentation or provider narrative; or
(f) Plan benefit limitations.
[
2025 c 219 s 1
.]
NOTES:
Rules
—
2025 c 219 ss 1 and 2:
"The insurance commissioner may adopt any rules necessary to implement sections 1 and 2 of this act." [
2025 c 219 s 3
.]
RCW 48.43.748
Dental only plan
—
Payments by credit card.
(1) A dental only plan offered by a carrier or limited health care service contractor, as defined in RCW 48.44.035, may pay a claim for reimbursement made by a dental care provider using a credit card if:
(a) The carrier or limited health care service contractor notifies the provider, in advance, of any fees associated with the use of the credit card;
(b) The carrier or limited health care service contractor offers the provider an alternative payment method that does not impose fees or similar charges on the provider; and
(c) The carrier or limited health care service contractor advises the provider of available methods of payment and provides clear instructions to the provider as to how to select an alternative payment method.
(2) If a carrier or limited health care service contractor contracts with a vendor to process payments of dental providers' claims, the carrier or limited health care service contractor shall require the vendor to comply with the provisions of subsection (1)(a) of this section.
[
2025 c 219 s 2
.]
NOTES:
Rules
—
2025 c 219 ss 1 and 2:
See note following RCW 48.43.747
.
RCW 48.43.750
Health care provider credentialing applications
—
Use of electronic database by health carriers.
(1)(a) A health carrier must use the database selected pursuant to RCW 48.165.035
to accept and manage credentialing applications from health care providers. A health carrier may not require a health care provider to submit credentialing information in any format other than through the database selected pursuant to RCW 48.165.035
.
(b) Effective June 1, 2018, a health carrier shall make a determination approving or denying a credentialing application submitted to the carrier no later than ninety days after receiving a complete application from a health care provider.
(c) Effective June 1, 2020, a health carrier shall make a determination approving or denying a credentialing application submitted to the carrier no later than ninety days after receiving a complete application from a health care provider. All determinations made by a health carrier in approving or denying credentialing applications must average no more than sixty days.
(d) This section does not require health carriers to approve a credentialing application or to place providers into a network.
(2) This section does not apply to health care entities that utilize credentialing delegation arrangements in the credentialing of their health care providers with health carriers.
(3) For purposes of this section, "credentialing" means the collection, verification, and assessment of whether a health care provider meets relevant licensing, education, and training requirements.
(4) Nothing in this section creates an oversight or enforcement duty on behalf of the office of the insurance commissioner against a health carrier for failure to comply with the terms of this section.
[
2020 c 4 s 1
;
2016 c 123 s 1
.]
NOTES:
Effective date
—
2016 c 123:
"This act takes effect June 1, 2018." [
2016 c 123 s 3
.]
RCW 48.43.755
Health care provider credentialing applications
—
Use of electronic database by providers.
(1) When submitting a credentialing application to a health carrier, a health care provider shall submit the application to health carriers using the database selected pursuant to RCW 48.165.035
.
(2) A health care provider shall update credentialing information as necessary to provide for the purposes of recredentialing.
(3) This section does not apply to providers practicing at entities that utilize credentialing delegation arrangements in the credentialing of their health care providers with health carriers.
(4) The definitions in this subsection apply throughout this section unless the context clearly requires otherwise.
(a) "Credentialing" has the same meaning as in RCW 48.43.750
.
(b) "Health care provider" has the same meaning as in *RCW 48.43.005
(23)(a).
(c) "Health carrier" has the same meaning as in RCW 48.43.005
.
[
2016 c 123 s 2
.]
NOTES:
*Reviser's note:
RCW 48.43.005
was alphabetized pursuant to RCW 1.08.015
(2)(k), changing subsection (23) to subsection (24), and effective January 1, 2020, changing subsection (23) to subsection (26). RCW 48.43.005
was alphabetized pursuant to RCW 1.08.015
(2)(k), changing subsection (26) to subsection (28). Subsequently, RCW 48.43.005
was amended by 2024 c 218 s 1, changing subsection (28) to subsection (30).
Effective date
—
2016 c 123:
See note following RCW 48.43.750
.
RCW 48.43.757
Health care provider credentialing applications
—
Reimbursement requirements.
(1) If a carrier approves a health care provider's credentialing application, upon completion of the credentialing process, the carrier must reimburse a health care provider under the following circumstances:
(a) When credentialing a new health care provider through a new provider contract, the carrier must reimburse the health care provider for covered services provided to the carrier's enrollee retroactively to the date of contract effectiveness if the credentialing process extends beyond the effective date of the new contract.
(b) When credentialing a provider to be added to an approved and in-use provider contract where a relationship existed between the carrier and the health care provider or the entity for whom the health care provider is employed or engaged at the time the health care provider submitted the completed credentialing application, the carrier must reimburse the health care provider for covered health care services provided to the carrier's enrollees during the credentialing process beginning when the health care provider submitted a completed credentialing application to the carrier.
(2) The health carrier must reimburse the health care provider at the contracted rate for the applicable health benefit plan that the health care provider would have been paid at the time the services were provided if the health care provider were fully credentialed by the carrier.
(3) Nothing in this section requires reimbursement of health care provider-rendered services that are not benefits or services covered by the health carrier's health benefit plan.
(4) Nothing in this section requires a health carrier to pay reimbursement for any covered medical services provided by a health care provider applicant if the health care provider's credentialing application is not approved or if the carrier and health care provider do not enter into a contractual relationship.
[
2020 c 4 s 2
.]
RCW 48.43.760
Opioid use disorder
—
Coverage without prior authorization.
For health plans issued or renewed on or after January 1, 2020, a health carrier 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 37
.]
NOTES:
Declaration
—
2019 c 314:
See note following RCW 18.22.810
.
RCW 48.43.761
Withdrawal management services
—
Substance use disorder treatment services
—
Prior authorization
—
Utilization review
—
Medical necessity review.
(1) Except as provided in subsection (2) of this section, a health plan issued or renewed on or after January 1, 2021, may not require an enrollee to obtain prior authorization for withdrawal management services or inpatient or residential substance use disorder treatment services in a behavioral health agency licensed or certified under RCW 71.24.037
.
(2)(a) A health plan issued or renewed on or after January 1, 2021, must:
(i) Provide coverage for no less than two business days, excluding weekends and holidays, in a behavioral health agency that provides inpatient or residential substance use disorder treatment prior to conducting a utilization review; and
(ii) Provide coverage for no less than three days in a behavioral health agency that provides withdrawal management services prior to conducting a utilization review.
(b)(i) The health plan may not require an enrollee to obtain prior authorization for the services specified in (a) of this subsection as a condition for payment of services prior to the times specified in (a) of this subsection.
(ii) Once the times specified in (a) of this subsection have passed, the health plan may initiate utilization management review procedures if the behavioral health agency continues to provide services or is in the process of arranging for a seamless transfer to an appropriate facility or lower level of care under subsection (6) of this section. For a health plan issued or renewed on or after January 1, 2025, if a health plan authorizes inpatient or residential substance use disorder treatment services pursuant to (a)(i) of this subsection following the initial medical necessity review process under (c)(iii) of this subsection, the length of the initial authorization may not be less than 14 days from the date that the patient was admitted to the behavioral health agency. Any subsequent reauthorization that the health plan approves after the first 14 days must continue for no less than seven days prior to requiring further reauthorization. Nothing prohibits a health plan from requesting information to assist with a seamless transfer under this subsection.
(c)(i) The behavioral health agency under (a) of this subsection must notify an enrollee's health plan as soon as practicable after admitting the enrollee, but not later than twenty-four hours after admitting the enrollee. The time of notification does not reduce the requirements established in (a) of this subsection.
(ii) The behavioral health agency under (a) of this subsection must provide the health plan with its initial assessment and initial treatment plan for the enrollee within two business days of admission, excluding weekends and holidays, or within three days in the case of a behavioral health agency that provides withdrawal management services.
(iii) After the time period in (a) of this subsection and receipt of the material provided under (c)(ii) of this subsection, the plan may initiate a medical necessity review process. Medical necessity review must be based on the standard set of criteria established under RCW 41.05.528
. In a review for inpatient or residential substance use disorder treatment services, a health plan may not make a determination that a patient does not meet medical necessity criteria based primarily on the patient's length of abstinence. If the patient's abstinence from substance use was due to incarceration, hospitalization, or inpatient treatment, a health plan may not consider the patient's length of abstinence in determining medical necessity. If the health plan determines within one business day from the start of the medical necessity review period and receipt of the material provided under (c)(ii) of this subsection that the admission to the facility was not medically necessary and advises the agency of the decision in writing, the health plan is not required to pay the facility for services delivered after the start of the medical necessity review period, subject to the conclusion of a filed appeal of the adverse benefit determination. If the health plan's medical necessity review is completed more than one business day after the start of the medical necessity review period and receipt of the material provided under (c)(ii) of this subsection, the health plan must pay for the services delivered from the time of admission until the time at which the medical necessity review is completed and the agency is advised of the decision in writing.
(3)(a) The behavioral health agency shall document to the health plan the patient's need for continuing care and justification for level of care placement following the current treatment period, based on the standard set of criteria established under RCW 41.05.528, with documentation recorded in the patient's medical record.
(b) For a health plan issued or renewed on or after January 1, 2025, for inpatient or residential substance use disorder treatment services, the health plan may not consider the patient's length of stay at the behavioral health agency when making decisions regarding the authorization to continue care at the behavioral health agency.
(4) Nothing in this section prevents a health carrier from denying coverage based on insurance fraud.
(5) If the behavioral health agency under subsection (2)(a) of this section is not in the enrollee's network:
(a) The health plan is not responsible for reimbursing the behavioral health agency at a greater rate than would be paid had the agency been in the enrollee's network; and
(b) The behavioral health agency may not balance bill, as defined in RCW 48.43.005
.
(6) When the treatment plan approved by the health plan involves transfer of the enrollee to a different facility or to a lower level of care, the care coordination unit of the health plan shall work with the current agency to make arrangements for a seamless transfer as soon as possible to an appropriate and available facility or level of care. The health plan shall pay the agency for the cost of care at the current facility until the seamless transfer to the different facility or lower level of care is complete. A seamless transfer to a lower level of care may include same day or next day appointments for outpatient care, and does not include payment for nontreatment services, such as housing services. If placement with an agency in the health plan's network is not available, the health plan shall pay the current agency until a seamless transfer arrangement is made.
(7) The requirements of this section do not apply to treatment provided in out-of-state facilities.
(8) For the purposes of this section "withdrawal management services" means twenty-four hour medically managed or medically monitored detoxification and assessment and treatment referral for adults or adolescents withdrawing from alcohol or drugs, which may include induction on medications for addiction recovery.
[
2024 c 366 s 7
;
2020 c 345 s 3
.]
NOTES:
Findings
—
Intent
—
2024 c 366:
See note following RCW 71.24.847
.
Findings
—
Intent
—
2020 c 345:
See note following RCW 41.05.526
.
RCW 48.43.762
Opioid overdose reversal medication bulk purchasing and distribution program.
(1) For health plans issued or renewed on or after January 1, 2023, health carriers must participate in the opioid overdose reversal medication bulk purchasing and distribution program established in RCW 70.14.170
once the program is operational. A health plan may not impose enrollee cost sharing related to opioid overdose reversal medication provided through the bulk purchasing and distribution program established in RCW 70.14.170
.
(2) For health plans issued or renewed on or after January 1, 2025, a health carrier must reimburse a hospital or psychiatric hospital that bills for the following outpatient services:
(a) For opioid overdose reversal medication dispensed or distributed to a patient under RCW 70.41.485
as a separate reimbursable expense; and
(b) For the administration of long-acting injectable buprenorphine as a separate reimbursable expense.
(3) Reimbursements provided under subsection (2) of this section must be separate from any bundled payment for outpatient hospital or emergency department services.
[
2024 c 366 s 17
;
2021 c 273 s 11
.]
NOTES:
Findings
—
Intent
—
2024 c 366:
See note following RCW 71.24.847
.
Rules
—
2021 c 273 ss 7-12:
See note following RCW 70.14.170
.
Findings
—
Intent
—
2021 c 273:
See note following RCW 70.41.480
.
RCW 48.43.764
Standard set of criteria
—
Authority review.
When updated versions of the ASAM Criteria, treatment criteria for addictive, substance related, and co-occurring conditions, inclusive of adolescent and transition age youth versions, are published by the American society of addiction medicine, the health care authority and the office of the insurance commissioner shall jointly determine whether to use the updated version, and, if so, the date upon which the updated version must begin to be used by medicaid managed care organizations, carriers, and other relevant entities. Both agencies shall post notice of their decision on their websites. For purposes of the ASAM Criteria, 4th edition, medicaid managed care organizations and carriers shall begin to use the updated criteria no later than January 1, 2028, unless the health care authority and the office of the insurance commissioner jointly determine that it should not be used.
[
2025 c 335 s 2
;
2024 c 366 s 11
.]
NOTES:
Findings
—
Intent
—
2024 c 366:
See note following RCW 71.24.847
.
RCW 48.43.765
Health carrier network adequacy
—
Mental health and substance abuse treatment.
(1) The commissioner shall amend his or her rules on electronic provider directories to require health carriers to include a notation when any mental health provider or substance abuse provider is closed to new patients.
(2) Beginning January 1, 2020, a health carrier shall prominently post the information listed in (a) through (e) of this subsection on its website in an easily understandable format and in a manner that any interested party may obtain the information:
(a) Whether the health carrier classifies mental health treatment and substance abuse treatment as primary care or specialty care and the number of business days within which an enrollee must have access to covered mental health treatment services and substance abuse treatment services under network access standards pertaining to primary care or specialty care, as applicable, adopted by the commissioner;
(b) Information on actions an enrollee may take if he or she is unable to access covered mental health treatment services or substance abuse treatment services within the requisite number of business days, including any tools or resources the carrier makes available to enrollees to assist them in finding available providers and information on how to file a complaint with the office of the insurance commissioner;
(c) Any instances where the commissioner has taken disciplinary action against the health carrier for failing to comply with network access standards for covered mental health treatment services or substance abuse treatment services;
(d) A link to the commissioner's report published under subsection (5) of this section; and
(e) Resources for persons who are experiencing a mental health crisis including, but not limited to, information on the national suicide prevention lifeline.
(3) The commissioner shall, by rule, specify a model format for the information required to be posted on a health carrier's website under subsection (2) of this section.
(4) The commissioner may audit the information a health carrier provides under this section for accuracy.
(5) The commissioner shall annually publish on the commissioner's website a report on the number of consumer complaints per licensed health carrier the commissioner received in the previous calendar year regarding consumers who were not able to access covered mental health treatment services or substance abuse treatment services within the time limits established by the commissioner for primary care or specialty care.
[
2019 c 11 s 1
.]
NOTES:
Short title
—
2019 c 11:
"This act may be known and cited as Brennen's law." [
2019 c 11 s 2
.]
RCW 48.43.766
Mental health and substance use disorder services
—
Coverage
—
Utilization reviews.
(Effective January 1, 2027.)
(1) For the purposes of this section:
(a) "Clinical review criteria" means written guidelines, standards, protocols, or decision rules used by a health carrier, or health care benefit manager on behalf of a health carrier, during utilization review to evaluate the medical necessity of a patient's requested health care services.
(b) "Core treatment" means a standard treatment or course of treatment, therapy, service, or intervention indicated by generally accepted standards of mental health and substance use disorder care for a condition or disorder.
(c) "Generally accepted standards of mental health and substance use disorder care" means standards of care and clinical practice that are generally recognized by health care providers practicing in relevant clinical specialties such as psychiatry, psychology, clinical sociology, social work, addiction medicine and counseling, and behavioral health treatment.
(d) "Health plan" or "health benefit plan" means:
(i) A health plan as defined by RCW 48.43.005
; or
(ii) A plan deemed by the commissioner to have a short-term limited purpose or duration, or to be a student-only health plan that is guaranteed renewable while the covered person is enrolled as a regular, full-time undergraduate student at an accredited higher education institution.
(e) "Medically necessary" means a service or product addressing the specific needs of a patient, for the purpose of screening, preventing, diagnosing, managing, or treating an illness, injury, condition, or its symptoms, including minimizing the progression of an illness, injury, condition, or its symptoms, in a manner that is:
(i) In accordance with generally accepted standards of mental health and substance use disorder care;
(ii) Clinically appropriate in terms of type, frequency, extent, site, and duration of a service or product; and
(iii) Not primarily for the economic benefit of the insurer or purchaser or for the convenience of the patient, treating physician, or other health care provider.
(f) "Mental health and substance use disorder services" means:
(i) For health benefit plans issued or renewed before January 1, 2021, medically necessary outpatient and inpatient services provided to treat mental disorders covered by the diagnostic categories listed in the most current version of the diagnostic and statistical manual of mental disorders, published by the American psychiatric association, on June 11, 2020, or such subsequent date as may be provided by the insurance commissioner by rule, consistent with the purposes of chapter 6, Laws of 2005, with the exception of the following categories, codes, and services: (A) Substance-related disorders; (B) life transition problems, currently referred to as "V" codes, and diagnostic codes 302 through 302.9 as found in the diagnostic and statistical manual of mental disorders, 4th edition, published by the American psychiatric association; (C) skilled nursing facility services, home health care, residential treatment, and custodial care; and (D) court-ordered treatment, unless the insurer's medical director or designee determines the treatment to be medically necessary;
(ii) For a health benefit plan or a plan deemed by the commissioner to have a short-term limited purpose or duration, or to be a student-only health plan that is guaranteed renewable while the covered person is enrolled as a regular, full-time undergraduate student at an accredited higher education institution, issued or renewed on or after January 1, 2021, medically necessary outpatient services, residential care, partial hospitalization services, and inpatient services provided to treat mental health and substance use disorders covered by the diagnostic categories listed in the most current version of the diagnostic and statistical manual of mental disorders, published by the American psychiatric association, on June 11, 2020, or such subsequent date as may be provided by the insurance commissioner by rule, consistent with the purposes of chapter 6, Laws of 2005; and
(iii) For a health plan issued or renewed on or after January 1, 2027, medically necessary outpatient services, residential care, partial hospitalization services, inpatient services, and prescription drugs provided to treat mental health or substance use disorders covered by:
(A) The diagnostic categories listed in the most current version of the diagnostic and statistical manual of mental disorders, published by the American psychiatric association, on June 11, 2020, or any subsequent version as determined by the insurance commissioner in rule consistent with this section and the goals listed in section 1, chapter 227, Laws of 2025;
(B) The diagnostic categories listed in the mental, behavioral, and neurodevelopmental chapters of the version available on January 13, 2025, of the international classification of diseases adopted by the federal department of health and human services through 42 C.F.R. Sec. 162.002 or any subsequent version as determined by the insurance commissioner in rule consistent with this section and the goals listed in section 1, chapter 227, Laws of 2025; or
(C) The diagnostic categories listed in the DC:0-5 diagnostic classification of mental health and developmental disorders of infancy and early childhood available on January 13, 2025, or any subsequent version as determined by the insurance commissioner in rule consistent with this section and the goals listed in section 1, chapter 227, Laws of 2025.
(g) "Nonprofit professional association" means a not-for-profit health care provider professional association or specialty society that is generally recognized by clinicians practicing in the relevant clinical specialty and issues peer-reviewed guidelines, criteria, or other clinical recommendations developed through a transparent process.
(h) "Utilization review" has the same meaning as in RCW 48.43.005
.
(2) Each health plan providing coverage for medical and surgical services shall provide coverage for mental health and substance use disorder services. Any cost sharing for mental health and substance use disorder services and any treatment limitations related to mental health and substance use disorder services must comply with the quantitative and nonquantitative treatment limitation requirements in the provisions of 89 Fed. Reg. 77586 et seq., as published on September 23, 2024.
(3) Utilization review and clinical review criteria may not deviate from generally accepted standards of mental health and substance use disorder care.
(4)(a) Except as otherwise provided in (c) of this subsection, in conducting utilization reviews relating to service intensity or level of care placement, continued stay, or transfer or discharge, the health carrier shall apply relevant age-appropriate patient placement criteria from nonprofit professional associations and shall authorize placement at the service intensity and level of care consistent with that criteria. The health carrier may not apply conflicting or more restrictive criteria. A carrier may continue to use software-based clinical decision support tools, including those developed by commercial entities, so long as such tools incorporate and apply with fidelity the relevant age-appropriate patient placement criteria consistent with the requirements of this subsection.
(b) If the carrier's application of the relevant age-appropriate patient placement criteria under (a) of this subsection is not consistent with the service intensity or level of care placement requested by the covered person or their provider, any adverse benefit determination notice must include full details of the carrier's assessment under the relevant criteria to the provider and the covered person.
(c) A carrier may use patient placement criteria in addition to the relevant age-appropriate placement criteria under (a) of this subsection only to approve requested services and may not rely on additional patient placement criteria to issue an adverse benefit determination or otherwise deny, restrict, or limit access to requested services.
(d) For utilization review not relating to service intensity or level of care placement, continued stay, or transfer or discharge, a carrier may use clinical review criteria from either for-profit or nonprofit sources provided that the clinical review criteria meet the requirements of subsection (3) of this section.
(e) To ensure appropriate use of all clinical review criteria used by a carrier to conduct utilization reviews, carriers must comply with any oversight measures deemed appropriate by the commissioner.
(5) A health carrier may not limit benefits or coverage for medically necessary mental health and substance use disorder services on the basis that those services should or could be covered by a public entitlement program including, but not limited to, special education or an individualized education program, medicaid, medicare, supplemental security income, or social security disability insurance, and may not include or enforce a contract term that excludes otherwise covered benefits on the basis that those services should or could be covered by a public entitlement program. Nothing in this subsection may be construed to require a carrier to cover benefits that have been authorized and provided for a covered person by a public entitlement program, except as otherwise required by state or federal law.
(6) This section applies to any health care benefit manager, as defined in RCW 48.200.020
[,] or contracted provider that performs utilization review functions directly or indirectly on a health carrier's behalf.
(7) A health carrier may not adopt, impose, or enforce terms in its policies or provider agreements, in writing or in operation, in a manner that undermines, alters, or conflicts with the requirements of this section.
(8) If a health carrier provides any benefits for a mental health condition or substance use disorder in any classification of benefits, it shall provide meaningful benefits for that mental health condition or substance use disorder in every classification in which medical or surgical benefits are provided. For purposes of this subsection, whether the benefits provided are considered "meaningful benefits" is determined in comparison to the benefits provided for medical conditions and surgical procedures in the classification and requires, at a minimum, coverage of benefits for that condition or disorder in each classification in which the health carrier provides benefits for one or more medical conditions or surgical procedures. A health carrier does not provide meaningful benefits under this subsection unless it provides benefits for a core treatment for that condition or disorder in each classification in which the health carrier provides benefits for a core treatment for one or more medical conditions or surgical procedures. If there is no core treatment for a covered mental health condition or substance use disorder with respect to a classification, the health carrier is not required to provide benefits for a core treatment for such condition or disorder in that classification, but shall provide benefits for such condition or disorder in every classification in which medical or surgical benefits are provided.
(9) The provisions of 89 Fed. Reg. 77586 et seq., as published on September 23, 2024, and any guidance issued by federal departments of health and human services, labor, and the treasury to implement the rules adopted in September 2024 are incorporated in this section in their entirety.
(10) If, following an adverse benefit determination, a covered person requests one or more nonquantitative treatment limitation parity compliance analyses that the health carrier is required to have completed by 29 U.S.C. Sec. 1185a or 42 U.S.C. Sec. 300gg–26, the health carrier shall provide the requested analyses free of charge within 30 days.
(11) This section does not prohibit a requirement that mental health and substance use disorder services be medically necessary, if a comparable requirement is applicable to medical and surgical services.
[
2025 c 227 s 2
.]
NOTES:
Effective date
—
2025 c 227 ss 1-8:
"Sections 1 through 8 of this act take effect January 1, 2027." [
2025 c 227 s 10
.]
Findings
—
Intent
—
2025 c 227:
"(1) The legislature finds that:
(a) Access to mental health and substance use disorder treatment is critical to the health and well-being of individuals with these conditions and that access to appropriate care is important to reducing preventable emergency department visits, hospitalizations, and physical health care costs associated with significant comorbidities;
(b) Health insurance coverage is essential to ensuring that individuals can access needed mental health and substance use disorder treatment and that health carriers should make medical necessity determinations based on the objective needs of the patient; and
(c) The mental health and substance use disorder workforce faces a number of administrative barriers and undue financial risks with respect to participation in health carriers' provider networks that should be alleviated.
(2) Therefore, it is the intent of the legislature to increase access to mental health and substance use disorder treatment by updating Washington's mental health parity requirements, requiring that medical necessity determinations be consistent with generally accepted standards of care and recommendations from nonprofit health care provider associations, requiring consistent rules for both mental health and substance use disorders, and eliminating harmful barriers to care." [
2025 c 227 s 1
.]
Rules
—
2025 c 227:
"The insurance commissioner may adopt rules necessary to implement this act, including requiring submission of quantitative data to determine in-operation parity compliance." [
2025 c 227 s 9
.]
RCW 48.43.767
Behavioral health services
—
Network access.
By July 1, 2025, every carrier shall provide access to services provided by behavioral health support specialists in a manner sufficient to meet the network access standards set forth in rules established by the office of the insurance commissioner.
[
2023 c 270 s 12
.]
RCW 48.43.770
Individual market health plan availability
—
Annual report.
The commissioner shall submit an annual report to the appropriate committees of the legislature on the number of health plans available per county in the individual market.
[
2019 c 364 s 7
.]
RCW 48.43.775
Qualified health plan participation
—
Reimbursement rate for other health plans.
A carrier may not require a provider or facility participating in a qualified health plan under RCW 41.05.410
to, as a condition of participation in a qualified health plan under RCW 41.05.410, accept a reimbursement rate for other health plans offered by the carrier at the same rate as the provider or facility is reimbursed for a qualified health plan under RCW 41.05.410
.
[
2019 c 364 s 8
.]
RCW 48.43.780
Cap on enrollee's required payment amount for specific drugs and equipment
—
Cost-sharing requirements.
(1)(a) Except as required in (b) of this subsection, a health plan issued or renewed on or after January 1, 2023, that provides coverage for prescription insulin drugs for the treatment of diabetes must cap the total amount that an enrollee is required to pay for a covered insulin drug at an amount not to exceed $35 per 30-day supply of the drug. Prescription insulin drugs must be covered without being subject to a deductible, and any cost sharing paid by an enrollee must be applied toward the enrollee's deductible obligation.
(b) If the federal internal revenue service removes insulin from the list of preventive care services which can be covered by a qualifying health plan for a health savings account before the deductible is satisfied, for a health plan that provides coverage for prescription insulin drugs for the treatment of diabetes and is offered as a qualifying health plan for a health savings account, the carrier must establish the plan's cost sharing for the coverage of prescription insulin for diabetes at the minimum level necessary to preserve the enrollee's ability to claim tax exempt contributions from his or her health savings account under internal revenue service laws and regulations.
(2)(a) Except as provided in (b) of this subsection, a health plan issued or renewed on or after January 1, 2025, that provides coverage for prescription asthma inhalers for the treatment of asthma shall cap the total amount that an enrollee is required to pay for at least one covered inhaled corticosteroid and at least one covered inhaled corticosteroid combination that is federal food and drug administration approved for the treatment of asthma at an amount not to exceed $35 per 30-day supply of the drug. A health plan must ensure that a covered inhaled corticosteroid and a covered inhaled corticosteroid combination is always available to a patient at the amount required by this subsection. Except as provided in (b) of this subsection, prescription asthma inhalers must be covered without being subject to a deductible, and any cost sharing paid by an enrollee must be applied toward the enrollee's deductible obligation.
(b) For a health plan that is offered as a qualifying health plan for a health savings account, the health carrier shall establish the plan's cost sharing for asthma inhalers that are not on the federal internal revenue service's list of preventive care services at the minimum level necessary to preserve the enrollee's ability to claim tax exempt contributions and withdrawals from the enrollee's health savings account under internal revenue service laws and regulations. If the federal internal revenue service removes asthma inhalers from the list of preventive care services which can be covered by a qualifying health plan for a health savings account before the deductible is satisfied, for a health plan that provides coverage for prescription asthma inhalers for the treatment of asthma and is offered as a qualifying health plan for a health savings account, the carrier shall establish the plan's cost sharing for the coverage of prescription asthma inhalers at the minimum level necessary to preserve the enrollee's ability to claim tax exempt contributions from the enrollee's health savings account under internal revenue service laws and regulations.
(3)(a) Except as provided in (b) of this subsection, a health plan issued or renewed on or after January 1, 2025, that provides coverage for prescription epinephrine autoinjectors for the treatment of allergic reaction shall cap the total amount that an enrollee is required to pay for at least one covered epinephrine autoinjector product containing at least two autoinjectors at an amount not to exceed $35. A health plan must ensure that a covered epinephrine autoinjector is always available to a patient at the amount required by this subsection. Except as provided in (b) of this subsection, prescription epinephrine autoinjectors must be covered without being subject to a deductible, and any cost sharing paid by an enrollee must be applied toward the enrollee's deductible obligation.
(b) For a health plan that is offered as a qualifying health plan for a health savings account, the health carrier shall establish the plan's cost sharing for epinephrine autoinjectors at the minimum level necessary to preserve the enrollee's ability to claim tax exempt contributions and withdrawals from the enrollee's health savings account under internal revenue service laws and regulations. If the federal internal revenue service adds epinephrine autoinjectors to the list of preventive care services which can be covered by a qualifying health plan for a health savings account before the deductible is satisfied, coverage must be provided as described in (a) of this subsection without being subject to the deductible.
(4) The office of the insurance commissioner must provide written notice of any changes in internal revenue service guidance regarding any prescription drug covered in this section to affected parties, the chief clerk of the house of representatives, the secretary of the senate, the office of the code reviser, and others as deemed appropriate by the office.
(5) To the extent not prohibited under this section, health plans may apply drug utilization management strategies to prescription drugs covered under subsections (2) and (3) of this section.
[
2024 c 226 s 1
;
2023 c 16 s 1
;
2022 c 10 s 1
. Prior:
2020 c 346 s 5
;
2020 c 245 s 1
.]
NOTES:
Effective date
—
2022 c 10 s 1:
"Section 1 of this act takes effect January 1, 2023." [
2022 c 10 s 3
.]
Intent
—
2020 c 346:
See note following RCW 70.14.165
.