RCW 48.43.001
Intent.
It is the intent of the legislature to ensure that all enrollees in managed care settings have access to adequate information regarding health care services covered by health carriers' health plans, and provided by health care providers and health care facilities. It is only through such disclosure that Washington state citizens can be fully informed as to the extent of health insurance coverage, availability of health care service options, and necessary treatment. With such information, citizens are able to make knowledgeable decisions regarding their health care.
[
1996 c 312 s 1
.]
RCW 48.43.005
Definitions.
Unless otherwise specifically provided, the definitions in this section apply throughout this chapter.
(1) "Adjusted community rate" means the rating method used to establish the premium for health plans adjusted to reflect actuarially demonstrated differences in utilization or cost attributable to geographic region, age, family size, and use of wellness activities.
(2) "Adverse benefit determination" means a denial, reduction, or termination of, or a failure to provide or make payment, in whole or in part, for a benefit, including a denial, reduction, termination, or failure to provide or make payment that is based on a determination of an enrollee's or applicant's eligibility to participate in a plan, and including, with respect to group health plans, a denial, reduction, or termination of, or a failure to provide or make payment, in whole or in part, for a benefit resulting from the application of any utilization review, as well as a failure to cover an item or service for which benefits are otherwise provided because it is determined to be experimental or investigational or not medically necessary or appropriate.
(3) "Air ambulance service" has the same meaning as defined in section 2799A-2 of the public health service act (42 U.S.C. Sec. 300gg-112) and implementing federal regulations in effect on March 31, 2022.
(4) "Allowed amount" means the maximum portion of a billed charge a health carrier will pay, including any applicable enrollee cost-sharing responsibility, for a covered health care service or item rendered by a participating provider or facility or by a nonparticipating provider or facility.
(5) "Applicant" means a person who applies for enrollment in an individual health plan as the subscriber or an enrollee, or the dependent or spouse of a subscriber or enrollee.
(6) "Balance bill" means a bill sent to an enrollee by a nonparticipating provider or facility for health care services provided to the enrollee after the provider or facility's billed amount is not fully reimbursed by the carrier, exclusive of permitted cost-sharing.
(7) "Basic health plan" means the plan described under chapter
70.47
RCW, as revised from time to time.
(8) "Basic health plan model plan" means a health plan as required in RCW 70.47.060
(2)(e).
(9) "Basic health plan services" means that schedule of covered health services, including the description of how those benefits are to be administered, that are required to be delivered to an enrollee under the basic health plan, as revised from time to time.
(10) "Behavioral health emergency services provider" means emergency services provided in the following settings:
(a) A crisis stabilization unit as defined in RCW 71.05.020
;
(b) A 23-hour crisis relief center as defined in RCW 71.24.025
;
(c) An evaluation and treatment facility that can provide directly, or by direct arrangement with other public or private agencies, emergency evaluation and treatment, outpatient care, and timely and appropriate inpatient care to persons suffering from a mental disorder, and which is licensed or certified as such by the department of health;
(d) An agency certified by the department of health under chapter
71.24
RCW to provide outpatient crisis services;
(e) An agency certified by the department of health under chapter
71.24
RCW to provide medically managed or medically monitored withdrawal management services; or
(f) A mobile rapid response crisis team as defined in RCW 71.24.025
that is contracted with a behavioral health administrative services organization operating under RCW 71.24.045
to provide crisis response services in the behavioral health administrative services organization's service area.
(11) "Board" means the governing board of the Washington health benefit exchange established in chapter
43.71
RCW.
(12)(a) For grandfathered health benefit plans issued before January 1, 2014, and renewed thereafter, "catastrophic health plan" means:
(i) In the case of a contract, agreement, or policy covering a single enrollee, a health benefit plan requiring a calendar year deductible of, at a minimum, $1,750 and an annual out-of-pocket expense required to be paid under the plan (other than for premiums) for covered benefits of at least $3,500, both amounts to be adjusted annually by the insurance commissioner; and
(ii) In the case of a contract, agreement, or policy covering more than one enrollee, a health benefit plan requiring a calendar year deductible of, at a minimum, $3,500 and an annual out-of-pocket expense required to be paid under the plan (other than for premiums) for covered benefits of at least $6,000, both amounts to be adjusted annually by the insurance commissioner.
(b) In July 2008, and in each July thereafter, the insurance commissioner shall adjust the minimum deductible and out-of-pocket expense required for a plan to qualify as a catastrophic plan to reflect the percentage change in the consumer price index for medical care for a preceding 12 months, as determined by the United States department of labor. For a plan year beginning in 2014, the out-of-pocket limits must be adjusted as specified in section 1302(c)(1) of P.L. 111-148 of 2010, as amended. The adjusted amount shall apply on the following January 1st.
(c) For health benefit plans issued on or after January 1, 2014, "catastrophic health plan" means:
(i) A health benefit plan that meets the definition of catastrophic plan set forth in section 1302(e) of P.L. 111-148 of 2010, as amended; or
(ii) A health benefit plan offered outside the exchange marketplace that requires a calendar year deductible or out-of-pocket expenses under the plan, other than for premiums, for covered benefits, that meets or exceeds the commissioner's annual adjustment under (b) of this subsection.
(13) "Certification" means a determination by a review organization that an admission, extension of stay, or other health care service or procedure has been reviewed and, based on the information provided, meets the clinical requirements for medical necessity, appropriateness, level of care, or effectiveness under the auspices of the applicable health benefit plan.
(14) "Concurrent review" means utilization review conducted during a patient's hospital stay or course of treatment.
(15) "Covered person" or "enrollee" means a person covered by a health plan including an enrollee, subscriber, policyholder, beneficiary of a group plan, or individual covered by any other health plan.
(16) "Dependent" means, at a minimum, the enrollee's legal spouse and dependent children who qualify for coverage under the enrollee's health benefit plan.
(17) "Emergency medical condition" means a medical, mental health, or substance use disorder condition manifesting itself by acute symptoms of sufficient severity including, but not limited to, severe pain or emotional distress, such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical, mental health, or substance use disorder treatment attention to result in a condition (a) 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, (b) serious impairment to bodily functions, or (c) serious dysfunction of any bodily organ or part.
(18) "Emergency services" means:
(a)(i) A medical screening examination, as required under section 1867 of the social security act (42 U.S.C. Sec. 1395dd), that is within the capability of the emergency department of a hospital, including ancillary services routinely available to the emergency department to evaluate that emergency medical condition;
(ii) Medical examination and treatment, to the extent they are within the capabilities of the staff and facilities available at the hospital, as are required under section 1867 of the social security act (42 U.S.C. Sec. 1395dd) to stabilize the patient. Stabilize, with respect to an emergency medical condition, has the meaning given in section 1867(e)(3) of the social security act (42 U.S.C. Sec. 1395dd(e)(3)); and
(iii) Covered services provided by staff or facilities of a hospital after the enrollee is stabilized and as part of outpatient observation or an inpatient or outpatient stay with respect to the visit during which screening and stabilization services have been furnished. Poststabilization services relate to medical, mental health, or substance use disorder treatment necessary in the short term to avoid 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, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part; or
(b)(i) A screening examination that is within the capability of a behavioral health emergency services provider including ancillary services routinely available to the behavioral health emergency services provider to evaluate that emergency medical condition;
(ii) Examination and treatment, to the extent they are within the capabilities of the staff and facilities available at the behavioral health emergency services provider, as are required under section 1867 of the social security act (42 U.S.C. Sec. 1395dd) or as would be required under such section if such section applied to behavioral health emergency services providers, to stabilize the patient. Stabilize, with respect to an emergency medical condition, has the meaning given in section 1867(e)(3) of the social security act (42 U.S.C. Sec. 1395dd(e)(3)); and
(iii) Covered behavioral health services provided by staff or facilities of a behavioral health emergency services provider after the enrollee is stabilized and as part of outpatient observation or an inpatient or outpatient stay with respect to the visit during which screening and stabilization services have been furnished. Poststabilization services relate to mental health or substance use disorder treatment necessary in the short term to avoid 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, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part.
(19) "Employee" has the same meaning given to the term, as of January 1, 2008, under section 3(6) of the federal employee retirement income security act of 1974.
(20) "Enrollee point-of-service cost-sharing" or "cost-sharing" means amounts paid to health carriers directly providing services, health care providers, or health care facilities by enrollees and may include copayments, coinsurance, or deductibles.
(21) "Essential health benefit categories" means:
(a) Ambulatory patient services;
(b) Emergency services;
(c) Hospitalization;
(d) Maternity and newborn care;
(e) Mental health and substance use disorder services, including behavioral health treatment;
(f) Prescription drugs;
(g) Rehabilitative and habilitative services and devices;
(h) Laboratory services;
(i) Preventive and wellness services and chronic disease management; and
(j) Pediatric services, including oral and vision care.
(22) "Exchange" means the Washington health benefit exchange established under chapter
43.71
RCW.
(23) "Final external review decision" means a determination by an independent review organization at the conclusion of an external review.
(24) "Final internal adverse benefit determination" means an adverse benefit determination that has been upheld by a health plan or carrier at the completion of the internal appeals process, or an adverse benefit determination with respect to which the internal appeals process has been exhausted under the exhaustion rules described in RCW 48.43.530
and
48.43.535
.
(25) "Grandfathered health plan" means a group health plan or an individual health plan that under section 1251 of the patient protection and affordable care act, P.L. 111-148 (2010) and as amended by the health care and education reconciliation act, P.L. 111-152 (2010) is not subject to subtitles A or C of the act as amended.
(26) "Grievance" means a written complaint submitted by or on behalf of a covered person regarding service delivery issues other than denial of payment for medical services or nonprovision of medical services, including dissatisfaction with medical care, waiting time for medical services, provider or staff attitude or demeanor, or dissatisfaction with service provided by the health carrier.
(27) "Ground ambulance services" means:
(a) The rendering of medical treatment and care at the scene of a medical emergency or while transporting a patient from the scene to an appropriate health care facility or behavioral health emergency services provider when the services are provided by one or more ground ambulance vehicles designed for this purpose; and
(b) Ground ambulance transport between hospitals or behavioral health emergency services providers, hospitals or behavioral health emergency services providers and other health care facilities or locations, and between health care facilities when the services are medically necessary and are provided by one or more ground ambulance vehicles designed for this purpose.
(28) "Ground ambulance services organization" means a public or private organization licensed by the department of health under chapter
18.73
RCW to provide ground ambulance services. For purposes of this chapter, ground ambulance services organizations are not considered providers.
(29) "Health care facility" or "facility" means hospices licensed under chapter
70.127
RCW, hospitals licensed under chapter
70.41
RCW, rural health care facilities as defined in RCW 70.175.020, *psychiatric hospitals licensed under chapter
71.12
RCW, nursing homes licensed under chapter
18.51
RCW, community mental health centers licensed under chapter
71.05
or
71.24
RCW, kidney disease treatment centers licensed under chapter
70.41
RCW, ambulatory diagnostic, treatment, or surgical facilities licensed under chapter
70.41
or
70.230
RCW, drug and alcohol treatment facilities licensed under **chapter
70.96A
RCW, and home health agencies licensed under chapter
70.127
RCW, and includes such facilities if owned and operated by a political subdivision or instrumentality of the state and such other facilities as required by federal law and implementing regulations.
(30) "Health care provider" or "provider" means:
(a) A person regulated under Title 18 or chapter
70.127
RCW, to practice health or health-related services or otherwise practicing health care services in this state consistent with state law; or
(b) An employee or agent of a person described in (a) of this subsection, acting in the course and scope of his or her employment.
(31) "Health care service" means that service offered or provided by health care facilities and health care providers relating to the prevention, cure, or treatment of illness, injury, or disease.
(32) "Health carrier" or "carrier" means a disability insurer regulated under chapter
48.20
or
48.21
RCW, a health care service contractor as defined in RCW 48.44.010, or a health maintenance organization as defined in RCW 48.46.020, and includes "issuers" as that term is used in the patient protection and affordable care act (P.L. 111-148).
(33) "Health plan" or "health benefit plan" means any policy, contract, or agreement offered by a health carrier to provide, arrange, reimburse, or pay for health care services except the following:
(a) Long-term care insurance governed by chapter
48.84
or
48.83
RCW;
(b) Medicare supplemental health insurance governed by chapter
48.66
RCW;
(c) Coverage supplemental to the coverage provided under chapter 55, Title 10, United States Code;
(d) Limited health care services offered by limited health care service contractors in accordance with RCW 48.44.035
;
(e) Disability income;
(f) Coverage incidental to a property/casualty liability insurance policy such as automobile personal injury protection coverage and homeowner guest medical;
(g) Workers' compensation coverage;
(h) Accident only coverage;
(i) Specified disease or illness-triggered fixed payment insurance, hospital confinement fixed payment insurance, or other fixed payment insurance offered as an independent, noncoordinated benefit;
(j) Employer-sponsored self-funded health plans;
(k) Dental only and vision only coverage;
(l) Plans deemed by the insurance commissioner to have a short-term limited purpose or duration, or to be a student-only plan that is guaranteed renewable while the covered person is enrolled as a regular full-time undergraduate or graduate student at an accredited higher education institution, after a written request for such classification by the carrier and subsequent written approval by the insurance commissioner;
(m) Civilian health and medical program for the veterans affairs administration (CHAMPVA); and
(n) Stand-alone prescription drug coverage that exclusively supplements medicare part D coverage provided through an employer group waiver plan under federal social security act regulation 42 C.F.R. Sec. 423.458(c).
(34) "Individual market" means the market for health insurance coverage offered to individuals other than in connection with a group health plan.
(35) "In-network" or "participating" means a provider or facility that has contracted with a carrier or a carrier's contractor or subcontractor to provide health care services to enrollees and be reimbursed by the carrier at a contracted rate as payment in full for the health care services, including applicable cost-sharing obligations.
(36) "Local governmental entity" means any entity that is authorized to establish or provide ground ambulance services or set rates for ground ambulance services, including those as authorized in RCW 35.27.370, 35.23.456, 52.12.135, chapter
35.21
RCW, or as authorized under any state law.
(37) "Material modification" means a change in the actuarial value of the health plan as modified of more than five percent but less than fifteen percent.
(38) "Nonemergency health care services performed by nonparticipating providers at certain participating facilities" means covered items or services other than emergency services with respect to a visit at a participating health care facility, as provided in section 2799A-1(b) of the public health service act (42 U.S.C. Sec. 300gg-111(b)), 45 C.F.R. Sec. 149.30, and 45 C.F.R. Sec. 149.120 as in effect on March 31, 2022.
(39) "Open enrollment" means a period of time as defined in rule to be held at the same time each year, during which applicants may enroll in a carrier's individual health benefit plan without being subject to health screening or otherwise required to provide evidence of insurability as a condition for enrollment.
(40) "Out-of-network" or "nonparticipating" means a provider or facility that has not contracted with a carrier or a carrier's contractor or subcontractor to provide health care services to enrollees.
(41) "Out-of-pocket maximum" or "maximum out-of-pocket" means the maximum amount an enrollee is required to pay in the form of cost-sharing for covered benefits in a plan year, after which the carrier covers the entirety of the allowed amount of covered benefits under the contract of coverage.
(42) "Preexisting condition" means any medical condition, illness, or injury that existed any time prior to the effective date of coverage.
(43) "Premium" means all sums charged, received, or deposited by a health carrier as consideration for a health plan or the continuance of a health plan. Any assessment or any "membership," "policy," "contract," "service," or similar fee or charge made by a health carrier in consideration for a health plan is deemed part of the premium. "Premium" shall not include amounts paid as enrollee point-of-service cost-sharing.
(44)(a) "Protected individual" means:
(i) An adult covered as a dependent on the enrollee's health benefit plan, including an individual enrolled on the health benefit plan of the individual's registered domestic partner; or
(ii) A minor who may obtain health care without the consent of a parent or legal guardian, pursuant to state or federal law.
(b) "Protected individual" does not include an individual deemed not competent to provide informed consent for care under ***RCW 11.88.010
(1)(e).
(45) "Review organization" means a disability insurer regulated under chapter
48.20
or
48.21
RCW, health care service contractor as defined in RCW 48.44.010, or health maintenance organization as defined in RCW 48.46.020, and entities affiliated with, under contract with, or acting on behalf of a health carrier to perform a utilization review.
(46) "Sensitive health care services" means health services related to reproductive health, sexually transmitted diseases, substance use disorder, gender dysphoria, gender-affirming care, domestic violence, and mental health.
(47) "Small employer" or "small group" means any person, firm, corporation, partnership, association, political subdivision, sole proprietor, or self-employed individual that is actively engaged in business that employed an average of at least one but no more than 50 employees, during the previous calendar year and employed at least one employee on the first day of the plan year, is not formed primarily for purposes of buying health insurance, and in which a bona fide employer-employee relationship exists. In determining the number of employees, companies that are affiliated companies, or that are eligible to file a combined tax return for purposes of taxation by this state, shall be considered an employer. Subsequent to the issuance of a health plan to a small employer and for the purpose of determining eligibility, the size of a small employer shall be determined annually. Except as otherwise specifically provided, a small employer shall continue to be considered a small employer until the plan anniversary following the date the small employer no longer meets the requirements of this definition. A self-employed individual or sole proprietor who is covered as a group of one must also: (a) Have been employed by the same small employer or small group for at least twelve months prior to application for small group coverage, and (b) verify that he or she derived at least 75 percent of his or her income from a trade or business through which the individual or sole proprietor has attempted to earn taxable income and for which he or she has filed the appropriate internal revenue service form 1040, schedule C or F, for the previous taxable year, except a self-employed individual or sole proprietor in an agricultural trade or business, must have derived at least 51 percent of his or her income from the trade or business through which the individual or sole proprietor has attempted to earn taxable income and for which he or she has filed the appropriate internal revenue service form 1040, for the previous taxable year.
(48) "Special enrollment" means a defined period of time of not less than thirty-one days, triggered by a specific qualifying event experienced by the applicant, during which applicants may enroll in the carrier's individual health benefit plan without being subject to health screening or otherwise required to provide evidence of insurability as a condition for enrollment.
(49) "Standard health questionnaire" means the standard health questionnaire designated under chapter
48.41
RCW.
(50) "Utilization review" means the prospective, concurrent, or retrospective assessment of the necessity and appropriateness of the allocation of health care resources and services of a provider or facility, given or proposed to be given to an enrollee or group of enrollees.
(51) "Wellness activity" means an explicit program of an activity consistent with department of health guidelines, such as, smoking cessation, injury and accident prevention, reduction of alcohol misuse, appropriate weight reduction, exercise, automobile and motorcycle safety, blood cholesterol reduction, and nutrition education for the purpose of improving enrollee health status and reducing health service costs.
[
2024 c 218 s 1
;
2023 c 433 s 20
. Prior:
2022 c 263 s 2
;
2020 c 196 s 1
; prior:
2019 c 427 s 2
;
2019 c 56 s 2
;
2019 c 33 s 1
;
2016 c 65 s 2
; prior:
2012 c 211 s 17
;
2012 c 87 s 1
; prior:
2011 c 315 s 2
;
2011 c 314 s 3
; prior:
2010 c 292 s 1
; prior:
2008 c 145 s 20
;
2008 c 144 s 1
; prior:
2007 c 296 s 1
;
2007 c 259 s 32
;
2006 c 25 s 16
;
2004 c 244 s 2
; prior:
2001 c 196 s 5
;
2001 c 147 s 1
;
2000 c 79 s 18
; prior:
1997 c 231 s 202
;
1997 c 55 s 1
;
1995 c 265 s 4
.]
NOTES:
Reviser's note:
*(1) The term "psychiatric hospital" was changed to "behavioral health hospital" by
2024 c 121 s 19
.
**(2) Chapter
70.96A
RCW was repealed and/or recodified in its entirety pursuant to 2016 sp.s. c 29 ss 301, 601, and 701.
***(3) RCW 11.88.010
was repealed by 2020 c 312 s 904, effective January 1, 2022.
Effective date
—
2022 c 263:
See note following RCW 43.371.100
.
Effective date
—
2020 c 196:
"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 27, 2020]." [
2020 c 196 s 2
.]
Findings
—
Intent
—
Effective date
—
2019 c 427:
See RCW 48.49.003
and
48.49.900
.
Findings
—
Declarations
—
Effective date
—
2019 c 56:
See notes following RCW 48.43.5051
.
Effective date
—
2019 c 33:
"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 17, 2019]." [
2019 c 33 s 17
.]
Spiritual care services
—
2012 c 87:
See RCW 43.71.901
.
Intent
—
2011 c 315:
"The federal patient protection and affordable care act (P.L. 111-148) prohibits insurance carriers from applying preexisting condition limitations for persons under age nineteen, beginning on or after September 23, 2010. The guidance from the United States department of health and human services provides some direction for the implementation of the new policy requirement, and the office of the insurance commissioner further clarified open enrollment requirements to help prevent disruption in the individual health insurance marketplace. It is the intent of this act to:
(1) Maintain access to individual plan options for persons under age nineteen; and
(2) Provide clarity for the establishment of open enrollment and special open enrollment periods that balance access to guaranteed issue coverage with efforts that protect market stability." [
2011 c 315 s 1
.]
Application
—
2010 c 292:
"This act applies to policies issued or renewed on or after January 1, 2011." [
2010 c 292 s 9
.]
Contingent effective date
—
2010 c 292 ss 1 and 2:
"Sections 1 and 2 of this act take effect one hundred eighty days [September 29, 2010] after the date the insurance commissioner certifies to the secretary of the senate, the chief clerk of the house of representatives, and the code reviser's office that federal legislation has been signed into law by the President of the United States that includes guaranteed issue for individuals who purchase health coverage through the individual or small group markets." [
2010 c 292 s 11
.]
Effective date
—
2008 c 145:
See RCW 48.83.901
.
Subheadings not law
—
2007 c 259:
See note following RCW 7.70.060
.
Application
—
2004 c 244:
See note following RCW 48.21.045
.
Effective date
—
2001 c 196:
See note following RCW 48.20.025
.
Effective date
—
Severability
—
2000 c 79:
See notes following RCW 48.04.010
.
Short title
—
1997 c 231:
"This act shall be known as the consumer assistance and insurance market stabilization act." [
1997 c 231 s 402
.]
Part headings and captions not law
—
1997 c 231:
"Part headings and section captions used in this act are not part of the law." [
1997 c 231 s 403
.]
Severability
—
1997 c 231:
"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." [
1997 c 231 s 404
.]
Effective dates
—
1997 c 231:
"(1) Sections 104 through 108 and 301 of this act take effect January 1, 1998.
(2) Section 111 of this act is necessary for the immediate preservation of the public peace, health, or safety, or support of the state government and its existing public institutions, and takes effect July 1, 1997.
(3) Section 205 of 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." [
1997 c 231 s 405
.]
Effective date
—
1997 c 55:
"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 16, 1997]." [
1997 c 55 s 2
.]
Captions not law
—
Effective dates
—
Savings
—
Severability
—
1995 c 265:
See notes following RCW 70.47.015
.
RCW 48.43.007
Availability of price and quality information
—
Transparency tools for members
—
Requirements.
(1) Each carrier offering or renewing a health benefit plan on or after January 1, 2016, must offer member transparency tools with certain price and quality information to enable the member to make treatment decisions based on cost, quality, and patient experience. The transparency tools must aim for best practices and, at a minimum:
(a) Must display cost data for common treatments within the following categories:
(i) Inpatient treatments;
(ii) Outpatient treatments;
(iii) Diagnostic tests; and
(iv) Office visits;
(b) Recognizing integrated health care delivery systems focus on total cost of care, carrier's operating integrated care delivery systems may meet the requirement of (a) of this subsection by providing meaningful consumer data based on the total cost of care. This subsection applies only to the portion of enrollment a carrier offers pursuant to chapter
48.46
RCW and as part of an integrated delivery system, and does not exempt from (a) of this subsection coverage offered pursuant to chapter
48.21, 48.44, or
48.46
RCW if not part of an integrated delivery system;
(c) Are encouraged to display the cost for prescription medications on their member website or through a link to a third party that manages the prescription benefits;
(d) Must include a patient review option or method for members to provide a rating or feedback on their experience with the medical provider that allows other members to see the patient review, the feedback must be monitored for appropriateness and validity, and the site may include independently compiled quality of care ratings of providers and facilities;
(e) Must allow members to access the estimated cost of the treatment, or the total cost of care, as set forth in (a) and (b) of this subsection on a portable electronic device;
(f) Must display options based on the selected search criteria for members to compare;
(g) Must display the estimated cost of the treatment, or total cost of the care episode, and the estimated out-of-pocket costs of the treatment for the member and display the application of personalized benefits such as deductibles and cost-sharing;
(h) Must display quality information on providers when available; and
(i) Are encouraged to display alternatives that are more cost-effective when there are alternatives available, such as the use of an ambulatory surgical center when one is available or medical versus surgical alternatives as appropriate.
(2) In addition to the required features on cost and quality information, the member transparency tools must include information to allow a provider and hospital search of in-network providers and hospitals with provider information including specialists, distance from patient, the provider's contact information, the provider's education, board certification and other credentials, where to find information on malpractice history and disciplinary actions, affiliated hospitals and other providers in a clinic, and directions to provider offices and hospitals.
(3) Each carrier offering or renewing a health benefit plan on or after January 1, 2016, must provide enrollees with the performance information required by section 2717 of the patient protection and affordable care act, P.L. 111-148 (2010), as amended by the health care and education reconciliation act, P.L. 111-152 (2010), and any federal regulations or guidance issued under that section of the affordable care act.
(4) Each carrier offering or renewing a health benefit plan on or after January 1, 2016, must, within thirty days from the offer or renewal date, attest to the office of the insurance commissioner that the member transparency tools meet the requirements in this section and access to the tools is available on the home page within the health plan's secured member website.
[
2014 c 224 s 3
.]
NOTES:
Intent
—
2014 c 224:
"Consumers face a challenge finding reliable, consumer friendly information on health care pricing and quality. Greater transparency of health care prices and quality leads to engaged, activated consumers. Research indicates that engaged and educated consumers help control costs and improve quality with lower costs per patient, lower hospital readmission rates, and the use of higher quality providers. Washington is a leader in efforts to develop and publish provider quality information.
Although data is available today, research indicates the existing information is not user-friendly, consumers do not know which measures are most relevant, and quality ratings are inconsistent or nonstandardized. It is the intent of the legislature to ensure consumer tools are available to educate and engage patients in managing their care and understanding the costs and quality." [
2014 c 224 s 1
.]
RCW 48.43.008
Enrollment in employer-sponsored health plan
—
Person eligible for medical assistance.
When the health care authority determines that it is cost-effective to enroll a person eligible for medical assistance under chapter
74.09
RCW in an employer-sponsored health plan, a carrier shall permit the enrollment of the person in the health plan for which he or she is otherwise eligible without regard to any open enrollment period restrictions.
[
2011 1st sp.s. c 15 s 77
;
2007 c 259 s 24
.]
NOTES:
Effective date
—
Findings
—
Intent
—
Report
—
Agency transfer
—
References to head of health care authority
—
Draft legislation
—
2011 1st sp.s. c 15:
See notes following RCW 74.09.010
.
Subheadings not law
—
2007 c 259:
See note following RCW 7.70.060
.
RCW 48.43.009
Health care sharing ministries.
Health care sharing ministries are not health carriers as defined in RCW 48.43.005
or insurers as defined in RCW 48.01.050
. For purposes of this section, "health care sharing ministry" has the same meaning as in 26 U.S.C. Sec. 5000A.
[
2011 c 314 s 18
.]
RCW 48.43.012
Health plans
—
Preexisting conditions
—
Rules.
(1) No carrier may reject an individual for an individual or group health benefit plan based upon preexisting conditions of the individual.
(2) No carrier may deny, exclude, or otherwise limit coverage for an individual's preexisting health conditions including, but not limited to, preexisting condition exclusions or waiting periods.
(3) No carrier may avoid the requirements of this section through the creation of a new rate classification or the modification of an existing rate classification. A new or changed rate classification will be deemed an attempt to avoid the provisions of this section if the new or changed classification would substantially discourage applications for coverage from individuals who are higher than average health risks. These provisions apply only to individuals who are Washington residents.
(4) Unless preempted by federal law, the commissioner shall adopt any rules necessary to implement this section, consistent with federal rules and guidance in effect on January 1, 2017, implementing the patient protection and affordable care act.
[
2019 c 33 s 2
;
2011 c 315 s 3
;
2001 c 196 s 6
;
2000 c 79 s 19
.]
NOTES:
Effective date
—
2019 c 33:
See note following RCW 48.43.005
.
Intent
—
2011 c 315:
See note following RCW 48.43.005
.
Effective date
—
2001 c 196:
See note following RCW 48.20.025
.
Effective date
—
Severability
—
2000 c 79:
See notes following RCW 48.04.010
.
RCW 48.43.01211
Health plans
—
Eligibility
—
Health status-related factors
—
Rules.
(1) A health carrier or health plan may not establish rules for eligibility, including continued eligibility, of any individual to enroll under the terms of the plan or coverage based on any of the following health status-related factors in relation to the individual or a dependent of the individual:
(a) Health status;
(b) Medical condition, including both physical and mental illnesses;
(c) Claims experience;
(d) Receipt of health care;
(e) Medical history;
(f) Genetic information;
(g) Evidence of insurability, including conditions arising out of acts of domestic violence;
(h) Disability; or
(i) Any other health status-related factor determined appropriate by the commissioner.
(2) Unless preempted by federal law, the commissioner shall adopt any rules necessary to implement this section, consistent with federal rules and guidance in effect on January 1, 2017, implementing the patient protection and affordable care act.
[
2019 c 33 s 3
.]
NOTES:
Effective date
—
2019 c 33:
See note following RCW 48.43.005
.
RCW 48.43.0122
Individual health benefit plans
—
Open enrollment and special enrollment periods
—
Rules
—
Enforcement.
(1) The commissioner shall adopt rules establishing and implementing requirements for the open enrollment periods and special enrollment periods that carriers must follow for individual health benefit plans.
(2) The commissioner shall monitor the sale of individual health benefit plans and if a carrier refuses to sell guaranteed issue policies to persons in compliance with rules adopted by the commissioner pursuant to subsection (1) of this section, the commissioner may levy fines or suspend or revoke a certificate of authority as provided in chapter
48.05
RCW.
[
2019 c 33 s 11
;
2011 c 315 s 4
.]
NOTES:
Effective date
—
2019 c 33:
See note following RCW 48.43.005
.
Intent
—
2011 c 315:
See note following RCW 48.43.005
.
RCW 48.43.0123
Health plans
—
Rescission of coverage
—
Rules.
(1) A health plan or health carrier offering group or individual coverage may not rescind such coverage with respect to an enrollee once the enrollee is covered under the plan or coverage involved, except that this section does not apply to a covered person who has performed an act or practice that constitutes fraud or makes an intentional misrepresentation of material fact as prohibited by the terms of the plan or coverage. The plan or coverage may not be canceled except as permitted under RCW 48.43.035
or
48.43.038
.
(2) The commissioner shall adopt any rules necessary to implement this section, consistent with federal rules and guidance in effect on January 1, 2017, implementing the patient protection and affordable care act.
[
2019 c 33 s 8
.]
NOTES:
Effective date
—
2019 c 33:
See note following RCW 48.43.005
.
RCW 48.43.0124
Health plans
—
Cost sharing for essential health benefits
—
Rules.
(1) For plan years beginning in 2020, the cost sharing incurred under a health plan for the essential health benefits may not exceed the following amounts:
(a) For self-only coverage:
(i) The amount required under federal law for the calendar year; or
(ii) If there are no cost-sharing requirements under federal law, eight thousand two hundred dollars increased by the premium adjustment percentage for the calendar year.
(b) For coverage other than self-only coverage:
(i) The amount required under federal law for the calendar year; or
(ii) If there are no cost-sharing requirements under federal law, sixteen thousand four hundred dollars increased by the premium adjustment percentage for the calendar year.
(2) Regardless of whether an enrollee is covered by a self-only plan or a plan that is other than self-only, the enrollee's cost sharing for the essential health benefits may not exceed the self-only annual limitation on cost sharing.
(3) For purposes of this section, "the premium adjustment percentage for the calendar year" means the percentage, if any, by which the average per capita premium for health insurance in Washington for the preceding year, as estimated by the commissioner no later than April 1st of such preceding year, exceeds such average per capita premium for 2020 as determined by the commissioner.
(4) Unless preempted by federal law, the commissioner shall adopt any rules necessary to implement this section, consistent with federal rules and guidance in effect on January 1, 2017, implementing the patient protection and affordable care act.
[
2019 c 33 s 10
.]
NOTES:
Effective date
—
2019 c 33:
See note following RCW 48.43.005
.
RCW 48.43.0125
Essential health benefits
—
Annual or lifetime dollar limits.
A health carrier may not impose annual or lifetime dollar limits on an essential health benefit, other than those permitted as reference-based limitations under rules adopted by the commissioner.
[
2019 c 33 s 12
.]
NOTES:
Effective date
—
2019 c 33:
See note following RCW 48.43.005
.
RCW 48.43.0126
Summary of benefits and explanation of coverage
—
Standards and requirements
—
Notice of modification
—
Fines
—
Standards for definitions of health insurance terms
—
Rules.
(1) The commissioner shall develop standards for use by a health carrier offering individual or group coverage, in compiling and providing to applicants and enrollees a summary of benefits and coverage explanation that accurately describes the benefits and coverage under the applicable plan. In developing the standards, the commissioner must use the standards developed under 42 U.S.C. Sec. 300gg-15 in use on April 17, 2019.
(2) The standards must provide for the following:
(a) The standards must ensure that the summary of benefits and coverage is presented in a uniform format that does not exceed four pages in length and does not include print smaller than twelve-point font.
(b) The standards must ensure that the summary is presented in a culturally and linguistically appropriate manner and utilizes terminology understandable by the average plan enrollee.
(c) The standards must ensure that the summary of benefits and coverage includes:
(i) Uniform definitions of standard insurance and medical terms, consistent with the standard definitions developed under this section, so that consumers may compare health insurance coverage and understand the terms of coverage, or exceptions to such coverage;
(ii) A description of the coverage, including cost sharing for:
(A) The essential health benefits; and
(B) Other benefits identified by the commissioner;
(iii) The exceptions, reductions, and limitations on coverage;
(iv) The cost-sharing provisions, including deductible, coinsurance, and copayment obligations;
(v) The renewability and continuation of coverage provisions;
(vi) A coverage facts label that includes examples to illustrate common benefits scenarios, including pregnancy and serious or chronic medical conditions and related cost sharing. The scenarios must be based on recognized clinical practice guidelines;
(vii) A statement of whether the plan:
(A) Provides minimum essential coverage under 26 U.S.C. Sec. 5000A(f); and
(B) Ensures that the plan share of the total allowed costs of benefits provided under the plan is no less than sixty percent of the costs;
(viii) A statement that the outline is a summary of the policy or certificate and that the coverage document itself should be consulted to determine the governing contractual provisions; and
(ix) A contact number for the consumer to call with additional questions and a website where a copy of the actual individual coverage policy or group certificate of coverage may be reviewed and obtained.
(3) The commissioner shall periodically review and update the standards developed under this section.
(4) A health carrier must provide a summary of benefits and coverage explanation to:
(a) An applicant at the time of application;
(b) An enrollee prior to the time of enrollment or reenrollment, as applicable; and
(c) A policyholder or certificate holder at the time of issuance of the policy or delivery of the certificate.
(5) A health carrier may provide the summary of benefits and coverage either in paper or electronically.
(6) If a health carrier makes any material modification in any of the terms of the plan that is not reflected in the most recently provided summary of benefits and coverage, the carrier shall provide notice of the modification to enrollees no later than sixty days prior to the date on which the modification will become effective.
(7) A health carrier that fails to provide the information required under this section is subject to a fine of no more than one thousand dollars for each failure. A failure with respect to each enrollee constitutes a separate offense for purposes of this subsection.
(8) The commissioner shall, by rule, provide for the development of standards for the definitions of terms used in health insurance coverage, including the following:
(a) Insurance-related terms, including premium; deductible; coinsurance; copayment; out-of-pocket limit; preferred provider; nonpreferred provider; out-of-network copayments; usual, customary, and reasonable fees; excluded services; grievance; appeals; and any other terms the commissioner determines are important to define so that consumers may compare health insurance coverage and understand the terms of their coverage; and
(b) Medical terms, including hospitalization, hospital outpatient care, emergency room care, physician services, prescription drug coverage, durable medical equipment, home health care, skilled nursing care, rehabilitation services, hospice services, emergency medical transportation, and any other terms the commissioner determines are important to define so that consumers may compare the medical benefits offered by health insurance and understand the extent of those medical benefits or exceptions to those benefits.
(9) Unless preempted by federal law, the commissioner shall adopt any rules necessary to implement this section, consistent with federal rules and guidance in effect on January 1, 2017, implementing the patient protection and affordable care act.
[
2019 c 33 s 13
.]
NOTES:
Effective date
—
2019 c 33:
See note following RCW 48.43.005
.
RCW 48.43.0127
Group health plans
—
Waiting period
—
Rules.
(1) A group health plan and a health carrier offering group health coverage may not apply any waiting period that exceeds ninety days.
(2) Unless preempted by federal law, the commissioner shall adopt any rules necessary to implement this section, consistent with federal rules and guidance in effect on January 1, 2017, implementing the patient protection and affordable care act.
[
2019 c 33 s 14
.]
NOTES:
Effective date
—
2019 c 33:
See note following RCW 48.43.005
.
RCW 48.43.0128
Nongrandfathered health plans and plans issued or renewed on or after January 1, 2022
—
Prohibited discrimination
—
Rules.
(1) A health carrier offering a nongrandfathered health plan or a plan deemed by the commissioner to have a short-term limited purpose or duration, or to be a student-only plan that is guaranteed renewable while the covered person is enrolled as a regular, full-time undergraduate student at an accredited higher education institution may not:
(a) In its benefit design or implementation of its benefit design, discriminate against individuals because of their age, expected length of life, present or predicted disability, degree of medical dependency, quality of life, or other health conditions; and
(b) With respect to the health plan or plan deemed by the commissioner to have a short-term limited purpose or duration, or to be a student-only plan that is guaranteed renewable while the covered person is enrolled as a regular, full-time undergraduate student at an accredited higher education institution, discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, or sexual orientation.
(2) Nothing in this section may be construed to prevent a carrier from appropriately utilizing reasonable medical management techniques.
(3) For health plans issued or renewed on or after January 1, 2022:
(a) A health carrier may not deny or limit coverage for gender-affirming treatment when that treatment is prescribed to an individual because of, related to, or consistent with a person's gender expression or identity, as defined in RCW 49.60.040, is medically necessary, and is prescribed in accordance with accepted standards of care.
(b) A health carrier may not apply categorical cosmetic or blanket exclusions to gender-affirming treatment. When prescribed as medically necessary gender-affirming treatment, a health carrier may not exclude as cosmetic services facial feminization surgeries and other facial gender-affirming treatment, such as tracheal shaves, hair electrolysis, and other care such as mastectomies, breast reductions, breast implants, or any combination of gender-affirming procedures, including revisions to prior treatment.
(c) A health carrier may not issue an adverse benefit determination denying or limiting access to gender-affirming services, unless a health care provider with experience prescribing or delivering gender-affirming treatment has reviewed and confirmed the appropriateness of the adverse benefit determination.
(d) Health carriers must comply with all network access rules and requirements established by the commissioner.
(4) For the purposes of this section, "gender-affirming treatment" means a service or product that a health care provider, as defined in RCW 70.02.010, prescribes to an individual to treat any condition related to the individual's gender identity and is prescribed in accordance with generally accepted standards of care. Gender-affirming treatment must be covered in a manner compliant with the federal mental health parity and addiction equity act of 2008 and the federal affordable care act. Gender-affirming treatment can be prescribed to two spirit, transgender, nonbinary, intersex, and other gender diverse individuals.
(5) Nothing in this section may be construed to mandate coverage of a service that is not medically necessary.
(6) By December 1, 2022, the commissioner, in consultation with the health care authority and the department of health, must issue a report on geographic access to gender-affirming treatment across the state. The report must include the number of gender-affirming providers offering care in each county, the carriers and medicaid managed care organizations those providers have active contracts with, and the types of services provided by each provider in each region. The commissioner must update the report biennially and post the report on its website.
(7) The commissioner shall adopt any rules necessary to implement subsections (3), (4), and (5) of this section.
(8) Unless preempted by federal law, the commissioner shall adopt any rules necessary to implement subsections (1) and (2) of this section, consistent with federal rules and guidance in effect on January 1, 2017, implementing the patient protection and affordable care act.
[
2025 c 243 s 8
;
2021 c 280 s 3
;
2020 c 228 s 9
;
2019 c 33 s 15
.]
NOTES:
Short title
—
2021 c 280:
See note following RCW 49.60.178
.
Effective date
—
2019 c 33:
See note following RCW 48.43.005
.
RCW 48.43.016
Utilization management standards and criteria
—
Health carrier requirements
—
Definitions.
(Effective until January 1, 2027.)
(1) A health carrier or its contracted entity that imposes different prior authorization standards and criteria for a covered service among tiers of contracting providers of the same licensed profession in the same health plan shall inform an enrollee which tier an individual provider or group of providers is in by posting the information on its website in a manner accessible to both enrollees and providers.
(2)(a) A health carrier or its contracted entity may not require utilization management or review of any kind including, but not limited to, prior, concurrent, or postservice authorization for an initial evaluation and management visit and up to six treatment visits with a contracting provider in a new episode of care for each of the following: Chiropractic, physical therapy, occupational therapy, acupuncture and Eastern medicine, massage therapy, or speech and hearing therapies. Visits for which utilization management or review is prohibited under this section are subject to quantitative treatment limits of the health plan. Notwithstanding RCW 48.43.515
(5) this section may not be interpreted to limit the ability of a health plan to require a referral or prescription for the therapies listed in this section.
(b) For visits for which utilization management or review is prohibited under this section, a health carrier or its contracted entity may not:
(i) Deny or limit coverage on the basis of medical necessity or appropriateness; or
(ii) Retroactively deny care or refuse payment for the visits.
(3) A health carrier shall post on its website and provide upon the request of a covered person or contracting provider any prior authorization standards, criteria, or information the carrier uses for medical necessity decisions.
(4) A health care provider with whom a health carrier consults regarding a decision to deny, limit, or terminate a person's covered health care services must hold a license, certification, or registration, in good standing and must be in the same or related health field as the health care provider being reviewed or of a specialty whose practice entails the same or similar covered health care service.
(5) A health carrier may not require a provider to provide a discount from usual and customary rates for health care services not covered under a health plan, policy, or other agreement, to which the provider is a party.
(6) Nothing in this section prevents a health carrier from denying coverage based on insurance fraud.
(7) For purposes of this section:
(a) "New episode of care" means treatment for a new condition or diagnosis for which the enrollee has not been treated by a provider of the same licensed profession within the previous ninety days and is not currently undergoing any active treatment.
(b) "Contracting provider" does not include providers employed within an integrated delivery system operated by a carrier licensed under chapter
48.44
or
48.46
RCW.
[
2020 c 193 s 2
;
2019 c 308 s 22
;
2018 c 193 s 1
;
2015 c 251 s 2
.]
NOTES:
Intent
—
2020 c 193:
"The legislature intends to facilitate patient access to appropriate therapies for newly diagnosed health conditions while recognizing the necessity for health carriers to employ reasonable utilization management techniques." [
2020 c 193 s 1
.]
Findings
—
2019 c 308:
See note following RCW 18.06.010
.
Effective date
—
2015 c 251:
See note following RCW 41.05.074
.
PDF
RCW 48.43.016
Utilization management standards and criteria
—
Requirements
—
Definitions.
(Effective January 1, 2027.)
(1) A health carrier or health care benefit manager as defined in RCW 48.200.020
that imposes different prior authorization standards and criteria for a covered service among tiers of contracting providers of the same licensed profession in the same health plan shall inform an enrollee which tier an individual provider or group of providers is in by posting the information on its website in a manner accessible to both enrollees and providers.
(2)(a) A health carrier or health care benefit manager as defined in RCW 48.200.020
may not require utilization management or review of any kind including, but not limited to, prior, concurrent, or postservice authorization for an initial evaluation and management visit and up to six treatment visits with a contracting provider in a new episode of care for each of the following: Chiropractic, physical therapy, occupational therapy, acupuncture and Eastern medicine, massage therapy, outpatient mental health care office visits, outpatient substance use disorder care office visits, or speech and hearing therapies. Outpatient mental health office visits do not include procedures performed on an outpatient basis. Visits for which utilization management or review is prohibited under this section are subject to any quantitative treatment limits of the health plan. Notwithstanding RCW 48.43.515
(5) this section may not be interpreted to limit the ability of a health plan to require a referral or prescription for the therapies listed in this section. Quantitative treatment limitations and nonquantitative treatment limitations, including any referral and prescription requirements, for mental health or substance use disorder care shall comply with the requirements of the mental health parity and addiction equity act, state law, and any implementing regulations.
(b) For visits for which utilization management or review is prohibited under this section, a health carrier or health care benefit manager as defined in RCW 48.200.020
may not:
(i) Deny or limit coverage on the basis of medical necessity or appropriateness; or
(ii) Retroactively deny care or refuse payment for the visits.
(3) A health carrier shall post on its website and provide upon the request of a covered person or contracting provider any prior authorization standards, criteria, or information the carrier uses for medical necessity decisions.
(4) A health care provider with whom a health carrier consults regarding a decision to deny, limit, or terminate a person's covered health care services must hold a license, certification, or registration, in good standing and must be in the same or related health field as the health care provider being reviewed or of a specialty whose practice entails the same or similar covered health care service.
(5) A health carrier may not require a provider to provide a discount from usual and customary rates for health care services not covered under a health plan, policy, or other agreement, to which the provider is a party.
(6) Nothing in this section prevents a health carrier from denying coverage based on insurance fraud.
(7) For purposes of this section:
(a) "New episode of care" means treatment for a new condition or diagnosis for which the enrollee has not been treated by a provider of the same licensed profession within the previous ninety days and is not currently undergoing any active treatment.
(b) "Contracting provider" does not include providers employed within an integrated delivery system operated by a carrier licensed under chapter
48.44
or
48.46
RCW.
[
2025 c 227 s 3
;
2020 c 193 s 2
;
2019 c 308 s 22
;
2018 c 193 s 1
;
2015 c 251 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
.
Intent
—
2020 c 193:
"The legislature intends to facilitate patient access to appropriate therapies for newly diagnosed health conditions while recognizing the necessity for health carriers to employ reasonable utilization management techniques." [
2020 c 193 s 1
.]
Findings
—
2019 c 308:
See note following RCW 18.06.010
.
Effective date
—
2015 c 251:
See note following RCW 41.05.074
.
RCW 48.43.0161
Prior authorization practices
—
Carrier annual reporting requirements
—
Commissioner's standardized report.
(1) By October 1, 2020, and annually thereafter, for individual and group health plans issued by a carrier that has written at least one percent of the total accident and health insurance premiums written by all companies authorized to offer accident and health insurance in Washington in the most recently available year, the carrier shall report to the commissioner the following aggregated and deidentified data related to the carrier's prior authorization practices and experience for the prior plan year:
(a) Lists of the 10 inpatient medical or surgical codes:
(i) With the highest total number of prior authorization requests during the previous plan year, including the total number of prior authorization requests for each code and the percent of approved requests for each code;
(ii) With the highest percentage of approved prior authorization requests during the previous plan year, including the total number of prior authorization requests for each code and the percent of approved requests for each code; and
(iii) With the highest percentage of prior authorization requests that were initially denied and then subsequently approved on appeal, including the total number of prior authorization requests for each code and the percent of requests that were initially denied and then subsequently approved for each code;
(b) Lists of the 10 outpatient medical or surgical codes:
(i) With the highest total number of prior authorization requests during the previous plan year, including the total number of prior authorization requests for each code and the percent of approved requests for each code;
(ii) With the highest percentage of approved prior authorization requests during the previous plan year, including the total number of prior authorization requests for each code and the percent of approved requests for each code; and
(iii) With the highest percentage of prior authorization requests that were initially denied and then subsequently approved on appeal, including the total number of prior authorization requests for each code and the percent of requests that were initially denied and then subsequently approved for each code;
(c) Lists of the 10 inpatient mental health and substance use disorder service codes:
(i) With the highest total number of prior authorization requests during the previous plan year, including the total number of prior authorization requests for each code and the percent of approved requests for each code;
(ii) With the highest percentage of approved prior authorization requests during the previous plan year, including the total number of prior authorization requests for each code and the percent of approved requests for each code; and
(iii) With the highest percentage of prior authorization requests that were initially denied and then subsequently approved on appeal, including the total number of prior authorization requests for each code and the percent of requests that were initially denied and then subsequently approved for each code;
(d) Lists of the 10 outpatient mental health and substance use disorder service codes:
(i) With the highest total number of prior authorization requests during the previous plan year, including the total number of prior authorization requests for each code and the percent of approved requests for each code;
(ii) With the highest percentage of approved prior authorization requests during the previous plan year, including the total number of prior authorization requests for each code and the percent of approved requests for each code; and
(iii) With the highest percentage of prior authorization requests that were initially denied and then subsequently approved on appeal, including the total number of prior authorization requests for each code and the percent of requests that were initially denied and then subsequently approved;
(e) Lists of the 10 durable medical equipment codes:
(i) With the highest total number of prior authorization requests during the previous plan year, including the total number of prior authorization requests for each code and the percent of approved requests for each code;
(ii) With the highest percentage of approved prior authorization requests during the previous plan year, including the total number of prior authorization requests for each code and the percent of approved requests for each code; and
(iii) With the highest percentage of prior authorization requests that were initially denied and then subsequently approved on appeal, including the total number of prior authorization requests for each code and the percent of requests that were initially denied and then subsequently approved for each code;
(f) Lists of the 10 diabetes supplies and equipment codes:
(i) With the highest total number of prior authorization requests during the previous plan year, including the total number of prior authorization requests for each code and the percent of approved requests for each code;
(ii) With the highest percentage of approved prior authorization requests during the previous plan year, including the total number of prior authorization requests for each code and the percent of approved requests for each code; and
(iii) With the highest percentage of prior authorization requests that were initially denied and then subsequently approved on appeal, including the total number of prior authorization requests for each code and the percent of requests that were initially denied and then subsequently approved for each code;
(g) Lists of the 10 prescription drugs:
(i) With the highest total number of prior authorization requests during the previous plan year, including the total number of prior authorization requests for each prescription drug and the percent of approved requests for each prescription drug;
(ii) With the highest percentage of approved prior authorization requests during the previous plan year, including the total number of prior authorization requests for each prescription drug and the percent of approved requests for each prescription drug; and
(iii) With the highest percentage of prior authorization requests that were initially denied and then subsequently approved on appeal, including the total number of prior authorization requests for each prescription drug and the percent of requests that were initially denied and then subsequently approved for each prescription drug; and
(h) The average determination response time in hours for prior authorization requests to the carrier with respect to each code reported under (a) through (f) of this subsection for each of the following categories of prior authorization:
(i) Expedited decisions;
(ii) Standard decisions; and
(iii) Extenuating circumstances decisions.
(2) By January 1, 2021, and annually thereafter, the commissioner shall aggregate and deidentify the data collected under subsection (1) of this section into a standard report and may not identify the name of the carrier that submitted the data. The commissioner must make the report available to interested parties.
(3) The commissioner may request additional information from carriers reporting data under this section.
(4) The commissioner may adopt rules to implement this section. In adopting rules, the commissioner must consult stakeholders including carriers, health care practitioners, health care facilities, and patients.
(5) For the purpose of this section, "prior authorization" means a mandatory process that a carrier or its designated or contracted representative requires a provider or facility to follow before a service is delivered, 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, including any term used by a carrier or its designated or contracted representative to describe this process.
[
2023 c 382 s 4
;
2020 c 316 s 1
.]
NOTES:
Effective date
—
2023 c 382 s 4:
"Section 4 of this act takes effect January 1, 2024." [
2023 c 382 s 5
.]
RCW 48.43.021
Personally identifiable health information
—
Restrictions on release.
Except as otherwise required by statute or rule, a carrier and the Washington state health insurance pool, and persons acting at the direction of or on behalf of a carrier or the pool, who are in receipt of an enrollee's or applicant's personally identifiable health information included in the standard health questionnaire shall not disclose the identifiable health information unless such disclosure is explicitly authorized in writing by the person who is the subject of the information.
[
2000 c 79 s 22
.]
NOTES:
Effective date
—
Severability
—
2000 c 79:
See notes following RCW 48.04.010
.
RCW 48.43.022
Enrollee identification card
—
Social security number restriction.
After December 31, 2005, a health carrier that issues a card identifying a person as an enrollee, and requires the person to present the card to providers for purposes of claims processing, may not display on the card an identification number that includes more than a four-digit portion of the person's complete social security number.
[
2004 c 115 s 1
.]
RCW 48.43.023
Pharmacy identification cards
—
Rules.
(1) A health carrier that provides coverage for prescription drugs provided on an outpatient basis and issues a card or other technology for claims processing, or an administrator of a health benefit plan including, but not limited to, third-party administrators for self-insured plans, pharmacy benefits managers, and state administered plans, shall issue to its enrollees a pharmacy identification card or other technology containing all information required for proper prescription drug claims adjudication.
(2) Upon renewal of the health benefit plan, information on the pharmacy identification card or other technology shall be made current by the health carrier or other entity that issues the card.
(3) Nothing in this section shall be construed to require any health carrier or administrator of a health benefit plan to issue a pharmacy identification card or other technology separate from another identification card issued to an enrollee under the health benefit plan if the identification card contains all of the information required under subsection (1) of this section.
(4) This section applies to health benefit plans that are delivered, issued for delivery, or renewed on or after July 1, 2003. For the purposes of this section, renewal of a health benefit policy, contract, or plan occurs on each anniversary of the date on which coverage was first effective on the person or persons covered by the health benefit plan.
(5) The insurance commissioner may adopt rules to implement chapter 106, Laws of 2001, taking into consideration any relevant standards developed by the national council for prescription drug programs and the requirements of the federal health insurance portability and accountability act of 1996.
[
2001 c 106 s 2
.]
NOTES:
Intent
—
2001 c 106:
"It is the intent of the legislature to improve care to patients by minimizing confusion, eliminating unnecessary paperwork, decreasing administrative burdens, and streamlining dispensing of prescription products paid for by third-party payors." [
2001 c 106 s 1
.]
RCW 48.43.028
Eligibility to purchase certain health benefit plans
—
Small employers and small groups.
To the extent required of the federal health insurance portability and accountability act of 1996, the eligibility of an employer or group to purchase a health benefit plan set forth in RCW 48.21.045
(1)(b), 48.44.023
(1)(b), and
48.46.066
(1)(b) must be extended to all small employers and small groups as defined in RCW 48.43.005
.
[
2001 c 196 s 10
.]
NOTES:
Effective date
—
2001 c 196:
See note following RCW 48.20.025
.
RCW 48.43.035
Group health benefit plans
—
Guaranteed issue and continuity of coverage
—
Exceptions.
For group health benefit plans, the following shall apply:
(1) All health carriers shall accept for enrollment any state resident within the group to whom the plan is offered and within the carrier's service area and provide or assure the provision of all covered services regardless of age, sex, family structure, ethnicity, race, health condition, geographic location, employment status, socioeconomic status, other condition or situation, or the provisions of RCW 49.60.174
(2). The insurance commissioner may grant a temporary exemption from this subsection, if, upon application by a health carrier the commissioner finds that the clinical, financial, or administrative capacity to serve existing enrollees will be impaired if a health carrier is required to continue enrollment of additional eligible individuals.
(2) Except as provided in subsection (5) of this section, all health plans shall contain or incorporate by endorsement a guarantee of the continuity of coverage of the plan. For the purposes of this section, a plan is "renewed" when it is continued beyond the earliest date upon which, at the carrier's sole option, the plan could have been terminated for other than nonpayment of premium. The carrier may consider the group's anniversary date as the renewal date for purposes of complying with the provisions of this section.
(3) The guarantee of continuity of coverage required in health plans shall not prevent a carrier from canceling or nonrenewing a health plan for:
(a) Nonpayment of premium;
(b) Violation of published policies of the carrier approved by the insurance commissioner;
(c) Covered persons entitled to become eligible for medicare benefits by reason of age who fail to apply for a medicare supplement plan or medicare cost, risk, or other plan offered by the carrier pursuant to federal laws and regulations;
(d) Covered persons who fail to pay any deductible or copayment amount owed to the carrier and not the provider of health care services;
(e) Covered persons committing fraudulent acts as to the carrier;
(f) Covered persons who materially breach the health plan; or
(g) Change or implementation of federal or state laws that no longer permit the continued offering of such coverage.
(4) The provisions of this section do not apply in the following cases:
(a) A carrier has zero enrollment on a product;
(b) A carrier replaces a product and the replacement product is provided to all covered persons within that class or line of business, includes all of the services covered under the replaced product, and does not significantly limit access to the kind of services covered under the replaced product. The health plan may also allow unrestricted conversion to a fully comparable product;
(c) No sooner than January 1, 2005, a carrier discontinues offering a particular type of health benefit plan offered for groups of up to two hundred if: (i) The carrier provides notice to each group of the discontinuation at least ninety days prior to the date of the discontinuation; (ii) the carrier offers to each group provided coverage of this type the option to enroll, with regard to small employer groups, in any other small employer group plan, or with regard to groups of up to two hundred, in any other applicable group plan, currently being offered by the carrier in the applicable group market; and (iii) in exercising the option to discontinue coverage of this type and in offering the option of coverage under (c)(ii) of this subsection, the carrier acts uniformly without regard to any health status-related factor of enrolled individuals or individuals who may become eligible for this coverage;
(d) A carrier discontinues offering all health coverage in the small group market or for groups of up to two hundred, or both markets, in the state and discontinues coverage under all existing group health benefit plans in the applicable market involved if: (i) The carrier provides notice to the commissioner of its intent to discontinue offering all such coverage in the state and its intent to discontinue coverage under all such existing health benefit plans at least one hundred eighty days prior to the date of the discontinuation of coverage under all such existing health benefit plans; and (ii) the carrier provides notice to each covered group of the intent to discontinue the existing health benefit plan at least one hundred eighty days prior to the date of discontinuation. In the case of discontinuation under this subsection, the carrier may not issue any group health coverage in this state in the applicable group market involved for a five-year period beginning on the date of the discontinuation of the last health benefit plan not so renewed. This subsection (4) does not require a carrier to provide notice to the commissioner of its intent to discontinue offering a health benefit plan to new applicants when the carrier does not discontinue coverage of existing enrollees under that health benefit plan; or
(e) A carrier is withdrawing from a service area or from a segment of its service area because the carrier has demonstrated to the insurance commissioner that the carrier's clinical, financial, or administrative capacity to serve enrollees would be exceeded.
(5) The provisions of this section do not apply to health plans deemed by the insurance commissioner to be unique or limited or have a short-term purpose, after a written request for such classification by the carrier and subsequent written approval by the insurance commissioner.
[
2010 c 292 s 2
;
2004 c 244 s 4
;
2000 c 79 s 24
;
1995 c 265 s 7
.]
NOTES:
Application
—
Contingent effective date
—
2010 c 292:
See notes following RCW 48.43.005
.
Application
—
2004 c 244:
See note following RCW 48.21.045
.
Effective date
—
Severability
—
2000 c 79:
See notes following RCW 48.04.010
.
Captions not law
—
Effective dates
—
Savings
—
Severability
—
1995 c 265:
See notes following RCW 70.47.015
.
RCW 48.43.038
Individual health plans
—
Guarantee of continuity of coverage
—
Exceptions.
(1) Except as provided in subsection (4) of this section, all individual health plans shall contain or incorporate by endorsement a guarantee of the continuity of coverage of the plan. For the purposes of this section, a plan is "renewed" when it is continued beyond the earliest date upon which, at the carrier's sole option, the plan could have been terminated for other than nonpayment of premium.
(2) The guarantee of continuity of coverage required in individual health plans shall not prevent a carrier from canceling or nonrenewing a health plan for:
(a) Nonpayment of premium;
(b) Violation of published policies of the carrier approved by the commissioner;
(c) Covered persons entitled to become eligible for medicare benefits by reason of age who fail to apply for a medicare supplement plan or medicare cost, risk, or other plan offered by the carrier pursuant to federal laws and regulations;
(d) Covered persons who fail to pay any deductible or copayment amount owed to the carrier and not the provider of health care services;
(e) Covered persons committing fraudulent acts as to the carrier;
(f) Covered persons who materially breach the health plan; or
(g) Change or implementation of federal or state laws that no longer permit the continued offering of such coverage.
(3) This section does not apply in the following cases:
(a) A carrier has zero enrollment on a product;
(b) A carrier is withdrawing from a service area or from a segment of its service area because the carrier has demonstrated to the commissioner that the carrier's clinical, financial, or administrative capacity to serve enrollees would be exceeded;
(c) No sooner than the first day of the month following the expiration of a one hundred eighty-day period beginning on March 23, 2000, a carrier discontinues offering a particular type of health benefit plan offered in the individual market if: (i) The carrier provides notice to each covered individual provided coverage of this type of such discontinuation at least ninety days prior to the date of the discontinuation; (ii) the carrier offers to each individual provided coverage of this type the option, without being subject to the standard health questionnaire, to enroll in any other individual health benefit plan currently being offered by the carrier; and (iii) in exercising the option to discontinue coverage of this type and in offering the option of coverage under (c)(ii) of this subsection, the carrier acts uniformly without regard to any health status-related factor of enrolled individuals or individuals who may become eligible for such coverage; or
(d) A carrier discontinues offering all individual health coverage in the state and discontinues coverage under all existing individual health benefit plans if: (i) The carrier provides notice to the commissioner of its intent to discontinue offering all individual health coverage in the state and its intent to discontinue coverage under all existing health benefit plans at least one hundred eighty days prior to the date of the discontinuation of coverage under all existing health benefit plans; and (ii) the carrier provides notice to each covered individual of the intent to discontinue his or her existing health benefit plan at least one hundred eighty days prior to the date of such discontinuation. In the case of discontinuation under this subsection, the carrier may not issue any individual health coverage in this state for a five-year period beginning on the date of the discontinuation of the last health plan not so renewed. Nothing in this subsection (3) shall be construed to require a carrier to provide notice to the commissioner of its intent to discontinue offering a health benefit plan to new applicants where the carrier does not discontinue coverage of existing enrollees under that health benefit plan.
(4) The provisions of this section do not apply to health plans deemed by the commissioner to be unique or limited or have a short-term purpose, after a written request for such classification by the carrier and subsequent written approval by the commissioner.
[
2000 c 79 s 25
.]
NOTES:
Effective date
—
Severability
—
2000 c 79:
See notes following RCW 48.04.010
.
RCW 48.43.039
Grace period
—
Notification or information
—
Information concerning delinquencies or nonpayment of premiums
—
Defined.
(1) For an enrollee who is in the second or third month of the grace period, an issuer of a qualified health plan shall:
(a) Upon request by a health care provider or health care facility, provide information regarding the enrollee's eligibility status in real time;
(b) Notify a health care provider or health care facility that an enrollee is in the grace period within three business days after submittal of a claim or status request for services provided; and
(c) If the health care provider or health care facility is providing care to an enrollee in the grace period, the provider or facility shall, wherever possible, encourage the enrollee to pay delinquent premiums to the issuer and provide information regarding the impact of nonpayment of premiums on access to services.
(2) The information or notification required under subsection (1) of this section must, at a minimum:
(a) Indicate "grace period" or use the appropriate national coding standard as the reason for pending the claim if a claim is pended due to the enrollee's grace period status; and
(b) Except for notifications provided electronically, indicate that enrollee is in the second or third month of the grace period.
(3) No earlier than January 1, 2016, and once the exchange has terminated premium aggregation functionality for qualified health plans offered in the individual exchange and issuers are accepting all payments from enrollees directly, an issuer of a qualified health plan shall:
(a) For an enrollee in the grace period, include a statement in a delinquency notice that concisely explains the impact of nonpayment of premiums on access to coverage and health care services and encourages the enrollee to contact the issuer regarding coverage options that may be available;
(b) For an enrollee who has exhausted the grace period, include a statement in a termination notice for nonpayment of premium informing the enrollee that other coverage options such as medicaid may be available and to contact the issuer or the exchange for additional information; and
(c) For a delinquency notice described in this subsection, include concise information on how a subsidized enrollee may report to the exchange a change in income or circumstances, including any deadline for doing so, and an explanation that it may result in a change in premium or cost-sharing amount or program eligibility.
(4) Upon the transfer of premium collection to the qualified health plan, each qualified health plan must provide detailed reports to the exchange to support the legislative reporting requirements.
(5) For purposes of this section, "grace period" means nonpayment of premiums by an enrollee receiving advance payments of the premium tax credit, as defined in section 1412 of the patient protection and affordable care act, P.L. 111-148, as amended by the health care and education reconciliation act, P.L. 111-152, and implementing regulations issued by the federal department of health and human services.
[
2018 c 44 s 9
;
2015 3rd sp.s. c 33 s 4
;
2014 c 84 s 3
;
2014 c 84 s 2
.]
NOTES:
Contingent effective date
—
2014 c 84 s 3:
"Section 3 of this act takes effect January 1st following the issuance of a report under section 2(3) of this act indicating that coverage was terminated due to nonpayment of premium for ten thousand or more enrollees who were in the grace period in that calendar year. In no case may section 3 of this act take effect before January 1, 2015. The health benefit exchange must provide notice of the effective date of section 3 of this act 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 health benefit exchange." [
2014 c 84 s 4
.] The health benefit exchange issued a report meeting the contingency requirements of this section on December 1, 2014; therefore, the effective date of section 3, chapter 84, Laws of 2014 is January 1, 2015.
RCW 48.43.041
Individual health benefit plans
—
Mandatory benefits.
(1) All individual health benefit plans, other than catastrophic health plans, offered or renewed on or after October 1, 2000, shall include benefits described in this section. Nothing in this section shall be construed to require a carrier to offer an individual health benefit plan.
(a) Maternity services that include, with no enrollee cost-sharing requirements beyond those generally applicable cost-sharing requirements: Diagnosis of pregnancy; prenatal care; delivery; care for complications of pregnancy; physician services; hospital services; operating or other special procedure rooms; radiology and laboratory services; appropriate medications; anesthesia; and services required under RCW 48.43.115
; and
(b) Prescription drug benefits with at least a two thousand dollar benefit payable by the carrier annually.
(2) If a carrier offers a health benefit plan that is not a catastrophic health plan to groups, and it chooses to offer a health benefit plan to individuals, it must offer at least one health benefit plan to individuals that is not a catastrophic health plan.
[
2000 c 79 s 26
.]
NOTES:
Effective dates
—
2000 c 79 ss 26, 38, and 39:
"(1) Section 38 of this act takes effect July 1, 2000.
(2) Section 39 of this act takes effect September 1, 2000.
(3) *Section 26 of this act takes effect on the first day of the month following the expiration of a one hundred eighty-day period beginning on the effective date of section 25 of this act." [
2000 c 79 s 50
.]
*Reviser's note:
Section 26 of this act takes effect October 1, 2000.
Severability
—
2000 c 79:
See note following RCW 48.04.010
.
RCW 48.43.043
Colorectal cancer examinations and laboratory tests
—
Required benefits or coverage.
(1) Health plans issued or renewed on or after July 1, 2008, must provide benefits or coverage for colorectal cancer examinations and laboratory tests consistent with the guidelines or recommendations of the United States preventive services task force or the federal centers for disease control and prevention. Benefits or coverage must be provided:
(a) For any of the colorectal screening examinations and tests in the selected guidelines or recommendations, at a frequency identified in such guidelines or recommendations, as deemed appropriate by the patient's physician after consultation with the patient; and
(b) To a covered individual who is:
(i) At least fifty years old; or
(ii) Less than fifty years old and at high risk or very high risk for colorectal cancer according to such guidelines or recommendations.
(2) To encourage colorectal cancer screenings, patients and health care providers must not be required to meet burdensome criteria or overcome significant obstacles to secure such coverage. An individual may not be required to pay an additional deductible or coinsurance for testing that is greater than an annual deductible or coinsurance established for similar benefits. If the health plan does not cover a similar benefit, a deductible or coinsurance may not be set at a level that materially diminishes the value of the colorectal cancer benefit required.
(3)(a) A health carrier is not required under this section to provide for a referral to a nonparticipating health care provider, unless the carrier does not have an appropriate health care provider that is available and accessible to administer the screening exam and that is a participating health care provider with respect to such treatment.
(b) If a health carrier refers an individual to a nonparticipating health care provider pursuant to this section, screening exam services or resulting treatment, if any, must be provided at no additional cost to the individual beyond what the individual would otherwise pay for services provided by a participating health care provider.
[
2007 c 23 s 1
.]
RCW 48.43.045
Health plan requirements
—
Annual reports
—
Exemptions.
(1) Every health plan delivered, issued for delivery, or renewed by a health carrier on and after January 1, 1996, shall:
(a) Permit every category of health care provider to provide health services or care included in the basic essential health benefits benchmark plan established by the commissioner consistent with RCW 48.43.715, to the extent that:
(i) The provision of such health services or care is within the health care providers' permitted scope of practice;
(ii) The providers agree to abide by standards related to:
(A) Provision, utilization review, and cost containment of health services;
(B) Management and administrative procedures; and
(C) Provision of cost-effective and clinically efficacious health services; and
(iii) The plan covers such services or care in the essential health benefits benchmark plan. The reference to the essential health benefits does not create a mandate to cover a service that is otherwise not a covered benefit.
(b) Annually report the names and addresses of all officers, directors, or trustees of the health carrier during the preceding year, and the amount of wages, expense reimbursements, or other payments to such individuals, unless substantially similar information is filed with the commissioner or the national association of insurance commissioners. This requirement does not apply to a foreign or alien insurer regulated under chapter
48.20
or
48.21
RCW that files a supplemental compensation exhibit in its annual statement as required by law.
(2) The requirements of subsection (1)(a) 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.
[
2015 c 237 s 2
;
2007 c 253 s 12
;
2007 c 98 s 18
;
2006 c 25 s 7
;
1997 c 231 s 205
;
1995 c 265 s 8
.]
NOTES:
Effective date
—
Implementation
—
2007 c 253:
See RCW 18.250.901
and
18.250.902
.
Effective dates
—
2007 c 98:
See RCW 18.74.912
.
Short title
—
Part headings and captions not law
—
Severability
—
Effective dates
—
1997 c 231:
See notes following RCW 48.43.005
.
Captions not law
—
Effective dates
—
Savings
—
Severability
—
1995 c 265:
See notes following RCW 70.47.015
.
RCW 48.43.047
Health plans
—
Minimum coverage for preventive services
—
No cost-sharing requirements.
(1) A nongrandfathered health plan issued on or after June 6, 2024, must, at a minimum, provide coverage for the following preventive services as the recommendations or guidelines existed on January 8, 2024:
(a) Evidence-based items or services that have a rating of A or B in the current recommendations of the United States preventive services task force with respect to the enrollee;
(b) Immunizations for routine use in children, adolescents, and adults that have in effect a recommendation from the advisory committee on immunization practices of the centers for disease control and prevention with respect to the enrollee. For purposes of this subsection, a recommendation from the advisory committee on immunization practices of the centers for disease control and prevention is considered in effect after the recommendation has been adopted by the director of the centers for disease control and prevention, and a recommendation is considered to be for routine use if the recommendation is listed on the immunization schedules of the centers for disease control and prevention;
(c) With respect to infants, children, and adolescents, evidence-informed preventive care and screenings provided for in comprehensive guidelines supported by the health resources and services administration; and
(d) With respect to women, additional preventive care and screenings that are not listed with a rating of A or B by the United States preventive services task force but that are provided for in comprehensive guidelines supported by the health resources and services administration.
(2) A nongrandfathered health plan must provide coverage for the preventive services required to be covered under subsection (1) of this section consistent with federal rules and guidance related to coverage of preventive services in effect on January 8, 2024.
(3) A nongrandfathered health plan must provide coverage for the preventive services required to be covered under subsection (1) of this section for plan years that begin on or after the date that is one year after the date the recommendation or guideline is issued.
(4) A nongrandfathered health plan is no longer required to provide coverage for particular items or services specified in the recommendations or guidelines described in subsection (1) of this section if such a recommendation or guideline is revised by the recommending entities described in subsection (1) of this section to no longer include the preventive item or service as defined in subsection (1) of this section.
(5) Annually, a health carrier shall determine whether any additional items or services must be covered without cost-sharing requirements or whether any items or services are no longer required to be covered as provided in subsections (2) and (3) of this section. The carrier's determination must be included in its health plan filings submitted to the commissioner.
(6)(a) Except as provided in (b) of this subsection, the health plan may not impose cost-sharing requirements for the preventive services required to be covered under subsection (1) of this section when the services are provided by an in-network provider. If a plan does not have in its network a provider who can provide an item or service described in subsection (1) of this section, the plan must cover the item or service when performed by an out-of-network provider and may not impose cost sharing with respect to the item or service.
(b) If any portion of 42 U.S.C. Sec. 300gg-13 is found invalid, for a health plan offered as a qualifying health plan for a health savings account, the carrier may apply cost sharing to coverage of the services that have been invalidated only 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.
(7) A carrier may use reasonable medical management techniques to determine the frequency, method, treatment, or setting for an item or service described in subsection (1) of this section to the extent not specified in the relevant recommendation or guideline, federal rules and guidance related to the coverage of preventive services in effect on January 8, 2024, and any rules adopted by the insurance commissioner.
(8) The insurance commissioner shall enforce this section consistent with federal rules and guidance in effect on January 8, 2024.
(9) The insurance commissioner may adopt rules necessary to implement this section, consistent with federal statutes, rules, and guidance in effect on January 8, 2024. The insurance commissioner may also adopt rules related to any future preventive services recommendations and guidelines issued by the United States preventive services task force, the advisory committee on immunization practices of the centers for disease control and prevention, and the health resources and services administration or related federal rules or guidance.
[
2024 c 314 s 1
;
2018 c 14 s 1
.]
RCW 48.43.055
Procedures for review and adjudication of health care provider complaints
—
Requirements.
(1) Except as provided by subsection (2) of this section, each health carrier as defined under RCW 48.43.005
shall file with the commissioner its procedures for review and adjudication of complaints initiated by health care providers. Procedures filed under this section shall provide a fair review for consideration of complaints. Every health carrier shall provide reasonable means allowing any health care provider aggrieved by actions of the health carrier to be heard after submitting a written request for review. If the health carrier fails to grant or reject a request within thirty days after it is made, the complaining health care provider may proceed as if the complaint had been rejected. A complaint that has been rejected by the health carrier may be submitted to nonbinding mediation. Mediation shall be conducted under chapter
7.07
RCW, or any other rules of mediation agreed to by the parties. This section is solely for resolution of provider complaints. Complaints by, or on behalf of, a covered person are subject to the grievance processes in RCW 48.43.530
.
(2) For purposes of out-of-network payment disputes between a health carrier and health care provider covered under the provisions of chapter
48.49
RCW, the arbitration provisions of chapter
48.49
RCW apply.
[
2019 c 427 s 28
;
2005 c 172 s 19
;
2002 c 300 s 6
;
1995 c 265 s 20
.]
NOTES:
Findings
—
Intent
—
Effective date
—
2019 c 427:
See RCW 48.49.003
and
48.49.900
.
Short title
—
Effective date
—
2005 c 172:
See RCW 7.07.900
and
7.07.904
.
Captions not law
—
Effective dates
—
Savings
—
Severability
—
1995 c 265:
See notes following RCW 70.47.015
.
RCW 48.43.059
Payments made by a second-party payment process
—
Definition.
(1) For the purposes of this section, "second-party payment process" means a process in which: (a) An individual has an account under his or her name maintained with a financial institution and is either managed by the financial institution or an entity that, with the express agreement with the individual, has established the account on behalf of the individual with a financial institution; (b) the account is funded with funds from the individual or his or her family members or in a manner otherwise consistent with federal law including, but not limited to, federal guidance implementing the federal patient protection and affordable care act; and (c) the account is under the control of the covered person, such that the covered person may authorize payments from the account.
(2) All issuers must accept any payments made by a second-party payment process; however, no issuer need accept payment by a second-party payment process if the second-party payer is controlled by or receives funding from any entity where such entity may be reimbursed by an issuer for providing health care services or if the account under the control of the covered person is funded by any such entity, except those third-party entities from whom federal law requires such issuer to accept payment.
(3) Payments made under subsection (2) of this section may be made with any legal tender denominated in United States dollars.
[
2015 c 284 s 2
.]
NOTES:
Recognition
—
Intent
—
2015 c 284:
"(1) The legislature recognizes that under regulations implementing the federal patient protection and affordable care act, issuers offering individual market qualified health plans are required to accept third-party premium and cost-sharing payments from the Ryan White HIV/AIDS program under Title XXVI of the public health service act, Indian tribes, tribal organizations or urban Indian organizations, and state and federal government programs. However, federal regulators have stated that they have serious concerns about payments made on a third-party basis by hospitals, health care providers, and other commercial entities using their own funds because of the potential that such payments could cause distortions in the insurance market.
(2) The legislature intends to clarify that an entity that makes premium payments from accounts that are owned and controlled by the covered person do not constitute a third party for the purposes of acceptance of premium payments by an issuer. The legislature does not intend to impact third-party payment programs required under federal law , including, but not limited to, federal guidance implementing the federal patient protection and affordable care act." [
2015 c 284 s 1
.]
RCW 48.43.065
Right of individuals to receive services
—
Right of providers, carriers, and facilities to refuse to participate in or pay for services for reason of conscience or religion
—
Requirements.
(1) The legislature recognizes that every individual possesses a fundamental right to exercise their religious beliefs and conscience. The legislature further recognizes that in developing public policy, conflicting religious and moral beliefs must be respected. Therefore, while recognizing the right of conscientious objection to participating in specific health services, the state shall also recognize the right of individuals enrolled with plans containing the basic health plan services to receive the full range of services covered under the plan.
(2)(a) No individual health care provider, religiously sponsored health carrier, or health care facility may be required by law or contract in any circumstances to participate in the provision of or payment for a specific service if they object to so doing for reason of conscience or religion. No person may be discriminated against in employment or professional privileges because of such objection.
(b) The provisions of this section are not intended to result in an enrollee being denied timely access to any service included in the basic health plan services. Each health carrier shall:
(i) Provide written notice to enrollees, upon enrollment with the plan, listing services that the carrier refuses to cover for reason of conscience or religion;
(ii) Provide written information describing how an enrollee may directly access services in an expeditious manner; and
(iii) Ensure that enrollees refused services under this section have prompt access to the information developed pursuant to (b)(ii) of this subsection.
(c) The insurance commissioner shall establish by rule a mechanism or mechanisms to recognize the right to exercise conscience while ensuring enrollees timely access to services and to assure prompt payment to service providers.
(3)(a) No individual or organization with a religious or moral tenet opposed to a specific service may be required to purchase coverage for that service or services if they object to doing so for reason of conscience or religion.
(b) The provisions of this section shall not result in an enrollee being denied coverage of, and timely access to, any service or services excluded from their benefits package as a result of their employer's or another individual's exercise of the conscience clause in (a) of this subsection.
(c) The insurance commissioner shall define by rule the process through which health carriers may offer the basic health plan services to individuals and organizations identified in (a) and (b) of this subsection in accordance with the provisions of subsection (2)(c) of this section.
(4) Nothing in this section requires a health carrier, health care facility, or health care provider to provide any health care services without appropriate payment of premium or fee.
[
1995 c 265 s 25
.]
NOTES:
Captions not law
—
Effective dates
—
Savings
—
Severability
—
1995 c 265:
See notes following RCW 70.47.015
.
RCW 48.43.071
Health care information
—
Requirement to provide free copy to covered person appealing denial of social security benefits
—
Exceptions.
Upon request of a covered person or a covered person's personal representative, an issuer shall provide the covered person or representative with one copy of the covered person's health care information free of charge if the covered person is appealing the denial of federal supplemental security income or social security disability benefits. The issuer may provide the health care information in either paper or electronic format. An issuer is not required to provide a covered person or a covered person's personal representative with a free copy of health care information that has previously been provided free of charge pursuant to a request within the preceding two years. For purposes of this section, "health care information" has the same meaning as in RCW 70.02.010
.
[
2018 c 87 s 4
.]
RCW 48.43.072
Required reproductive health care coverage
—
Restrictions on copayments, deductibles, and other form of cost sharing.
(1) A health plan or student health plan, including student health plans deemed by the insurance commissioner to have a short-term limited purpose or duration or to be guaranteed renewable while the covered person is enrolled as a regular full-time undergraduate or graduate student at an accredited higher education institution, shall provide coverage for:
(a) All contraceptive drugs, devices, and other products, approved by the federal food and drug administration, including over-the-counter contraceptive drugs, devices, and products, approved by the federal food and drug administration. This includes condoms, regardless of the gender or sexual orientation of the covered person, and regardless of whether they are to be used for contraception or exclusively for the prevention of sexually transmitted infections;
(b) Voluntary sterilization procedures;
(c) The consultations, examinations, procedures, and medical services that are necessary to prescribe, dispense, insert, deliver, distribute, administer, or remove the drugs, devices, and other products or services in (a) and (b) of this subsection;
(d) The following preventive services:
(i) Screening for physical, mental, sexual, and reproductive health care needs that arise from a sexual assault; and
(ii) Well-person preventive visits;
(e) Medically necessary services and prescription medications for the treatment of physical, mental, sexual, and reproductive health care needs that arise from a sexual assault; and
(f) The following reproductive health-related over-the-counter drugs and products approved by the federal food and drug administration: Prenatal vitamins for pregnant persons; and breast pumps for covered persons expecting the birth or adoption of a child.
(2) The coverage required by subsection (1) of this section:
(a) May not require copayments, deductibles, or other forms of cost sharing:
(i) Except for:
(A) The medically necessary services and prescription medications required by subsection (1)(e) of this section; and
(B) The drugs and products in subsection (1)(f) of this section; or
(ii) Unless the health plan is offered as a qualifying health plan for a health savings account. For such a qualifying health plan, the carrier must establish the plan's cost sharing for the coverage required by subsection (1) of 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 internal revenue service laws and regulations; and
(b) May not require a prescription to trigger coverage of over-the-counter contraceptive drugs, devices, and products, approved by the federal food and drug administration, except those reproductive health-related drugs and products as set forth in subsection (1)(f) of this section.
(3) A health carrier may not deny the coverage required in subsection (1) of this section because an enrollee changed the enrollee's contraceptive method within a twelve-month period.
(4) Except as otherwise authorized under this section, a health benefit plan may not impose any restrictions or delays on the coverage required under this section, such as medical management techniques that limit enrollee choice in accessing the full range of contraceptive drugs, devices, or other products, approved by the federal food and drug administration.
(5) Benefits provided under this section must be extended to all enrollees, enrolled spouses, and enrolled dependents.
(6) This section may not be construed to allow for denial of care on the basis of race, color, national origin, sex, sexual orientation, gender expression or identity, marital status, age, citizenship, immigration status, or disability.
(7) A health plan or student health plan, including student health plans deemed by the insurance commissioner to have a short-term limited purpose or duration or to be guaranteed renewable while the covered person is enrolled as a regular full-time undergraduate or graduate student at an accredited higher education institution, issued or renewed on or after January 1, 2021, may not issue automatic initial denials of coverage for reproductive health care services that are ordinarily or exclusively available to individuals of one gender, based on the fact that the individual's gender assigned at birth, gender identity, or gender otherwise recorded in one or more government-issued documents, is different from the one to which such health services are ordinarily or exclusively available.
(8) The definitions in this subsection apply throughout this section unless the context clearly requires otherwise.
(a) "Gender expression" means a person's gender-related appearance and behavior, whether or not stereotypically associated with the person's gender assigned at birth.
(b) "Gender identity" means a person's internal sense of the person's own gender, regardless of the person's gender assigned at birth.
(c) "Reproductive health care services" means any medical services or treatments, including pharmaceutical and preventive care service or treatments, directly involved in the reproductive system and its processes, functions, and organs involved in reproduction, in all stages of life. Reproductive health care services does not include infertility treatment.
(d) "Reproductive system" includes, but is not limited to: Genitals, gonads, the uterus, ovaries, fallopian tubes, and breasts.
(e) "Well-person preventive visits" means the preventive annual visits recommended by the federal health resources and services administration women's preventive services guidelines, with the understanding that those visits must be covered for women, and when medically appropriate, for transgender, nonbinary, and intersex individuals.
(9) This section may not be construed to authorize discrimination on the basis of gender identity or expression, or perceived gender identity or expression, in the provision of nonreproductive health care services.
(10) The commissioner, under RCW 48.30.300, and the human rights commission, under chapter
49.60
RCW[,] shall share enforcement authority over complaints of discrimination under this section as set forth in RCW 49.60.178
.
(11) The commissioner may adopt rules to implement this section.
[
2019 c 399 s 3
;
2018 c 119 s 2
.]
NOTES:
Recommendations
—
Preexposure and postexposure prophylaxis financial support awareness
—
2019 c 399:
"The department of health shall develop recommendations for increasing awareness about financial support that is available for preexposure and postexposure prophylaxis. The department of health shall consult with the state board of health, the health care authority, and the health benefit exchange in developing its recommendation related to outreach and education to affected populations. By December 1, 2019, the department of health shall provide its recommendations to the appropriate committees of the legislature." [
2019 c 399 s 7
.]
Effective dates
—
2019 c 399 ss 2 and 3:
See note following RCW 74.09.875
.
Findings
—
Short title
—
2019 c 399:
See notes following RCW 74.09.875
.
Findings
—
Declarations
—
2018 c 119:
"The legislature finds and declares that:
(1) Washington has a long history of protecting gender equity and women's reproductive health;
(2) Access to the full range of health benefits and preventive services, as guaranteed under the laws of this state, provides all Washingtonians with the opportunity to lead healthier and more productive lives;
(3) Reproductive health care is the care necessary to support the reproductive system, the capability to reproduce, and the freedom and services necessary to decide if, when, and how often to do so, which can include contraception, cancer and disease screenings, abortion, preconception, maternity, prenatal, and postpartum care. This care is an essential part of primary care for women and teens, and often reproductive health issues are the primary reason they seek routine medical care;
(4) Neither a woman's income level nor her type of insurance should prevent her from having access to a full range of reproductive health care, including contraception and abortion services;
(5) Restrictions and barriers to health coverage for reproductive health care have a disproportionate impact on low-income women, women of color, immigrant women, and young women, and these women are often already disadvantaged in their access to the resources, information, and services necessary to prevent an unintended pregnancy or to carry a healthy pregnancy to term;
(6) This state has a history of supporting and expanding timely access to comprehensive contraceptive access to prevent unintended pregnancy;
(7) Existing state and federal law should be enhanced to ensure greater contraceptive coverage and timely access for all individuals covered by health plans in Washington to all methods of contraception approved by the federal food and drug administration;
(8) Nearly half of pregnancies in both the United States and Washington are unintended. Unintended pregnancy is associated with negative outcomes, such as delayed prenatal care, maternal depression, increased risk of physical violence during pregnancy, low birth weight, decreased mental and physical health during childhood, and lower education attainment for the child;
(9) Access to contraception has been directly connected to the economic success of women and the ability of women to participate in society equally;
(10) Cost-sharing requirements and other barriers can dramatically reduce the use of preventive health care measures, particularly for women in lower income households, and eliminating cost sharing and other barriers for contraceptives leads to sizable increases in the use of preventive health care measures;
(11) It is vital that the full range of contraceptives are available to women because contraindications may restrict the use of certain types of contraceptives and because women need access to the contraceptive method most effective for their health;
(12) Medical management techniques such as denials, step therapy, or prior authorization in public and private health care coverage can impede access to the most effective contraceptive methods;
(13) Many insurance companies do not typically cover male methods of contraception, or they require high cost sharing despite the critical role men play in the prevention of unintended pregnancy; and
(14) Restrictions on abortion coverage interfere with a woman's personal, private pregnancy decision making, with his or her health and well-being, and with his or her constitutionally protected right to safe and legal medical abortion care." [
2018 c 119 s 1
.]
RCW 48.43.0725
Reproductive health plan coverage
—
Immediate postpartum contraception devices.
(1) For births taking place in a licensed hospital or birthing center, a health plan must allow a provider to separately bill for devices, implants, professional services, or a combination thereof, associated with immediate postpartum contraception and may not consider such devices, implants, services, or combinations thereof to be part of any payments for general obstetric procedures.
(2) For purposes of this section, "immediate postpartum contraception" means the postpartum insertion of intrauterine devices or contraceptive implants performed before the patient is discharged from the hospital or birthing center and includes the devices or implants themselves.
(3) This section does not apply to facility services associated with immediate postpartum contraception.
(4) Nothing in this section affects an enrollee's right to directly access women's health care services, including contraceptive services.
(5) This section applies to health plans issued or renewed on or after January 1, 2023.
[
2022 c 122 s 3
.]
NOTES:
Findings
—
Intent
—
2022 c 122:
See note following RCW 41.05.430
.
RCW 48.43.073
Required abortion coverage
—
Limitations.
(1)(a) Except as provided in subsection (5) of this section, if a health plan issued or renewed on or after January 1, 2019, provides coverage for maternity care or services, the health plan must also provide a covered person with substantially equivalent coverage to permit the abortion of a pregnancy. Except as provided in subsection (5) of this section, if a student health plan, including student health plans deemed by the insurance commissioner to have a short-term limited purpose or duration or to be guaranteed renewable while the covered person is enrolled as a regular full-time undergraduate or graduate student at an accredited higher education institution, issued or renewed on or after January 1, 2022, provides coverage for maternity care or services, the health plan must also provide a covered person with substantially equivalent coverage to permit the abortion of a pregnancy.
(b) Except as provided in (c) of this subsection, for health plans issued or renewed on or after January 1, 2024, a health carrier may not impose cost sharing for abortion of a pregnancy.
(c) For a health plan that provides coverage for abortion of a pregnancy and is offered as a qualifying health plan for a health savings account, the health carrier shall 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 internal revenue service laws and regulations.
(2)(a) Except as provided in (b) of this subsection, a health plan or student health plan subject to subsection (1) of this section may not limit in any way a person's access to services related to the abortion of a pregnancy.
(b)(i) Coverage for the abortion of a pregnancy may be subject to terms and conditions generally applicable to the health plan or student health plan's coverage of maternity care or services.
(ii) A health plan or student health plan is not required to cover abortions that would be unlawful under RCW 9.02.120
.
(3) Nothing in this section may be interpreted to limit in any way an individual's constitutionally or statutorily protected right to voluntarily terminate a pregnancy.
(4) This section does not, pursuant to 42 U.S.C. Sec. 18054(a)(6), apply to a multistate plan that does not provide coverage for the abortion of a pregnancy.
(5) If the application of this section to a health plan or student health plan results in noncompliance with federal requirements that are a prescribed condition to the allocation of federal funds to the state, this section is inapplicable to the plan to the minimum extent necessary for the state to be in compliance. The inapplicability of this section to a specific health plan or student health plan under this subsection does not affect the operation of this section in other circumstances.
[
2023 c 194 s 1
;
2021 c 53 s 1
;
2018 c 119 s 3
.]
NOTES:
Findings
—
Declarations
—
2018 c 119:
See note following RCW 48.43.072
.
RCW 48.43.074
Qualified health plans
—
Single invoice billing
—
Certification of compliance required in the segregation plan for premium amounts attributable to coverage of abortion services.
(1) The legislature intends to codify the state's current practice of requiring health carriers to bill enrollees with a single invoice and to segregate into a separate account the premium attributable to abortion services for which federal funding is prohibited. Washington has achieved full compliance with section 1303 of the federal patient protection and affordable care act by requiring health carriers to submit a single invoice to enrollees and to segregate into a separate account the premium amounts attributable to coverage of abortion services for which federal funding is prohibited. Further, section 1303 states that the act does not preempt or otherwise have any effect on state laws regarding the prohibition of, or requirement of, coverage, funding, or procedural requirements on abortions.
(2) In accordance with RCW 48.43.073
related to requirements for coverage and funding of abortion services, an issuer offering a qualified health plan must:
(a) Bill enrollees and collect payment through a single invoice that includes all benefits and services covered by the qualified health plan; and
(b) Include in the segregation plan required under applicable federal and state law a certification that the issuer's billing and payment processes meet the requirements of this section.
[
2019 c 399 s 5
.]
NOTES:
Effective date
—
2019 c 399 s 5:
"Section 5 of this act is necessary for the immediate preservation of the public peace, health, or safety, or support of the state government and its existing public institutions, and takes effect immediately [May 13, 2019]." [
2019 c 399 s 10
.]
Findings
—
Short title
—
2019 c 399:
See notes following RCW 74.09.875
.
Recommendations
—
Preexposure and postexposure prophylaxis financial support awareness
—
2019 c 399:
See note following RCW 48.43.072
.
RCW 48.43.076
Digital breast examinations
—
Cost sharing.
(1) Except as provided in subsection (2) of this section, for nongrandfathered health plans issued or renewed on or after January 1, 2024, that include coverage of supplemental breast examinations and diagnostic breast examinations, health carriers may not impose cost sharing for such examinations.
(2) For a health plan that provides coverage of supplemental breast examinations and diagnostic breast examinations and is offered as a qualifying health plan for a health savings account, the health carrier shall establish the plan's cost sharing for the coverage of the services described in this section at the minimum level necessary to preserve the enrollee's ability to claim tax exempt contributions from their health savings account under internal revenue service laws and regulations.
(3) For purposes of this section:
(a) "Diagnostic breast examination" means a medically necessary and appropriate examination of the breast, including an examination using diagnostic mammography, digital breast tomosynthesis, also called three dimensional mammography, breast magnetic resonance imaging, or breast ultrasound, that is used to evaluate an abnormality:
(i) Seen or suspected from a screening examination for breast cancer; or
(ii) Detected by another means of examination.
(b) "Supplemental breast examination" means a medically necessary and appropriate examination of the breast, including an examination using breast magnetic resonance imaging or breast ultrasound, that is:
(i) Used to screen for breast cancer when there is no abnormality seen or suspected; and
(ii) Based on personal or family medical history, or additional factors that may increase the individual's risk of breast cancer.
[
2023 c 366 s 2
.]
NOTES:
Intent
—
2023 c 366:
"(1) In 1989 the legislature enacted Substitute House Bill No. 1074 requiring disability insurers, group disability insurers, health care service contractors, health maintenance organizations, and plans offered to public employees that provide benefits for hospital or medical care to provide benefits for screening and diagnostic mammography services.
(2) In 2010 the United States congress enacted the patient protection and affordable care act, which required coverage of certain preventative care services including screening mammograms with no cost sharing.
(3) In 2013 the Washington state office of the insurance commissioner adopted rules establishing the essential health benefits benchmark plan, which listed diagnostic and screening mammogram services as state benefit requirements under preventative and wellness services.
(4) In 2018 the legislature enacted Senate Bill No. 5912 which directed the office of the insurance commissioner to clarify that the existing mandates for mammography included coverage for tomosynthesis, also known as three-dimensional mammography, under the same terms and conditions allowed for mammography.
(5) The legislature intends to establish that the requirements for coverage of mammography services predated the affordable care act and are already included in the state's essential health benefits benchmark plan. Furthermore, the legislature intends to prohibit cost sharing for certain types of breast examinations." [
2023 c 366 s 1
.]
RCW 48.43.078
Digital breast tomosynthesis
—
Intent to ensure women with access
—
Commissioner's and health care authority's duty to clarify mandates.
(1) Digital breast tomosynthesis, also called three-dimensional mammography, is the latest advancement in breast imaging. Studies indicate that digital breast tomosynthesis can result in a forty-one percent increase in invasive cancer detection, a fifteen percent decrease in the recall rate from screening mammography, and a twenty-nine percent increase in the detection of all breast cancers. In addition, the American college of radiology has indicated that tomosynthesis is no longer investigational. Therefore, it is the intent of the legislature to ensure women have access to the most effective breast imaging and to clarify that the existing mandate for mammography must include tomosynthesis.
(2) The legislature directs the office of the insurance commissioner to clarify that the existing mandates for mammography in RCW 48.20.393, 48.21.225, 48.44.325, and
48.46.275
include coverage for tomosynthesis under the same terms and conditions currently allowed for mammography. The application of a deductible and cost sharing is prohibited, consistent with 42 U.S.C. Sec. 300-gg-13.
(3) The legislature also directs the health care authority to clarify that the existing mandate for mammography in RCW 41.05.180
includes coverage for tomosynthesis under the same terms and conditions currently allowed for mammography. The application of a deductible and cost sharing is prohibited, consistent with 42 U.S.C. Sec. 300-gg-13.
[
2018 c 115 s 1
.]
RCW 48.43.081
Anatomic pathology services
—
Payment for services
—
Definitions.
(1) A clinical laboratory or physician, located in this state, or in another state, providing anatomic pathology services for patients in this state, shall present or cause to be presented a claim, bill, or demand for payment for these services only to the following:
(a) The patient;
(b) The responsible insurer or other third-party payer;
(c) The hospital, public health clinic, or nonprofit health clinic ordering such services;
(d) A direct patient-provider primary care practice regulated by chapter
48.150
RCW, provided the practice:
(i) Is in compliance with all applicable provisions of law to regulate that practice;
(ii) Has furnished a written confirmation to the physician or laboratory providing the anatomic pathology service that the patient is not covered for anatomic pathology services under any health insurance plan or program;
(iii) Furnishes the patient with an itemized bill that does not, directly or indirectly, mark up or increase the actual amount billed by the physician or clinical laboratory that performed the service; and
(iv) Discloses to the patient, through printed material or through a website, that all anatomic pathology services are billed at exactly the amount charged for the service by the physician or laboratory that provided the service, and the identity of the provider;
(e) The referring laboratory, excluding a laboratory of a physician's office or group practice that does not perform the professional component of the anatomic pathology service for which such claim, bill, or demand is presented; or
(f) Governmental agencies or their specified public or private agent, agency, or organization on behalf of the recipient of the services.
(2) Except for a physician at a referring laboratory that has been billed pursuant to subsection (1)(d) or (6) of this section, no licensed practitioner in the state may, directly or indirectly, charge, bill, or otherwise solicit payment for anatomic pathology services unless such services were rendered personally by the licensed practitioner or under the licensed practitioner's direct supervision in accordance with section 353 of the public health service act (42 U.S.C. Sec. 263a).
(3) No patient, insurer, third-party payer, hospital, public health clinic, or nonprofit health clinic may be required to reimburse any licensed practitioner for charges or claims submitted in violation of this section.
(4) Nothing in this section may be construed to mandate the assignment of benefits for anatomic pathology services as defined in this section.
(5) For purposes of this section, "anatomic pathology services" means:
(a) Histopathology or surgical pathology, meaning the gross and microscopic examination performed by a physician or under the supervision of a physician, including histologic processing;
(b) Cytopathology, meaning the microscopic examination of cells from the following: (i) Fluids, (ii) aspirates, (iii) washings, (iv) brushings, or (v) smears, including the pap test examination performed by a physician or under the supervision of a physician;
(c) Hematology, meaning the microscopic evaluation of bone marrow aspirates and biopsies performed by a physician, or under the supervision of a physician, and peripheral blood smears when the attending or treating physician, or technologist requests that a blood smear be reviewed by a pathologist;
(d) Subcellular pathology or molecular pathology, meaning the assessment of a patient specimen for the detection, localization, measurement, or analysis of one or more protein or nucleic acid targets; and
(e) Blood-banking services performed by pathologists.
(6) The provisions of this section do not prohibit billing of a referring laboratory for anatomic pathology services in instances where a sample or samples must be sent to another physician or laboratory for consultation or histologic processing, except that for purposes of this subsection the term "referring laboratory" does not include a laboratory of a physician's office or group practice that does not perform the professional component of the anatomic pathology service involved.
(7) The uniform disciplinary act, chapter
18.130
RCW, governs the discipline of any practitioner who violates the provisions of this section.
[
2012 c 100 s 1
;
2011 c 128 s 1
.]
NOTES:
Retroactive application
—
2012 c 100:
"Section 1 of this act applies retroactively to July 22, 2011, so that no entity is liable for having presented or caused to be presented a claim, bill, or demand for payment to a direct patient-provider primary care practice in accordance with section 1(1)(d) of this act." [
2012 c 100 s 2
.]
RCW 48.43.083
Chiropractor services
—
Participating provider agreement
—
Health carrier reimbursement.
(1) A health carrier must reimburse a chiropractor who has signed a participating provider agreement for services determined by the carrier to be medically necessary if:
(a) The service is:
(i) Covered chiropractic health care, as defined in RCW 48.43.515, by the health plan under which the enrollee received the services; and
(ii) Provided by the chiropractor, or the chiropractor's employee specified in RCW 18.25.190
(2) or (3) who works in the same location as the chiropractor and to whom the chiropractor, pursuant to rules adopted by the Washington state chiropractic quality assurance commission, has delegated the service. The employee must meet the health carrier's reasonable qualifications for all such providers in the relevant class, including but not limited to standards for education and background checks, as applicable; and
(b) The chiropractor complies with the terms and conditions of the participating provider agreement. Violations of the participating provider agreement by an employee of the chiropractor to whom he or she has delegated a service may be deemed by the carrier to have been committed by the chiropractor.
(2) If a health carrier offers a participating provider agreement to a chiropractor within a single practice organized as a sole proprietorship, partnership, or corporation, the carrier must offer the same participating provider agreement to any other chiropractor within that practice providing services at the same location. The agreement may allow either party to terminate it without cause.
[
2007 c 502 s 1
.]
NOTES:
Savings
—
2007 c 502:
"This act does not affect any existing right acquired or liability or obligation incurred prior to January 1, 2008." [
2007 c 502 s 3
.]
Severability
—
2007 c 502:
"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." [
2007 c 502 s 4
.]
Effective date
—
2007 c 502:
"This act takes effect January 1, 2008." [
2007 c 502 s 5
.]
RCW 48.43.085
Health carrier may not prohibit its enrollees from contracting for services outside the health care plan.
Notwithstanding any other provision of law, no health carrier subject to the jurisdiction of the state of Washington may prohibit directly or indirectly its enrollees from freely contracting at any time to obtain any health care services outside the health care plan on any terms or conditions the enrollees choose. Nothing in this section shall be construed to bind a carrier for any services delivered outside the health plan. The provisions of this section shall be disclosed pursuant to *RCW 48.43.095
(2). The insurance commissioner is prohibited from adopting rules regarding this section.
[
1996 c 312 s 3
.]
NOTES:
*Reviser's note:
RCW 48.43.095
was repealed by 2000 c 5 s 29, effective July 1, 2001.
RCW 48.43.087
Contracting for services at enrollee's expense
—
Mental health care practitioner
—
Conditions
—
Exception.
(1) For purposes of this section:
(a) "Health carrier" includes disability insurers regulated under chapter
48.20
or
48.21
RCW, health care services contractors regulated under chapter
48.44
RCW, plans operating under the health care authority under chapter
41.05
RCW, the basic health plan operating under chapter
70.47
RCW, the state health insurance pool operating under chapter
48.41
RCW, insuring entities regulated under this chapter, and health maintenance organizations regulated under chapter
48.46
RCW.
(b) "Intermediary" means a person duly authorized to negotiate and execute provider contracts with health carriers on behalf of mental health care practitioners.
(c) Consistent with their lawful scopes of practice, "mental health care practitioners" includes only the following: Any generally recognized medical specialty of practitioners licensed under chapter
18.57
or
18.71
RCW who provide mental health services, advanced practice psychiatric nurses as authorized by the state board of nursing under chapter
18.79
RCW, psychologists licensed under chapter
18.83
RCW, and mental health counselors, marriage and family therapists, and social workers licensed under chapter
18.225
RCW.
(d) "Mental health services" means outpatient services.
(2) Consistent with federal and state law and rule, no contract between a mental health care practitioner and an intermediary or between a mental health care practitioner and a health carrier that is written, amended, or renewed after June 6, 1996, may contain a provision prohibiting a practitioner and an enrollee from agreeing to contract for services solely at the expense of the enrollee as follows:
(a) On the exhaustion of the enrollee's mental health care coverage;
(b) During an appeal or an adverse certification process;
(c) When an enrollee's condition is excluded from coverage; or
(d) For any other clinically appropriate reason at any time.
(3) If a mental health care practitioner provides services to an enrollee during an appeal or adverse certification process, the practitioner must provide to the enrollee written notification that the enrollee is responsible for payment of these services, unless the health carrier elects to pay for services provided.
(4) This section does not apply to a mental health care practitioner who is employed full time on the staff of a health carrier.
[
2025 c 58 s 5050
;
2001 c 251 s 33
;
1996 c 304 s 1
.]
NOTES:
Explanatory note
—
2025 c 58:
See note following RCW 1.16.050
.
Severability
—
2001 c 251:
See RCW 18.225.900
.
RCW 48.43.091
Health carrier coverage of outpatient mental health services
—
Requirements.
Every health carrier that provides coverage for any outpatient mental health service shall comply with the following requirements:
(1) In performing a utilization review of mental health services for a specific enrollee, the utilization review is limited to accessing only the specific health care information contained in the enrollee's record.
(2) In performing an audit of a provider that has furnished mental health services to a carrier's enrollees, the audit is limited to accessing only the records of enrollees covered by the specific health carrier for which the audit is being performed, except as otherwise permitted by RCW 70.02.050
and *
71.05.630
.
[
1999 c 87 s 1
.]
NOTES:
*Reviser's note:
RCW 71.05.630
was repealed by 2013 c 200 s 34, effective July 1, 2014.
RCW 48.43.093
Health carrier coverage of emergency medical services
—
Requirements
—
Conditions.
(1)(a) A health carrier shall cover emergency services provided to a covered person if a prudent layperson acting reasonably would have believed that an emergency medical condition existed. In addition, a health carrier shall not require prior authorization of emergency services if a prudent layperson acting reasonably would have believed that an emergency medical condition existed. With respect to care obtained from a nonparticipating hospital emergency department or behavioral health emergency services provider, a health carrier shall cover emergency services. In addition, a health carrier shall not require prior authorization of emergency services.
(b) A health carrier shall cover emergency services without limiting what constitutes an emergency medical condition solely on the basis of diagnosis codes. Any determination of whether the prudent layperson standard has been met must be based on all pertinent documentation and be focused on the presenting symptoms and not solely on the final diagnosis.
(2) Coverage of emergency services may be subject to applicable in-network copayments, coinsurance, and deductibles, as provided in chapter
48.49
RCW.
(3) Nothing in this section is to be construed as prohibiting a health carrier from:
(a) Requiring notification of stabilization or inpatient admission within the time frame specified in its contract with the hospital or behavioral health emergency services provider or as soon thereafter as medically possible but no less than twenty-four hours; or
(b) Requiring a hospital or emergency behavioral health emergency services provider to make a documented good faith effort to notify the covered person's health carrier within 48 hours of stabilization, or by the end of the business day following the day the stabilization occurs, whichever is later, if the covered person needs to be stabilized. If a health carrier requires such notification, the health carrier shall provide access to an authorized representative seven days a week to receive notifications.
(4) Except to the extent provided otherwise in this section, follow-up care that is a direct result of the emergency must be obtained in accordance with the health plan's usual terms and conditions of coverage. All other terms and conditions of coverage may be applied to emergency services.
[
2022 c 263 s 3
;
2019 c 427 s 3
;
1997 c 231 s 301
.]
NOTES:
Effective date
—
2022 c 263:
See note following RCW 43.371.100
.
Findings
—
Intent
—
Effective date
—
2019 c 427:
See RCW 48.49.003
and
48.49.900
.
Short title
—
Part headings and captions not law
—
Severability
—
Effective dates
—
1997 c 231:
See notes following RCW 48.43.005
.
RCW 48.43.094
Pharmacist provided services
—
Health plan requirements.
(Effective until June 30, 2027.)
(1) For health plans issued or renewed on or after January 1, 2017:
(a) Benefits shall not be denied for any health care service performed by a pharmacist licensed under chapter
18.64
RCW if:
(i) The service performed was within the lawful scope of such person's license;
(ii) The plan would have provided benefits if the service had been performed by a physician licensed under chapter
18.71
or
18.57
RCW, an *advanced registered nurse practitioner licensed under chapter
18.79
RCW, or a physician's assistant licensed under chapter
18.71A
RCW; and
(iii) The pharmacist is included in the plan's network of participating providers; and
(b) The health plan must include an adequate number of pharmacists in its network of participating medical providers.
(2) The participation of pharmacies in the plan network's drug benefit does not satisfy the requirement that plans include pharmacists in their networks of participating medical providers.
(3) For health benefit plans issued or renewed on or after January 1, 2016, but before January 1, 2017, health plans that delegate credentialing agreements to contracted health care facilities must accept credentialing for pharmacists employed or contracted by those facilities. Health plans must reimburse facilities for covered services provided by network pharmacists within the pharmacists' scope of practice per negotiations with the facility.
(4) This section does not supersede the requirements of RCW 48.43.045
.
[
2020 c 80 s 36
;
2015 c 237 s 1
.]
NOTES:
*Reviser's note:
The term "advanced registered nurse practitioner" was changed to "advanced practice registered nurse" by 2024 c 239 s 1, effective June 30, 2027.
Effective date
—
2020 c 80 ss 12-59:
See note following RCW 7.68.030
.
Intent
—
2020 c 80:
See note following RCW 18.71A.010
.
Lead organization and advisory committee
—
2015 c 237:
"(1) The insurance commissioner shall designate a lead organization to establish and facilitate an advisory committee to implement the provisions of section 1 of this act. The lead organization and advisory committee shall develop best practice recommendations on standards for credentialing, privileging, billing, and payment processes to ensure pharmacists are adequately included and appropriately utilized in participating provider networks of health plans. In developing these standards, the committee shall also discuss topics as they relate to implementation including current credentialing requirements for health care providers consistent with chapter
18.64
RCW, existing processes of similarly situated health care providers, pharmacist training, care coordination, and the role of pharmacist prescriptive authority agreements pursuant to WAC 246-863-100.
(2) The lead organization shall create an advisory committee including, but not limited to, representatives of the following stakeholders:
(a) The insurance commissioner or designee;
(b) The secretary of health or designee;
(c) An organization representing pharmacists;
(d) An organization representing physicians;
(e) An organization representing hospitals;
(f) A hospital conducting internal credentialing of pharmacists;
(g) A clinic with pharmacists providing medical services;
(h) A community pharmacy with pharmacists providing medical services;
(i) The two largest health carriers in Washington based upon enrollment;
(j) A health care system that coordinates care and coverage;
(k) A school or college of pharmacy in Washington;
(l) A representative from a pharmacy benefit manager or organization that represents pharmacy benefit managers; and
(m) Other representatives appointed by the insurance commissioner.
(3) No later than December 1, 2015, the advisory committee shall present initial best practice recommendations to the insurance commissioner and the department of health. If necessary, the insurance commissioner or department of health may adopt rules to implement the standards developed by the lead organization and advisory committee. The advisory committee will remain intact to assist the insurance commissioner or department of health in rule making. The rules adopted by the insurance commissioner or the department of health must be consistent with the recommendations developed by the advisory committee.
(4) For purposes of this section, "lead organization" means a private sector organization or organizations designated by the insurance commissioner to lead development of processes, guidelines, and standards to streamline health care administration to be adopted by payors and providers of health care services operating in the state." [
2015 c 237 s 3
.]
PDF
RCW 48.43.094
Pharmacist provided services
—
Health plan requirements.
(Effective June 30, 2027.)
(1) For health plans issued or renewed on or after January 1, 2017:
(a) Benefits shall not be denied for any health care service performed by a pharmacist licensed under chapter
18.64
RCW if:
(i) The service performed was within the lawful scope of such person's license;
(ii) The plan would have provided benefits if the service had been performed by a physician licensed under chapter
18.71
or
18.57
RCW, an advanced practice registered nurse licensed under chapter
18.79
RCW, or a physician's assistant licensed under chapter
18.71A
RCW; and
(iii) The pharmacist is included in the plan's network of participating providers; and
(b) The health plan must include an adequate number of pharmacists in its network of participating medical providers.
(2) The participation of pharmacies in the plan network's drug benefit does not satisfy the requirement that plans include pharmacists in their networks of participating medical providers.
(3) For health benefit plans issued or renewed on or after January 1, 2016, but before January 1, 2017, health plans that delegate credentialing agreements to contracted health care facilities must accept credentialing for pharmacists employed or contracted by those facilities. Health plans must reimburse facilities for covered services provided by network pharmacists within the pharmacists' scope of practice per negotiations with the facility.
(4) This section does not supersede the requirements of RCW 48.43.045
.
[
2025 c 58 s 5104
;
2020 c 80 s 36
;
2015 c 237 s 1
.]
NOTES:
Effective date
—
2025 c 58 ss 5058-5170:
See note following RCW 7.68.030
.
Explanatory note
—
2025 c 58:
See note following RCW 1.16.050
.
Effective date
—
2020 c 80 ss 12-59:
See note following RCW 7.68.030
.
Intent
—
2020 c 80:
See note following RCW 18.71A.010
.
Lead organization and advisory committee
—
2015 c 237:
"(1) The insurance commissioner shall designate a lead organization to establish and facilitate an advisory committee to implement the provisions of section 1 of this act. The lead organization and advisory committee shall develop best practice recommendations on standards for credentialing, privileging, billing, and payment processes to ensure pharmacists are adequately included and appropriately utilized in participating provider networks of health plans. In developing these standards, the committee shall also discuss topics as they relate to implementation including current credentialing requirements for health care providers consistent with chapter
18.64
RCW, existing processes of similarly situated health care providers, pharmacist training, care coordination, and the role of pharmacist prescriptive authority agreements pursuant to WAC 246-863-100.
(2) The lead organization shall create an advisory committee including, but not limited to, representatives of the following stakeholders:
(a) The insurance commissioner or designee;
(b) The secretary of health or designee;
(c) An organization representing pharmacists;
(d) An organization representing physicians;
(e) An organization representing hospitals;
(f) A hospital conducting internal credentialing of pharmacists;
(g) A clinic with pharmacists providing medical services;
(h) A community pharmacy with pharmacists providing medical services;
(i) The two largest health carriers in Washington based upon enrollment;
(j) A health care system that coordinates care and coverage;
(k) A school or college of pharmacy in Washington;
(l) A representative from a pharmacy benefit manager or organization that represents pharmacy benefit managers; and
(m) Other representatives appointed by the insurance commissioner.
(3) No later than December 1, 2015, the advisory committee shall present initial best practice recommendations to the insurance commissioner and the department of health. If necessary, the insurance commissioner or department of health may adopt rules to implement the standards developed by the lead organization and advisory committee. The advisory committee will remain intact to assist the insurance commissioner or department of health in rule making. The rules adopted by the insurance commissioner or the department of health must be consistent with the recommendations developed by the advisory committee.
(4) For purposes of this section, "lead organization" means a private sector organization or organizations designated by the insurance commissioner to lead development of processes, guidelines, and standards to streamline health care administration to be adopted by payors and providers of health care services operating in the state." [
2015 c 237 s 3
.]
RCW 48.43.096
Medication synchronization policy required for health plans covering prescription drugs
—
Requirements
—
Definitions.
(1) A health benefit plan issued or renewed after December 31, 2015, that provides coverage for prescription drugs must implement a medication synchronization policy for the dispensing of prescription drugs to the plan's enrollees.
(a) If an enrollee requests medication synchronization for a new prescription, the health plan must permit filling the drug: (i) For less than a one-month supply of the drug if synchronization will require more than a fifteen-day supply of the drug; or (ii) for more than a one-month supply of the drug if synchronization will require a fifteen-day supply of the drug or less.
(b) The health benefit plan shall adjust the enrollee cost-sharing for a prescription drug subject to coinsurance that is dispensed for less than the standard refill amount for the purpose of synchronizing the medications.
(c) The health benefit plan shall adjust the enrollee cost-sharing for a prescription drug with a copayment that is dispensed for less than the standard refill amount for the purpose of synchronizing the medications by:
(i) Discounting the copayment rate by fifty percent;
(ii) Discounting the copayment rate based on fifteen-day increments; or
(iii) Any other method that meets the intent of this section and is approved by the office of the insurance commissioner.
(2) Upon request of an enrollee, the prescribing provider or pharmacist shall:
(a) Determine that filling or refilling the prescription is in the best interest of the enrollee, taking into account the appropriateness of synchronization for the drug being dispensed;
(b) Inform the enrollee that the prescription will be filled to less than the standard refill amount for the purpose of synchronizing his or her medications; and
(c) Deny synchronization on the grounds of threat to patient safety or suspected fraud or abuse.
(3) For purposes of this section, the following terms have the following meanings unless the context clearly requires otherwise:
(a) "Medication synchronization" means the coordination of medication refills for a patient taking two or more medications for a chronic condition such that the patient's medications are refilled on the same schedule for a given time period.
(b) "Prescription" has the same meaning as in RCW 18.64.011
.
[
2015 c 213 s 1
.]
RCW 48.43.0961
Continuity of coverage for health plans covering prescription drugs for behavioral health.
(1) Except as provided in subsection (2) of this section, for health plans that include prescription drug coverage issued or renewed on or after January 1, 2025, a health carrier or its health care benefit manager may not require the substitution of a nonpreferred drug with a preferred drug in a given therapeutic class, or increase an enrollee's cost-sharing obligation mid-plan year for the drug, if the prescription is for a refill of an antipsychotic, antidepressant, antiepileptic, or other drug prescribed to the enrollee to treat a serious mental illness, the enrollee is medically stable on the drug, and a participating provider continues to prescribe the drug.
(2) Nothing in this section prohibits:
(a) The carrier from requiring generic substitution during the current plan year;
(b) The carrier from adding new drugs to its formulary during the current plan year;
(c) The carrier from removing a drug from its formulary for reasons of patient safety concerns, drug recall or removal from the market, or medical evidence indicating no therapeutic effect of the drug; or
(d) A participating provider from prescribing a different drug that is covered by the plan and medically appropriate for the enrollee.
(3) For the purposes of this section:
(a) "Refill" means a second or subsequent filling of a previously issued prescription.
(b) "Serious mental illness" means a mental disorder, as defined in the most recent edition of the diagnostic and statistical manual of mental disorders published by the American psychiatric association, that results in serious functional impairment that substantially interferes with or limits one or more major life activities.
[
2023 c 325 s 1
.]
RCW 48.43.097
Filing of financial statements
—
Every health carrier.
Every health carrier holding a registration from the commissioner shall file its financial statements as required by this code and by the commissioner in accordance with the accounting practices and procedures manuals as adopted by the national association of insurance commissioners, unless otherwise provided by law.
[
1999 c 33 s 3
.]
RCW 48.43.105
Preparation of documents that compare health carriers
—
Immunity
—
Due diligence.
(1) A public or private entity who exercises due diligence in preparing a document of any kind that compares health carriers of any kind is immune from civil liability from claims based on the document and the contents of the document.
(2)(a) There is absolute immunity to civil liability from claims based on such a comparison document and its contents if the information was provided by the carrier, was substantially accurately presented, and contained the effective date of the information that the carrier supplied, if any.
(b) Where due diligence efforts to obtain accurate information have been taken, there is immunity from claims based on such a comparison document and its contents if the publisher of the comparison document asked for such information from the carrier, was refused, and relied on any usually reliable source for the information including, but not limited to, carrier enrollees, customers, insurance producers, or providers. The carrier enrollees, customers, insurance producers, or providers are likewise immune from civil liability on claims based on information they provided if they believed the information to be accurate and had exercised due diligence in their efforts to confirm the accuracy of the information provided.
(3) The immunity from liability contained in this section applies only if the comparison document contains the following in a conspicuous place and in easy to read typeface:
This comparison is based on information believed to be reliable by its publisher, but the accuracy of the information cannot be guaranteed. Caution is suggested to all readers who are encouraged to confirm data of importance to the reader before any purchasing or other decisions are made.
(4) The insurance commissioner is prohibited from adopting rules regarding this section.
[
2008 c 217 s 48
;
1996 c 312 s 5
.]
NOTES:
Severability
—
Effective date
—
2008 c 217:
See notes following RCW 48.03.020
.
RCW 48.43.115
Maternity services
—
Intent
—
Definitions
—
Patient preference
—
Clinical sovereignty of provider
—
Notice to policyholders
—
Application.
(Effective until June 30, 2027.)
(1) The legislature recognizes the role of health care providers as the appropriate authority to determine and establish the delivery of quality health care services to maternity patients and their newly born children. It is the intent of the legislature to recognize patient preference and the clinical sovereignty of providers as they make determinations regarding services provided and the length of time individual patients may need to remain in a health care facility after giving birth. It is not the intent of the legislature to diminish a carrier's ability to utilize managed care strategies but to ensure the clinical judgment of the provider is not undermined by restrictive carrier contracts or utilization review criteria that fail to recognize individual postpartum needs.
(2) Unless otherwise specifically provided, the following definitions apply throughout this section:
(a) "Attending provider" means a provider who: Has clinical hospital privileges consistent with RCW 70.43.020
; is included in a provider network of the carrier that is providing coverage; and is a physician licensed under chapter
18.57
or
18.71
RCW, a certified nurse midwife licensed under chapter
18.79
RCW, a midwife licensed under chapter
18.50
RCW, a physician's assistant licensed under chapter
18.71A
RCW, or an *advanced registered nurse practitioner licensed under chapter
18.79
RCW.
(b) "Health carrier" or "carrier" means disability insurers regulated under chapter
48.20
or
48.21
RCW, health care services contractors regulated under chapter
48.44
RCW, health maintenance organizations regulated under chapter
48.46
RCW, plans operating under the health care authority under chapter
41.05
RCW, the state health insurance pool operating under chapter
48.41
RCW, and insuring entities regulated under this chapter.
(3)(a) Every health carrier that provides coverage for maternity services must permit the attending provider, in consultation with the mother, to make decisions on the length of inpatient stay, rather than making such decisions through contracts or agreements between providers, hospitals, and insurers. These decisions must be based on accepted medical practice.
(b) Covered eligible services may not be denied for inpatient, postdelivery care to a mother and her newly born child after a vaginal delivery or a cesarean section delivery for such care as ordered by the attending provider in consultation with the mother.
(c) At the time of discharge, determination of the type and location of follow-up care must be made by the attending provider in consultation with the mother rather than by contract or agreement between the hospital and the insurer. These decisions must be based on accepted medical practice.
(d) Covered eligible services may not be denied for follow-up care, including in-person care, as ordered by the attending provider in consultation with the mother. Coverage for providers of follow-up services must include, but need not be limited to, attending providers as defined in this section, home health agencies licensed under chapter
70.127
RCW, and registered nurses licensed under chapter
18.79
RCW.
(e) This section does not require attending providers to authorize care they believe to be medically unnecessary.
(f) Coverage for the newly born child must be no less than the coverage of the child's mother for no less than three weeks, even if there are separate hospital admissions.
(4) A carrier that provides coverage for maternity services may not deselect, terminate the services of, require additional documentation from, require additional utilization review of, reduce payments to, or otherwise provide financial disincentives to any attending provider or health care facility solely as a result of the attending provider or health care facility ordering care consistent with this section. This section does not prevent any insurer from reimbursing an attending provider or health care facility on a capitated, case rate, or other financial incentive basis.
(5) Every carrier that provides coverage for maternity services must provide notice to policyholders regarding the coverage required under this section. The notice must be in writing and must be transmitted at the earliest of the next mailing to the policyholder, the yearly summary of benefits sent to the policyholder, or January 1 of the year following June 6, 1996.
(6) This section does not establish a standard of medical care.
(7) This section applies to coverage for maternity services under a contract issued or renewed by a health carrier after June 6, 1996, and applies to plans operating under the health care authority under chapter
41.05
RCW beginning January 1, 1998.
[
2020 c 80 s 37
;
2003 c 248 s 14
;
1996 c 281 s 1
.]
NOTES:
*Reviser's note:
The term "advanced registered nurse practitioner" was changed to "advanced practice registered nurse" by 2024 c 239 s 1, effective June 30, 2027.
Effective date
—
2020 c 80 ss 12-59:
See note following RCW 7.68.030
.
Intent
—
2020 c 80:
See note following RCW 18.71A.010
.
Short title
—
1996 c 281:
"This act shall be known as "the Erin Act.""  [
1996 c 281 s 3
.]
PDF
RCW 48.43.115
Maternity services
—
Intent
—
Definitions
—
Patient preference
—
Clinical sovereignty of provider
—
Notice to policyholders
—
Application.
(Effective June 30, 2027.)
(1) The legislature recognizes the role of health care providers as the appropriate authority to determine and establish the delivery of quality health care services to maternity patients and their newly born children. It is the intent of the legislature to recognize patient preference and the clinical sovereignty of providers as they make determinations regarding services provided and the length of time individual patients may need to remain in a health care facility after giving birth. It is not the intent of the legislature to diminish a carrier's ability to utilize managed care strategies but to ensure the clinical judgment of the provider is not undermined by restrictive carrier contracts or utilization review criteria that fail to recognize individual postpartum needs.
(2) Unless otherwise specifically provided, the following definitions apply throughout this section:
(a) "Attending provider" means a provider who: Has clinical hospital privileges consistent with RCW 70.43.020
; is included in a provider network of the carrier that is providing coverage; and is a physician licensed under chapter
18.57
or
18.71
RCW, a certified nurse midwife licensed under chapter
18.79
RCW, a midwife licensed under chapter
18.50
RCW, a physician's assistant licensed under chapter
18.71A
RCW, or an advanced practice registered nurse licensed under chapter
18.79
RCW.
(b) "Health carrier" or "carrier" means disability insurers regulated under chapter
48.20
or
48.21
RCW, health care services contractors regulated under chapter
48.44
RCW, health maintenance organizations regulated under chapter
48.46
RCW, plans operating under the health care authority under chapter
41.05
RCW, the state health insurance pool operating under chapter
48.41
RCW, and insuring entities regulated under this chapter.
(3)(a) Every health carrier that provides coverage for maternity services must permit the attending provider, in consultation with the mother, to make decisions on the length of inpatient stay, rather than making such decisions through contracts or agreements between providers, hospitals, and insurers. These decisions must be based on accepted medical practice.
(b) Covered eligible services may not be denied for inpatient, postdelivery care to a mother and her newly born child after a vaginal delivery or a cesarean section delivery for such care as ordered by the attending provider in consultation with the mother.
(c) At the time of discharge, determination of the type and location of follow-up care must be made by the attending provider in consultation with the mother rather than by contract or agreement between the hospital and the insurer. These decisions must be based on accepted medical practice.
(d) Covered eligible services may not be denied for follow-up care, including in-person care, as ordered by the attending provider in consultation with the mother. Coverage for providers of follow-up services must include, but need not be limited to, attending providers as defined in this section, home health agencies licensed under chapter
70.127
RCW, and registered nurses licensed under chapter
18.79
RCW.
(e) This section does not require attending providers to authorize care they believe to be medically unnecessary.
(f) Coverage for the newly born child must be no less than the coverage of the child's mother for no less than three weeks, even if there are separate hospital admissions.
(4) A carrier that provides coverage for maternity services may not deselect, terminate the services of, require additional documentation from, require additional utilization review of, reduce payments to, or otherwise provide financial disincentives to any attending provider or health care facility solely as a result of the attending provider or health care facility ordering care consistent with this section. This section does not prevent any insurer from reimbursing an attending provider or health care facility on a capitated, case rate, or other financial incentive basis.
(5) Every carrier that provides coverage for maternity services must provide notice to policyholders regarding the coverage required under this section. The notice must be in writing and must be transmitted at the earliest of the next mailing to the policyholder, the yearly summary of benefits sent to the policyholder, or January 1 of the year following June 6, 1996.
(6) This section does not establish a standard of medical care.
(7) This section applies to coverage for maternity services under a contract issued or renewed by a health carrier after June 6, 1996, and applies to plans operating under the health care authority under chapter
41.05
RCW beginning January 1, 1998.
[
2025 c 58 s 5105
;
2020 c 80 s 37
;
2003 c 248 s 14
;
1996 c 281 s 1
.]
NOTES:
Effective date
—
2025 c 58 ss 5058-5170:
See note following RCW 7.68.030
.
Explanatory note
—
2025 c 58:
See note following RCW 1.16.050
.
Effective date
—
2020 c 80 ss 12-59:
See note following RCW 7.68.030
.
Intent
—
2020 c 80:
See note following RCW 18.71A.010
.
Short title
—
1996 c 281:
"This act shall be known as "the Erin Act.""  [
1996 c 281 s 3
.]
RCW 48.43.121
Ground ambulance services organizations
—
Coverage.
(1) For health plans issued or renewed on or after January 1, 2025, a health carrier shall provide coverage for ground ambulance transports to behavioral health emergency services providers for enrollees who are experiencing an emergency medical condition as defined in RCW 48.43.005
. A health carrier may not require prior authorization of ground ambulance services if a prudent layperson acting reasonably would have believed that an emergency medical condition existed.
(2) Coverage of ground ambulance transports to behavioral health emergency services providers may be subject to applicable in-network copayments, coinsurance, and deductibles, as provided in chapter
48.49
RCW.
[
2024 c 218 s 12
.]
RCW 48.43.125
Coverage at a long-term care facility following hospitalization
—
Definition.
(1) A carrier that provides coverage for a person at a long-term care facility following the person's hospitalization shall, upon the request of the person or his or her legal representative as authorized in RCW 7.70.065, provide such coverage at the facility in which the person resided immediately prior to the hospitalization if:
(a) The person's primary care physician determines that the medical care needs of the person can be met at the requested facility;
(b) The requested facility has all applicable licenses and certifications, and is not under a stop placement order that prevents the person's readmission;
(c) The requested facility agrees to accept payment from the carrier for covered services at the rate paid to similar facilities that otherwise contract with the carrier to provide such services; and
(d) The requested facility, with regard to the following, agrees to abide by the standards, terms, and conditions required by the carrier of similar facilities with which the carrier otherwise contracts: (i) Utilization review, quality assurance, and peer review; and (ii) management and administrative procedures, including data and financial reporting that may be required by the carrier.
(2) For purposes of this section, "long-term care facility" or "facility" means a nursing facility licensed under chapter
18.51
RCW, continuing care retirement community defined under RCW 70.38.025, or assisted living facility licensed under chapter
18.20
RCW.
[
2012 c 10 s 43
;
1999 c 312 s 2
.]
NOTES:
Application
—
2012 c 10:
See note following RCW 18.20.010
.
Findings
—
1999 c 312:
"The legislature finds that a long-term care facility is home for any individual who resides there, and the individual has the right to receive services in his or her own home and to be cared for by the organization with which he or she has a contractual agreement to provide housing and related services. The legislature further finds that restricting individuals from returning to the long-term care facility in which they were residing prior to hospitalization may detrimentally impact the health and well-being of frail individuals and their families." [
1999 c 312 s 1
.]
Short title
—
1999 c 312:
"This act may be known and cited as the Kitson act." [
1999 c 312 s 3
.]
RCW 48.43.135
Hearing instruments
—
Coverage.
(1) For nongrandfathered group health plans other than small group health plans issued or renewed on or after January 1, 2024, and for health plans issued or renewed on or after January 1, 2026, a health carrier shall include coverage for hearing instruments, including bone conduction hearing devices. This section does not include coverage of over-the-counter hearing instruments.
(2) Coverage shall also include the initial assessment, fitting, adjustment, auditory training, and ear molds as necessary to maintain optimal fit. Coverage of the services in this subsection shall include services for enrollees who intend to obtain or have already obtained any hearing instrument, including an over-the-counter hearing instrument.
(3)(a) Until the date specified in (b) of this subsection, a health carrier shall provide coverage for hearing instruments as provided in subsection (1) of this section at no less than $3,000 per ear with hearing loss every 36 months.
(b) For health plans issued or renewed on or after January 1, 2026, a health carrier shall provide coverage for hearing instruments as provided in subsection (1) of this section every 36 months per ear with hearing loss and may not establish any lifetime or annual limit on the dollar amount of coverage for services described in subsection (1) or (2) of this section for any individual, whether provided in-network or out-of-network.
(c) A health carrier may require prior authorization or adopt other appropriate utilization controls in approving coverage for medically necessary hearing instruments.
(4) The services and hearing instruments covered under this section are not subject to the enrollee's deductible unless the health plan is offered as a qualifying health plan for a health savings account. For such a qualifying health plan, the carrier may apply a deductible to coverage of the services covered under this section only 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.
(5) Coverage for a minor under 18 years of age shall be available under this section only after the minor has received medical clearance within the preceding six months from:
(a) An otolaryngologist for an initial evaluation of hearing loss; or
(b) A licensed physician, which indicates there has not been a substantial change in clinical status since the initial evaluation by an otolaryngologist.
(6) For the purposes of this section:
(a) "Hearing instrument" has the same meaning as defined in RCW 18.35.010
.
(b) "Over-the-counter hearing instrument" has the same meaning as "over-the-counter hearing aid" in 21 C.F.R. Sec. 800.30 as of December 28, 2022.
[
2025 c 243 s 9
;
2023 c 245 s 1
.]
RCW 48.43.176
Eosinophilic gastrointestinal associated disorder
—
Elemental formula.
(1) Each health benefit plan issued or renewed after December 31, 2015, must offer benefits or coverage for medically necessary elemental formula, regardless of delivery method, when a licensed physician or other health care provider with prescriptive authority:
(a) Diagnoses a patient with an eosinophilic gastrointestinal associated disorder; and
(b) Orders and supervises the use of the elemental formula.
(2) Nothing in this section prohibits a health benefit plan from requiring prior authorization or imposing other appropriate utilization controls in approving coverage for medically necessary elemental formula.
[
2014 c 115 s 2
.]
RCW 48.43.180
Denturist services.
Notwithstanding any provision of any certified health plan covering dental care as provided for in this chapter, effective January 1, 1995, benefits shall not be denied thereunder for any service performed by a denturist licensed under chapter
18.30
RCW if (1) the service performed was within the lawful scope of such person's license, and (2) such plan would have provided benefits if such service had been performed by a dentist licensed under chapter
18.32
RCW.
[
1995 c 1 s 23
(Initiative Measure No. 607, approved November 8, 1994).]
NOTES:
Short title
—
1995 c 1 (Initiative Measure No. 607):
See RCW 18.30.900
.
RCW 48.43.185
General anesthesia services for dental procedures.
(1) Each group health benefit plan that provides coverage for hospital, medical, or ambulatory surgery center services must cover general anesthesia services and related facility charges in conjunction with any dental procedure performed in a hospital or ambulatory surgical center if such anesthesia services and related facility charges are medically necessary because the covered person:
(a) Is under the age of seven, or physically or developmentally disabled, with a dental condition that cannot be safely and effectively treated in a dental office; or
(b) Has a medical condition that the person's physician determines would place the person at undue risk if the dental procedure were performed in a dental office. The procedure must be approved by the person's physician.
(2) Each group health benefit plan or group dental plan that provides coverage for dental services must cover medically necessary general anesthesia services in conjunction with any covered dental procedure performed in a dental office if the general anesthesia services are medically necessary because the covered person is under the age of seven or physically or developmentally disabled.
(3) This section does not prohibit a group health benefit plan or group dental plan from:
(a) Applying cost-sharing requirements, maximum annual benefit limitations, and prior authorization requirements to the services required under this section; or
(b) Covering only those services performed by a health care provider, or in a health care facility, that is part of its provider network; nor does it limit the health carrier in negotiating rates and contracts with specific providers.
(4) This section does not apply to medicare supplement policies, or supplemental contracts covering a specified disease or other limited benefits.
(5) For the purpose of this section, "general anesthesia services" means services to induce a state of unconsciousness accompanied by a loss of protective reflexes, including the ability to maintain an airway independently and respond purposefully to physical stimulation or verbal command.
(6) This section applies to group health benefit plans and group dental plans issued or renewed on or after January 1, 2002.
[
2001 c 321 s 2
.]
RCW 48.43.190
Payment of chiropractic services
—
Parity.
(1)(a) A health carrier may not pay a chiropractor less for a service or procedure identified under a particular physical medicine and rehabilitation code, evaluation and management code, or spinal manipulation code, as listed in a nationally recognized services and procedures code book such as the American medical association current procedural terminology code book, than it pays any other type of provider licensed under Title
18
RCW for a service or procedure under the same or substantially similar code, except as provided in (b) of this subsection. A carrier may not circumvent this requirement by creating a chiropractor-specific code not listed in the nationally recognized code book otherwise used by the carrier for provider payment.
(b) This section does not affect a health carrier's:
(i) Implementation of a health care quality improvement program to promote cost-effective and clinically efficacious health care services, including but not limited to pay-for-performance payment methodologies and other programs fairly applied to all health care providers licensed under Title
18
RCW that are designed to promote evidence-based and research-based practices;
(ii) Health care provider contracting to comply with the network adequacy standards;
(iii) Authority to pay in-network providers differently than out-of-network providers; and
(iv) Authority to pay a chiropractor less than another provider for procedures or services under the same or a substantially similar code based upon differences in the cost of maintaining a practice or carrying malpractice insurance, as recognized by a nationally accepted reimbursement methodology.
(c) This section does not, and may not be construed to:
(i) Require the payment of provider billings that do not meet the definition of a clean claim as set forth in rules adopted by the commissioner;
(ii) Require any health plan to include coverage of any condition; or
(iii) Expand the scope of practice for any health care provider.
(2) This section applies only to payments made on or after January 1, 2009.
[
2018 c 181 s 1
;
2008 c 304 s 1
.]
NOTES:
Rules
—
2018 c 181 s 1:
"The office of the insurance commissioner may adopt any rules necessary to implement section 1 of this act." [
2018 c 181 s 2
.]
Effective date
—
2018 c 181 s 1:
"Section 1 of this act takes effect January 1, 2019." [
2018 c 181 s 3
.]
RCW 48.43.195
Contraceptive drugs
—
Twelve-month refill coverage.
(Effective until January 1, 2026.)
(1) A health benefit plan issued or renewed on or after January 1, 2018, that includes coverage for contraceptive drugs must provide reimbursement for a twelve-month refill of contraceptive drugs obtained at one time by the enrollee, unless the enrollee requests a smaller supply or the prescribing provider instructs that the enrollee must receive a smaller supply. The health plan must allow enrollees to receive the contraceptive drugs on-site at the provider's office, if available. Any dispensing practices required by the plan must follow clinical guidelines for appropriate prescribing and dispensing to ensure the health of the patient while maximizing access to effective contraceptive drugs.
(2) Nothing in this section prohibits a health plan from limiting refills that may be obtained in the last quarter of the plan year if a twelve-month supply of the contraceptive drug has already been dispensed during the plan year.
(3) For purposes of this section, "contraceptive drugs" means all drugs approved by the United States food and drug administration that are used to prevent pregnancy, including, but not limited to, hormonal drugs administered orally, transdermally, and intravaginally.
[
2017 c 293 s 2
.]
NOTES:
Finding
—
Intent
—
2017 c 293:
"The legislature finds that a significant percentage of pregnancies are unintended and could be averted with broader access to health care and effective contraception. Research suggests that moving from twenty-eight day dispensing of contraceptive drugs to twelve-month dispensing improves adherence to maintenance of the drugs and effective use of the contraceptives. It is therefore the intent of the legislature to require private health insurers to require dispensing of contraceptive drugs with up to a twelve-month supply provided at one time." [
2017 c 293 s 1
.]
PDF
RCW 48.43.195
Contraceptive drugs
—
Twelve-month refill coverage.
(Effective January 1, 2026.)
(1) A health benefit plan issued or renewed on or after January 1, 2026, that includes coverage for contraceptive drugs must provide reimbursement for a 12-month supply of contraceptive drugs obtained at one time by the enrollee, unless the enrollee requests a smaller supply or the prescribing provider instructs that the enrollee must receive a smaller supply. The health plan must allow enrollees to receive the contraceptive drugs on-site at the provider's office, if available. Any dispensing practices required by the plan must follow clinical guidelines for appropriate prescribing and dispensing to ensure the health of the patient while maximizing access to effective contraceptive drugs.
(2) Nothing in this section prohibits a health plan from limiting refills that may be obtained in the last quarter of the plan year if a 12-month supply of the contraceptive drug has already been dispensed during the plan year.
(3) For purposes of this section, "contraceptive drugs" means all drugs approved by the United States food and drug administration that are used to prevent pregnancy, including, but not limited to, hormonal drugs administered orally, transdermally, and intravaginally.
[
2025 c 147 s 1
;
2017 c 293 s 2
.]
NOTES:
Effective date
—
2025 c 147:
"This act takes effect January 1, 2026." [
2025 c 147 s 2
.]
Finding
—
Intent
—
2017 c 293:
"The legislature finds that a significant percentage of pregnancies are unintended and could be averted with broader access to health care and effective contraception. Research suggests that moving from twenty-eight day dispensing of contraceptive drugs to twelve-month dispensing improves adherence to maintenance of the drugs and effective use of the contraceptives. It is therefore the intent of the legislature to require private health insurers to require dispensing of contraceptive drugs with up to a twelve-month supply provided at one time." [
2017 c 293 s 1
.]
RCW 48.43.200
Disclosure of certain material transactions
—
Report
—
Information is confidential.
(1) Every certified health plan domiciled in this state shall file a report with the commissioner disclosing material acquisitions and dispositions of assets or material nonrenewals, cancellations, or revisions of ceded reinsurance agreements unless these acquisitions and dispositions of assets or material nonrenewals, cancellations, or revisions of ceded reinsurance agreements have been submitted to the commissioner for review, approval, or information purposes under other provisions of this title or other requirements.
(2) The report required in subsection (1) of this section is due within fifteen days after the end of the calendar month in which any of the transactions occur.
(3) One complete copy of the report, including any exhibits or other attachments filed as part of the report, shall be filed with the:
(a) Commissioner; and
(b) National association of insurance commissioners.
(4) All reports obtained by or disclosed to the commissioner under this section and RCW 48.43.205
through
48.43.225
are exempt from public inspection and copying and shall not be subject to subpoena. These reports shall not be made public by the commissioner, the national association of insurance commissioners, or any other person, except to insurance departments of other states, without the prior written consent of the certified health plan to which it pertains unless the commissioner, after giving the certified health plan that would be affected by disclosure notice and a hearing under chapter
48.04
RCW, determines that the interest of policyholders, subscribers, shareholders, or the public will be served by the publication, in which event the commissioner may publish all or any part of the report in the manner he or she deems appropriate.
[
1995 c 86 s 7
.]
RCW 48.43.205
Material acquisitions or dispositions.
No acquisitions or dispositions of assets need be reported pursuant to RCW 48.43.200
if the acquisitions or dispositions are not material. For purposes of RCW 48.43.200
through
48.43.225, a material acquisition, or the aggregate of any series of related acquisitions during any thirty-day period; or disposition, or the aggregate of any series of related dispositions during any thirty-day period is an acquisition or disposition that is nonrecurring and not in the ordinary course of business and involves more than five percent of the reporting certified health plan's total assets as reported in its most recent statutory statement filed with the commissioner.
[
1995 c 86 s 8
.]
RCW 48.43.210
Asset acquisitions
—
Asset dispositions.
(1) Asset acquisitions subject to RCW 48.43.200
through
48.43.225
include every purchase, lease, exchange, merger, consolidation, succession, or other acquisition other than the construction or development of real property by or for the reporting certified health plan or the acquisition of materials for such purpose.
(2) Asset dispositions subject to RCW 48.43.200
through
48.43.225
include every sale, lease, exchange, merger, consolidation, mortgage, hypothecation, abandonment, destruction, other disposition, or assignment, whether for the benefit of creditors or otherwise.
[
1995 c 86 s 9
.]
RCW 48.43.215
Report of a material acquisition or disposition of assets
—
Information required.
(1) The following information is required to be disclosed in any report of a material acquisition or disposition of assets:
(a) Date of the transaction;
(b) Manner of acquisition or disposition;
(c) Description of the assets involved;
(d) Nature and amount of the consideration given or received;
(e) Purpose of or reason for the transaction;
(f) Manner by which the amount of consideration was determined;
(g) Gain or loss recognized or realized as a result of the transaction; and
(h) Names of the persons from whom the assets were acquired or to whom they were disposed.
(2) Certified health plans are required to report material acquisitions and dispositions on a nonconsolidated basis unless the certified health plan is part of a consolidated group of insurers that utilizes a pooling arrangement or one hundred percent reinsurance agreement that affects the solvency and integrity of the certified health plan's reserves and such certified health plan ceded substantially all of its direct and assumed business to the pool. A certified health plan has ceded substantially all of its direct and assumed business to a pool if the certified health plan has less than one million dollars total direct plus assumed written premiums during a calendar year that are not subject to a pooling arrangement and the net income of the business not subject to the pooling arrangement represents less than five percent of the certified health plan's net worth.
[
1995 c 86 s 10
.]
RCW 48.43.220
Material nonrenewals, cancellations, or revisions of ceded reinsurance agreements.
(1) No nonrenewals, cancellations, or revisions of ceded reinsurance agreements need be reported under RCW 48.43.200
if the nonrenewals, cancellations, or revisions are not material. For purposes of RCW 48.43.200
through
48.43.225, a material nonrenewal, cancellation, or revision is one that affects:
(a) More than fifty percent of a certified health plan's total reserve credit taken for business ceded, on an annualized basis, as indicated in the certified health plan's most recent annual statement;
(b) More than ten percent of a certified health plan's total cession when it is replaced by one or more unauthorized reinsurers; or
(c) Previously established collateral requirements, when they have been reduced or waived as respects one or more unauthorized reinsurers representing collectively more than ten percent of a total cession.
(2) However, a filing is not required if the certified health plan's total reserve credit taken for business ceded represents, on an annualized basis, less than ten percent of the statutory reserve requirement prior to any cession.
[
1995 c 86 s 11
.]
RCW 48.43.225
Report of a material nonrenewal, cancellation, or revision of ceded reinsurance agreements
—
Information required.
(1) The following is required to be disclosed in any report of a material nonrenewal, cancellation, or revision of ceded reinsurance agreements:
(a) The effective date of the nonrenewal, cancellation, or revision;
(b) The description of the transaction with an identification of the initiator;
(c) The purpose of or reason for the transaction; and
(d) If applicable, the identity of the replacement reinsurers.
(2) Certified health plans are required to report all material nonrenewals, cancellations, or revisions of ceded reinsurance agreements on a nonconsolidated basis unless the certified health plan is part of a consolidated group of insurers which utilizes a pooling arrangement or one hundred percent reinsurance agreement that affects the solvency and integrity of the certified health plan's reserves and the certified health plan ceded substantially all of its direct and assumed business to the pool. A certified health plan has ceded substantially all of its direct and assumed business to a pool if the certified health plan has less than one million dollars total direct plus assumed written premiums during a calendar year that are not subject to a pooling arrangement and the net income of the business not subject to the pooling arrangement represents less than five percent of the certified health plan's net worth.
[
1995 c 86 s 12
.]
RCW 48.43.290
Coverage for prescribed durable medical equipment and mobility enhancing equipment
—
Sales and use taxes
—
Definitions.
(1) Health plans issued or renewed on or after January 1, 2011, that include coverage for prescribed durable medical equipment and mobility enhancing equipment must include the sales tax or use tax calculation in plan payment, consistent with the application of sales tax in chapter
82.08
RCW or use tax in chapter
82.12
RCW.
(2) The payment for covered durable medical equipment and mobility enhancing equipment must:
(a) Reflect the negotiated provider agreement for the prescribed equipment; and
(b) Separately identify the sales tax or use tax calculation that is included in the payment if the provider submitting a claim or invoice for reimbursement submits to the health plan a claim or invoice with a separate line item for the geographically adjusted sales tax.
(3) The following definitions apply to this section unless the context clearly requires otherwise.
(a) "Durable medical equipment" means equipment, including repair and replacement parts for durable medical equipment that:
(i) Can withstand repeated use;
(ii) Is primarily and customarily used to serve a medical purpose;
(iii) Generally is not useful to a person in the absence of illness or injury; and
(iv) Is not worn in or on the body.
(b) "Mobility enhancing equipment" means equipment, including repair and replacement parts for mobility enhancing equipment that:
(i) Is primarily and customarily used to provide or increase the ability to move from one place to another and that is appropriate for use either in a home or a motor vehicle;
(ii) Is not generally used by persons with normal mobility; and
(iii) Does not include any motor vehicle or equipment on a motor vehicle normally provided by a motor vehicle manufacturer.
[
2010 c 44 s 1
.]
RCW 48.43.300
Definitions.
The definitions in this section apply throughout RCW 48.43.300
through
48.43.370
unless the context clearly requires otherwise.
(1) "Adjusted RBC report" means an RBC report that has been adjusted by the commissioner in accordance with RCW 48.43.305
(4).
(2) "Corrective order" means an order issued by the commissioner specifying corrective actions that the commissioner has determined are required.
(3) "Domestic carrier" means any carrier domiciled in this state, or any person or entity subject to chapter
48.42
RCW domiciled in this state.
(4) "Foreign or alien carrier" means any carrier that is licensed to do business in this state but is not domiciled in this state, or any person or entity subject to chapter
48.42
RCW not domiciled in this state.
(5) "NAIC" means the national association of insurance commissioners.
(6) "Negative trend" means, with respect to a carrier, a negative trend over a period of time, as determined in accordance with the "trend test calculation" included in the RBC instructions.
(7) "RBC" means risk-based capital.
(8) "RBC instructions" means the RBC report including risk-based capital instructions adopted by the NAIC, as such RBC instructions may be amended by the NAIC from time to time in accordance with the procedures adopted by the NAIC.
(9) "RBC level" means a carrier's company action level RBC, regulatory action level RBC, authorized control level RBC, or mandatory control level RBC where:
(a) "Company action level RBC" means, with respect to any carrier, the product of 2.0 and its authorized control level RBC;
(b) "Regulatory action level RBC" means the product of 1.5 and its authorized control level RBC;
(c) "Authorized control level RBC" means the number determined under the risk-based capital formula in accordance with the RBC instructions;
(d) "Mandatory control level RBC" means the product of .70 and the authorized control level RBC.
(10) "RBC plan" means a comprehensive financial plan containing the elements specified in RCW 48.43.310
(2). If the commissioner rejects the RBC plan, and it is revised by the carrier, with or without the commissioner's recommendation, the plan shall be called the "revised RBC plan."
(11) "RBC report" means the report required in RCW 48.43.305
.
(12) "Total adjusted capital" means the sum of:
(a) Either a carrier's statutory capital and surplus or net worth, or both, as determined in accordance with statutory accounting applicable to the annual financial statements required to be filed with the commissioner; and
(b) Other items, if any, as the RBC instructions may provide.
[
1998 c 241 s 1
.]
RCW 48.43.305
Report of RBC levels
—
Distribution of report
—
Formula for determination
—
Commissioner may make adjustments.
(1) Every domestic carrier shall, on or prior to the filing date of March 1st, prepare and submit to the commissioner a report of its RBC levels as of the end of the calendar year just ended, in a form and containing such information as is required by the RBC instructions. In addition, every domestic carrier shall file its RBC report:
(a) With the NAIC in accordance with the RBC instructions; and
(b) With the insurance commissioner in any state in which the carrier is authorized to do business, if the insurance commissioner has notified the carrier of its request in writing, in which case the carrier shall file its RBC report not later than the later of:
(i) Fifteen days from the receipt of notice to file its RBC report with that state; or
(ii) The filing date.
(2) A carrier's RBC shall be determined in accordance with the formula set forth in the RBC instructions. The formula shall take into account (and may adjust for the covariance between):
(a) The risk with respect to the carrier's assets;
(b) The risk of adverse insurance experience with respect to the carrier's liabilities and obligations;
(c) The interest rate risk with respect to the carrier's business; and
(d) All other business risks and such other relevant risks as are set forth in the RBC instructions; determined in each case by applying the factors in the manner set forth in the RBC instructions.
(3) An excess of capital over the amount produced by the risk-based capital requirements contained in RCW 48.43.300
through
48.43.370
and the formulas, schedules, and instructions referenced in RCW 48.43.300
through
48.43.370
is desirable in the business of insurance. Accordingly, carriers should seek to maintain capital above the RBC levels required by RCW 48.43.300
through
48.43.370
. Additional capital is used and useful in the insurance business and helps to secure a carrier against various risks inherent in, or affecting, the business of insurance and not accounted for or only partially measured by the risk-based capital requirements contained in RCW 48.43.300
through
48.43.370
.
(4) If a domestic carrier files an RBC report that in the judgment of the commissioner is inaccurate, then the commissioner shall adjust the RBC report to correct the inaccuracy and shall notify the carrier of the adjustment. The notice shall contain a statement of the reason for the adjustment.
[
1998 c 241 s 2
.]