RCW 41.05.526
Withdrawal management services
—
Substance use disorder treatment services
—
Prior authorization
—
Utilization review
—
Medical necessity review.
(1) Except as provided in subsection (2) of this section, a health plan offered to employees and their covered dependents under this chapter issued or renewed on or after January 1, 2021, may not require an enrollee to obtain prior authorization for withdrawal management services or inpatient or residential substance use disorder treatment services in a behavioral health agency licensed or certified under RCW 71.24.037
.
(2)(a) A health plan offered to employees and their covered dependents under this chapter issued or renewed on or after January 1, 2021, must:
(i) Provide coverage for no less than two business days, excluding weekends and holidays, in a behavioral health agency that provides inpatient or residential substance use disorder treatment prior to conducting a utilization review; and
(ii) Provide coverage for no less than three days in a behavioral health agency that provides withdrawal management services prior to conducting a utilization review.
(b)(i) The health plan may not require an enrollee to obtain prior authorization for the services specified in (a) of this subsection as a condition for payment of services prior to the times specified in (a) of this subsection.
(ii) Once the times specified in (a) of this subsection have passed, the health plan may initiate utilization management review procedures if the behavioral health agency continues to provide services or is in the process of arranging for a seamless transfer to an appropriate facility or lower level of care under subsection (6) of this section. For a health plan issued or renewed on or after January 1, 2025, if a health plan authorizes inpatient or residential substance use disorder treatment services pursuant to (a)(i) of this subsection following the initial medical necessity review process under (c)(iii) of this subsection, the length of the initial authorization may not be less than 14 days from the date that the patient was admitted to the behavioral health agency. Any subsequent reauthorization that the health plan approves after the first 14 days must continue for no less than seven days prior to requiring further reauthorization. Nothing prohibits a health plan from requesting information to assist with a seamless transfer under this subsection.
(c)(i) The behavioral health agency under (a) of this subsection must notify an enrollee's health plan as soon as practicable after admitting the enrollee, but not later than twenty-four hours after admitting the enrollee. The time of notification does not reduce the requirements established in (a) of this subsection.
(ii) The behavioral health agency under (a) of this subsection must provide the health plan with its initial assessment and initial treatment plan for the enrollee within two business days of admission, excluding weekends and holidays, or within three days in the case of a behavioral health agency that provides withdrawal management services.
(iii) After the time period in (a) of this subsection and receipt of the material provided under (c)(ii) of this subsection, the plan may initiate a medical necessity review process. Medical necessity review must be based on the standard set of criteria established under RCW 41.05.528
. In a review for inpatient or residential substance use disorder treatment services, a health plan may not make a determination that a patient does not meet medical necessity criteria based primarily on the patient's length of abstinence. If the patient's abstinence from substance use was due to incarceration, hospitalization, or inpatient treatment, a health plan may not consider the patient's length of abstinence in determining medical necessity. If the health plan determines within one business day from the start of the medical necessity review period and receipt of the material provided under (c)(ii) of this subsection that the admission to the facility was not medically necessary and advises the agency of the decision in writing, the health plan is not required to pay the facility for services delivered after the start of the medical necessity review period, subject to the conclusion of a filed appeal of the adverse benefit determination. If the health plan's medical necessity review is completed more than one business day after the start of the medical necessity review period and receipt of the material provided under (c)(ii) of this subsection, the health plan must pay for the services delivered from the time of admission until the time at which the medical necessity review is completed and the agency is advised of the decision in writing.
(3)(a) The behavioral health agency shall document to the health plan the patient's need for continuing care and justification for level of care placement following the current treatment period, based on the standard set of criteria established under RCW 41.05.528, with documentation recorded in the patient's medical record.
(b) For a health plan issued or renewed on or after January 1, 2025, for inpatient or residential substance use disorder treatment services, the health plan may not consider the patient's length of stay at the behavioral health agency when making decisions regarding the authorization to continue care at the behavioral health agency.
(4) Nothing in this section prevents a health carrier from denying coverage based on insurance fraud.
(5) If the behavioral health agency under subsection (2)(a) of this section is not in the enrollee's network:
(a) The health plan is not responsible for reimbursing the behavioral health agency at a greater rate than would be paid had the agency been in the enrollee's network; and
(b) The behavioral health agency may not balance bill, as defined in RCW 48.43.005
.
(6) When the treatment plan approved by the health plan involves transfer of the enrollee to a different facility or to a lower level of care, the care coordination unit of the health plan shall work with the current agency to make arrangements for a seamless transfer as soon as possible to an appropriate and available facility or level of care. The health plan shall pay the agency for the cost of care at the current facility until the seamless transfer to the different facility or lower level of care is complete. A seamless transfer to a lower level of care may include same day or next day appointments for outpatient care, and does not include payment for nontreatment services, such as housing services. If placement with an agency in the health plan's network is not available, the health plan shall pay the current agency until a seamless transfer arrangement is made.
(7) The requirements of this section do not apply to treatment provided in out-of-state facilities.
(8) For the purposes of this section "withdrawal management services" means twenty-four hour medically managed or medically monitored detoxification and assessment and treatment referral for adults or adolescents withdrawing from alcohol or drugs, which may include induction on medications for addiction recovery.
[
2024 c 366 s 6
;
2020 c 345 s 2
.]
NOTES:
Findings
—
Intent
—
2024 c 366:
See note following RCW 71.24.847
.
Findings
—
Intent
—
2020 c 345:
"(1) The legislature finds that:
(a) Substance use disorder is a treatable brain disease from which people recover;
(b) Electing to go to addiction treatment is an act of great courage; and
(c) When people with substance use disorder are provided rapid access to quality treatment within their window of willingness, recovery happens.
(2) The legislature therefore intends to ensure that there is no wrong door for individuals accessing substance use disorder treatment services by requiring coverage, and prohibiting barriers created by prior authorization and premature utilization management review when persons with substance use disorders are ready or urgently in need of treatment services." [
2020 c 345 s 1
.]
RCW 41.05.527
Opioid overdose reversal medication bulk purchasing and distribution program.
(1) A health plan offered to public employees and their covered dependents under this chapter that is issued or renewed on or after January 1, 2023, must participate in the bulk purchasing and distribution program for opioid overdose reversal medication established in RCW 70.14.170
once the program is operational.
(2) For health plans issued or renewed on or after January 1, 2025, a health carrier must reimburse a hospital or psychiatric hospital that bills for the following outpatient services:
(a) For opioid overdose reversal medication dispensed or distributed to a patient under RCW 70.41.485
as a separate reimbursable expense; and
(b) For the administration of long-acting injectable buprenorphine as a separate reimbursable expense.
(3) Reimbursements provided under subsection (2) of this section must be separate from any bundled payment for outpatient hospital or emergency department services.
[
2024 c 366 s 16
;
2021 c 273 s 10
.]
NOTES:
Findings
—
Intent
—
2024 c 366:
See note following RCW 71.24.847
.
Rules
—
2021 c 273 ss 7-12:
See note following RCW 70.14.170
.
Findings
—
Intent
—
2021 c 273:
See note following RCW 70.41.480
.
RCW 41.05.528
Standard set of criteria
—
Medical necessity for substance use disorder treatment
—
Substance use disorder levels of care
—
Rules.
For the purposes of promoting standardized training for behavioral health professionals and facilitating communications between behavioral health agencies, executive agencies, managed care organizations, private health plans, and plans offered through the public employees' benefits board, it is the policy of the state to adopt a single standard set of criteria to define medical necessity for substance use disorder treatment and to define substance use disorder levels of care in Washington. The criteria selected must be comprehensive, widely understood and accepted in the field, and based on continuously updated research and evidence. The health care authority and the office of the insurance commissioner must independently review their regulations and practices by January 1, 2021. The health care authority may make rules if necessary to promulgate the selected standard set of criteria.
[
2020 c 345 s 6
.]
NOTES:
Findings
—
Intent
—
2020 c 345:
See note following RCW 41.05.526
.
RCW 41.05.530
Prescription drug assistance, education
—
Rules.
The authority may adopt rules to implement chapter 29, Laws of 2003 1st sp. sess.
[
2003 1st sp.s. c 29 s 10
.]
NOTES:
Finding
—
Intent
—
Severability
—
Conflict with federal requirements
—
Effective date
—
2003 1st sp.s. c 29:
See notes following RCW 74.09.650
.
RCW 41.05.531
Standard set of criteria
—
Updated versions
—
Review and use.
When updated versions of the ASAM Criteria, treatment criteria for addictive, substance related, and co-occurring conditions, inclusive of adolescent and transition age youth versions, are published by the American society of addiction medicine, the health care authority and the office of the insurance commissioner shall jointly determine whether to use the updated version, and, if so, the date upon which the updated version must begin to be used by medicaid managed care organizations, carriers, and other relevant entities. Both agencies shall post notice of their decision on their websites. For purposes of the ASAM Criteria, 4th edition, medicaid managed care organizations and carriers shall begin to use the updated criteria no later than January 1, 2026, unless the health care authority and the office of the insurance commissioner jointly determine that it should not be used.
[
2024 c 366 s 10
.]
NOTES:
Findings
—
Intent
—
2024 c 366:
See note following RCW 71.24.847
.
RCW 41.05.533
Medication synchronization policy required for health benefit plans covering prescription drugs
—
Requirements
—
Definitions.
(1) A health benefit plan offered to public employees and their covered dependents under this chapter that is not subject to chapter
48.43
RCW, that is issued or renewed after December 31, 2015, and 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 [benefit] 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 2
.]
RCW 41.05.540
State employee health program
—
Requirements.
(1) The health care authority, in coordination with the department of health, health plans participating in public employees' benefits board programs, and the University of Washington's center for health promotion, shall establish and maintain a state employee health program focused on reducing the health risks and improving the health status of state employees, dependents, and retirees enrolled in the public employees' benefits board. The program shall use public and private sector best practices to achieve goals of measurable health outcomes, measurable productivity improvements, positive impact on the cost of medical care, and positive return on investment. The program shall establish standards for health promotion and disease prevention activities, and develop a mechanism to update standards as evidence-based research brings new information and best practices forward.
(2) The state employee health program shall:
(a) Provide technical assistance and other services as needed to wellness staff in all state agencies and institutions of higher education;
(b) Develop effective communication tools and ongoing training for wellness staff;
(c) Contract with outside vendors for evaluation of program goals;
(d) Strongly encourage the widespread completion of online health assessment tools for all state employees, dependents, and retirees. The health assessment tool must be voluntary and confidential. Health assessment data and claims data shall be used to:
(i) Engage state agencies and institutions of higher education in providing evidence-based programs targeted at reducing identified health risks;
(ii) Guide contracting with third-party vendors to implement behavior change tools for targeted high-risk populations; and
(iii) Guide the benefit structure for state employees, dependents, and retirees to include covered services and medications known to manage and reduce health risks.
[
2023 c 51 s 21
;
2007 c 259 s 40
;
2005 c 360 s 8
.]
NOTES:
Subheadings not law
—
2007 c 259:
See note following RCW 7.70.060
.
Findings
—
Intent
—
2005 c 360:
See note following RCW 36.70A.070
.
RCW 41.05.550
Prescription drug assistance foundation
—
Nonprofit and tax-exempt corporation
—
Definitions
—
Liability.
(1) The definitions in this subsection apply throughout this section unless the context clearly requires otherwise.
(a) "Federal poverty level" means the official poverty level based on family size established and adjusted under section 673(2) of the omnibus budget reconciliation act of 1981 (P.L. 97-35; 42 U.S.C. Sec. 9902(2), as amended).
(b) "Foundation" means the prescription drug assistance foundation established in this section, a nonprofit corporation organized under the laws of this state to provide assistance in accessing prescription drugs to qualified uninsured individuals.
(c) "Health insurance coverage including prescription drugs" means prescription drug coverage under a private insurance plan, including a plan offered through the health benefit exchange under chapter
43.71
RCW, the medicaid program, the state children's health insurance program ("SCHIP"), the medicare program, the basic health plan, or any employer-sponsored health plan that includes a prescription drug benefit.
(d) "Qualified uninsured individual" means an uninsured person or an underinsured person who is a resident of this state and whose income meets financial criteria established by the foundation.
(e) "Underinsured" means an individual who has health insurance coverage including prescription drugs, but for whom the prescription drug coverage is inadequate for their needs.
(f) "Uninsured" means an individual who lacks health insurance coverage including prescription drugs.
(2)(a) The director shall establish the foundation as a nonprofit corporation, organized under the laws of this state. The foundation shall assist qualified uninsured individuals in obtaining prescription drugs at little or no cost.
(b) The foundation shall be administered in a manner that:
(i) Begins providing assistance to qualified uninsured individuals by January 1, 2006;
(ii) Defines the population that may receive assistance in accordance with this section; and
(iii) Complies with the eligibility requirements necessary to obtain and maintain tax-exempt status under federal law.
(c) The board of directors of the foundation consists of up to eleven with a minimum of five members appointed by the governor to staggered terms of three years. The governor shall select as members of the board individuals who (i) will represent the interests of persons who lack prescription drug coverage; and (ii) have demonstrated expertise in business management and in the administration of a not-for-profit organization.
(d) The foundation shall apply for and comply with all federal requirements necessary to obtain and maintain tax-exempt status with respect to the federal tax obligations of the foundation's donors.
(e) The foundation is authorized, subject to the direction and ratification of the board, to receive, solicit, contract for, collect, and hold in trust for the purposes of this section, donations, gifts, grants, and bequests in the form of money paid or promised, services, materials, equipment, or other things tangible or intangible that may be useful for helping the foundation to achieve its purpose. The foundation may use all sources of public and private financing to support foundation activities. No general fund-state funds shall be used for the ongoing operation of the foundation.
(f) No liability on the part of, and no cause of action of any nature, shall arise against any member of the board of directors of the foundation or against an employee or agent of the foundation for any lawful action taken by them in the performance of their administrative powers and duties under this section.
[
2023 c 51 s 22
;
2015 c 161 s 1
;
2008 c 87 s 1
;
2005 c 267 s 1
.]
NOTES:
RCW 41.05.600
Mental health services
—
Definition
—
Coverage required, when.
(1) For the purposes of this section, "mental health services" means:
(a) For health benefit plans issued or renewed before January 1, 2021, medically necessary outpatient and inpatient services provided to treat mental disorders covered by the diagnostic categories listed in the most current version of the diagnostic and statistical manual of mental disorders, published by the American psychiatric association, on June 11, 2020, or such subsequent date as may be provided by the director by rule, consistent with the purposes of chapter 6, Laws of 2005, with the exception of the following categories, codes, and services: (i) Substance related disorders; (ii) life transition problems, currently referred to as "V" codes, and diagnostic codes 302 through 302.9 as found in the diagnostic and statistical manual of mental disorders, 4th edition, published by the American psychiatric association; (iii) skilled nursing facility services, home health care, residential treatment, and custodial care; and (iv) court ordered treatment unless the authority's or contracted insuring entity's medical director determines the treatment to be medically necessary; and
(b) For health benefit plans issued or renewed on or after January 1, 2021, medically necessary outpatient and inpatient services provided to treat mental health and substance use disorders covered by the diagnostic categories listed in the most current version of the diagnostic and statistical manual of mental disorders, published by the American psychiatric association, on June 11, 2020, or such subsequent date as may be provided by the director by rule, consistent with the purposes of chapter 6, Laws of 2005.
(2) All health benefit plans offered to public employees and their covered dependents under this chapter that provide coverage for medical and surgical services shall provide coverage for:
(a) Mental health services. The copayment or coinsurance for mental health services may be no more than the copayment or coinsurance for medical and surgical services otherwise provided under the health benefit plan. Wellness and preventive services that are provided or reimbursed at a lesser copayment, coinsurance, or other cost sharing than other medical and surgical services are excluded from this comparison. If the health benefit plan imposes a maximum out-of-pocket limit or stop loss, it shall be a single limit or stop loss for medical, surgical, and mental health services. If the health benefit plan imposes any deductible, mental health services shall be included with medical and surgical services for the purpose of meeting the deductible requirement. Treatment limitations or any other financial requirements on coverage for mental health services are only allowed if the same limitations or requirements are imposed on coverage for medical and surgical services; and
(b) Prescription drugs intended to treat any of the disorders covered in subsection (1) of this section to the same extent, and under the same terms and conditions, as other prescription drugs covered by the health benefit plan.
(3) This section does not prohibit a requirement that mental health services be medically necessary, if a comparable requirement is applicable to medical and surgical services.
(4) Nothing in this section shall be construed to prevent the management of mental health.
(5) The director will consider care management techniques for mental health services if a comparable benefit management requirement is applicable to medical and surgical services, including but not limited to: (a) Authorized treatment plans; (b) preauthorization requirements based on the type of service; (c) concurrent and retrospective utilization review; (d) utilization management practices; (e) discharge coordination and planning; and (f) contracting with and using a network of participating providers.
[
2020 c 228 s 1
;
2005 c 6 s 2
.]
NOTES:
Findings
—
Intent
—
2005 c 6:
"The legislature finds that the costs of leaving mental disorders untreated or undertreated are significant, and often include: Decreased job productivity, loss of employment, increased disability costs, deteriorating school performance, increased use of other health services, treatment delays leading to more costly treatments, suicide, family breakdown and impoverishment, and institutionalization, whether in hospitals, juvenile detention, jails, or prisons.
Treatable mental disorders are prevalent and often have a high impact on health and productive life. The legislature finds that the potential benefits of improved access to mental health services are significant. Additionally, the legislature declares that it is not cost-effective to treat persons with mental disorders differently than persons with medical and surgical disorders.
Therefore, the legislature intends to require that insurance coverage be at parity for mental health services, which means this coverage be delivered under the same terms and conditions as medical and surgical services." [
2005 c 6 s 1
.]
Severability
—
2005 c 6:
"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." [
2005 c 6 s 13
.]
RCW 41.05.601
Mental health services
—
Rules.
The director may adopt rules to implement RCW 41.05.600
.
[
2023 c 51 s 23
;
2005 c 6 s 12
.]
NOTES:
Findings
—
Intent
—
Severability
—
2005 c 6:
See notes following RCW 41.05.600
.
RCW 41.05.620
Peer support services
—
Access.
(1) The authority shall contract with one or more external entities to expand access to peer support services.
(2) Beginning December 31, 2025, the entity or entities shall:
(a) Provide technical assistance to support primary care clinics, urgent care clinics, and hospitals to integrate certified peer support specialists into their clinical care models and bill health insurance carriers for those services;
(b) Develop detailed and innovative proposals to create low barrier and cost-effective opportunities for:
(i) Community-based agencies, including peer-run agencies and organizations that are not currently licensed as behavioral health agencies under chapter
71.24
RCW, to bill health carriers for peer support services;
(ii) Service providers to bill health carriers for behavioral health services that are currently funded by the state general fund, including the law enforcement assisted diversion program established under RCW 71.24.589, the recovery navigator program established under RCW 71.24.115, the arrest and jail alternatives program established under RCW 36.28A.450, and the homeless outreach stabilization transition program established under RCW 71.24.145
;
(iii) Community-based victim services agencies, including agencies that support domestic violence, sexual assault, and human trafficking victims, to bill health carriers for peer support services provided to victims of gender-based violence; and
(iv) Tribes, tribal health providers, and urban Indian health programs to bill for peer support services provided by tribal elders;
(c) Develop a proposal to establish the concept of, and billing mechanisms for, substance use disorder peer-run respite centers that are modeled after the mental health peer-run respite centers established under RCW 71.24.649
; and
(d) Explore options for health carriers to pay for peer support services through capitated payment arrangements rather than on a fee-for-service basis.
(3) By November 1, 2026, the contracted entity or entities shall submit reports to the authority to describe the type and quantity of technical assistance that have been provided, the proposals that have been developed, and the trends in health carriers providing payment for peer support services, and any policy or budget recommendations to encourage health carriers to reimburse providers for peer support services.
[
2025 c 360 s 2
.]
RCW 41.05.630
Annual report of customer service complaints and appeals.
Beginning in 2011, the state health care authority must process as a complaint an enrollee's expression of dissatisfaction about customer service or the quality or availability of a health service. The agency must require that each health plan that provides medical insurance offered under this chapter, including plans created by insuring entities, plans not subject to the provisions of Title
48
RCW, and plans created under RCW 41.05.140
must submit a summary of customer service complaints and appeals to the agency to be included in an annual report to the legislature. Each annual report must summarize the complaints and appeals processed by the state health care authority and contracted carriers in the preceding twelve months, and include an analysis of any trends identified. The report must be complete by September 30th of each year.
[
2010 c 293 s 1
.]
RCW 41.05.650
Community health care collaborative grant program
—
Grants
—
Administrative support
—
Eligibility.
(1) The community health care collaborative grant program is established to further the efforts of community-based coalitions to increase access to appropriate, affordable health care for Washington residents, particularly employed low-income persons and children in school who are uninsured and underinsured, through local programs addressing one or more of the following: (a) Access to medical treatment; (b) the efficient use of health care resources; and (c) quality of care.
(2) Consistent with funds appropriated for community health care collaborative grants specifically for this purpose, two-year grants may be awarded pursuant to RCW 41.05.660
by the director of the health care authority.
(3) The health care authority shall provide administrative support for the program. Administrative support activities may include health care authority facilitation of statewide discussions regarding best practices and standardized performance measures among grantees, or subcontracting for such discussions.
(4) Eligibility for community health care collaborative grants shall be limited to nonprofit organizations established to serve a defined geographic region or organizations with public agency status under the jurisdiction of a local, county, or tribal government. To be eligible, such entities must have a formal collaborative governance structure and decision-making process that includes representation by the following health care providers: Hospitals, public health, behavioral health, community health centers, rural health clinics, and private practitioners that serve low-income persons in the region, unless there are no such providers within the region, or providers decline or refuse to participate or place unreasonable conditions on their participation. The nature and format of the application, and the application procedure, shall be determined by the director of the health care authority. At a minimum, each application shall: (a) Identify the geographic region served by the organization; (b) show how the structure and operation of the organization reflects the interests of, and is accountable to, this region and members providing care within this region; (c) indicate the size of the grant being requested, and how the money will be spent; and (d) include sufficient information for an evaluation of the application based on the criteria established in RCW 41.05.660
.
[
2023 c 51 s 24
;
2009 c 299 s 1
.]
NOTES:
RCW 41.05.651
Rules
—
2009 c 299.
The health care authority may adopt rules to implement chapter 299, Laws of 2009.
[
2009 c 299 s 4
.]
RCW 41.05.660
Community health care collaborative grant program
—
Award and disbursement of grants.
(1) The community health care collaborative grants shall be awarded on a competitive basis based on a determination of which applicant organization will best serve the purposes of the grant program established in RCW 41.05.650
. In making this determination, priority for funding shall be given to the applicants that demonstrate:
(a) The initiatives to be supported by the community health care collaborative grant are likely to address, in a measurable fashion, documented health care access and quality improvement goals aligned with state health policy priorities and needs within the region to be served;
(b) The applicant organization must document formal, active collaboration among key community partners that includes local governments, school districts, large and small businesses, nonprofit organizations, tribal governments, carriers, private health care providers, public health agencies, and community public health and safety networks;
(c) The applicant organization will match the community health care collaborative grant with funds from other sources. The health care authority may award grants solely to organizations providing at least two dollars in matching funds for each community health care collaborative grant dollar awarded;
(d) The community health care collaborative grant will enhance the long-term capacity of the applicant organization and its members to serve the region's documented health care access needs, including the sustainability of the programs to be supported by the community health care collaborative grant;
(e) The initiatives to be supported by the community health care collaborative grant reflect creative, innovative approaches which complement and enhance existing efforts to address the needs of the uninsured and underinsured and, if successful, could be replicated in other areas of the state; and
(f) The programs to be supported by the community health care collaborative grant make efficient and cost-effective use of available funds through administrative simplification and improvements in the structure and operation of the health care delivery system.
(2) The director of the health care authority shall endeavor to disburse community health care collaborative grant funds throughout the state, supporting collaborative initiatives of differing sizes and scales, serving at-risk populations.
(3) Grants shall be disbursed over a two-year cycle, provided the grant recipient consistently provides timely reports that demonstrate the program is satisfactorily meeting the purposes of the grant and the objectives identified in the organization's application. The requirements for the performance reports shall be determined by the health care authority director. The performance measures shall be aligned with the community health care collaborative grant program goals and, where possible, shall be consistent with statewide policy trends and outcome measures required by other public and private grant funders.
[
2023 c 51 s 25
;
2009 c 299 s 2
.]
NOTES:
RCW 41.05.670
Chronic care management incentives
—
Provider reimbursement methods.
(1) Effective January 1, 2013, the authority must contract with all of the public employees' benefits board managed care plans and the self-insured plan or plans to include provider reimbursement methods that incentivize chronic care management within health homes resulting in reduced emergency department and inpatient use.
(2) Health home services contracted for under this section may be prioritized to enrollees with complex, high cost, or multiple chronic conditions.
(3) For the purposes of this section, "chronic care management" and "health home" have the same meaning as in RCW 74.09.010
.
(4) Contracts with fully insured plans and with any third-party administrator for the self-funded plan that include the items in subsection (1) of this section must be funded within the resources provided by employer funding rates provided for employee health benefits in the omnibus appropriations act.
(5) Nothing in this section shall require contracted third-party health plans administering the self-insured contract to expend resources to implement items in subsection (1) of this section beyond the resources provided by employer funding rates provided for employee health benefits in the omnibus appropriations act or from other sources in the absence of these provisions.
(6) The school employees' benefits board, under RCW 41.05.740, shall implement the provisions of this section, effective January 1, 2020.
[
2017 3rd sp.s. c 13 s 812
;
2011 c 316 s 6
.]
NOTES:
Intent
—
2017 3rd sp.s. c 13:
See note following RCW 28A.150.410
.
Collective bargaining agreements not impaired
—
2017 3rd sp.s. c 13:
See note following RCW 41.56.139
.
RCW 41.05.690
Performance measures committee
—
Membership
—
Selection of performance measures
—
Benchmarks for purchasing decisions
—
Public process for evaluation of measures.
(1) There is created a performance measures committee, the purpose of which is to identify and recommend standard statewide measures of health performance to inform public and private health care purchasers and to propose benchmarks to track costs and improvements in health outcomes.
(2) Members of the committee must include representation from state agencies, small and large employers, health plans, patient groups, federally recognized tribes, consumers, academic experts on health care measurement, hospitals, physicians, and other providers. The governor shall appoint the members of the committee, except that a statewide association representing hospitals may appoint a member representing hospitals, and a statewide association representing physicians may appoint a member representing physicians. The governor shall ensure that members represent diverse geographic locations and both rural and urban communities. The chief executive officer of the lead organization must also serve on the committee. The committee must be chaired by the director of the authority.
(3) The committee shall develop a transparent process for selecting performance measures, and the process must include opportunities for public comment.
(4) By January 1, 2015, the committee shall submit the performance measures to the authority. The measures must include dimensions of:
(a) Prevention and screening;
(b) Effective management of chronic conditions;
(c) Key health outcomes;
(d) Care coordination and patient safety; and
(e) Use of the lowest cost, highest quality care for preventive care and acute and chronic conditions.
(5) The committee shall develop a measure set that:
(a) Is of manageable size;
(b) Is based on readily available claims and clinical data;
(c) Gives preference to nationally reported measures and, where nationally reported measures may not be appropriate, measures used by state agencies that purchase health care or commercial health plans;
(d) Focuses on the overall performance of the system, including outcomes and total cost;
(e) Is aligned with the governor's performance management system measures and common measure requirements specific to medicaid delivery systems under RCW 70.320.020
and
71.24.435
;
(f) Considers the needs of different stakeholders and the populations served; and
(g) Is usable by multiple payers, providers, hospitals, purchasers, public health, and communities as part of health improvement, care improvement, provider payment systems, benefit design, and administrative simplification for providers and hospitals.
(6) State agencies shall use the measure set developed under this section to inform and set benchmarks for purchasing decisions.
(7) The committee shall establish a public process to periodically evaluate the measure set and make additions or changes to the measure set as needed.
[
2019 c 325 s 5009
;
2014 c 223 s 6
.]
NOTES:
Effective date
—
2019 c 325:
See note following RCW 71.24.011
.
Finding
—
2014 c 223:
"(1) The legislature finds that the state of Washington has an opportunity to transform its health care delivery system.
(2) The state health care innovation plan establishes the following primary drivers of health transformation, each with individual key actions that are necessary to achieve the objective:
(a) Improve health overall by stressing prevention and early detection of disease and integration of behavioral health;
(b) Developing linkages between the health care delivery system and community; and
(c) Supporting regional collaboratives for communities and populations, improve health care quality, and lower costs." [
2014 c 223 s 1
.]
RCW 41.05.700
Reimbursement of health care services provided through telemedicine or store and forward technology
—
Audio-only telemedicine.
(1)(a) A health plan offered to employees, school employees, and their covered dependents under this chapter issued or renewed on or after January 1, 2017, shall reimburse a provider for a health care service provided to a covered person through telemedicine or store and forward technology if:
(i) The plan provides coverage of the health care service when provided in person by the provider;
(ii) The health care service is medically necessary;
(iii) The health care service is a service recognized as an essential health benefit under section 1302(b) of the federal patient protection and affordable care act in effect on January 1, 2015;
(iv) The health care service is determined to be safely and effectively provided through telemedicine or store and forward technology according to generally accepted health care practices and standards, and the technology used to provide the health care service meets the standards required by state and federal laws governing the privacy and security of protected health information; and
(v) Beginning January 1, 2023, for audio-only telemedicine, the covered person has an established relationship with the provider.
(b)(i) Except as provided in (b)(ii) of this subsection, a health plan offered to employees, school employees, and their covered dependents under this chapter issued or renewed on or after January 1, 2021, shall reimburse a provider for a health care service provided to a covered person through telemedicine the same amount of compensation the carrier would pay the provider if the health care service was provided in person by the provider.
(ii) Hospitals, hospital systems, telemedicine companies, and provider groups consisting of eleven or more providers may elect to negotiate an amount of compensation for telemedicine services that differs from the amount of compensation for in-person services.
(iii) For purposes of this subsection (1)(b), the number of providers in a provider group refers to all providers within the group, regardless of a provider's location.
(2) For purposes of this section, reimbursement of store and forward technology is available only for those covered services specified in the negotiated agreement between the health plan and health care provider.
(3) An originating site for a telemedicine health care service subject to subsection (1) of this section includes a:
(a) Hospital;
(b) Rural health clinic;
(c) Federally qualified health center;
(d) Physician's or other health care provider's office;
(e) Licensed or certified behavioral health agency;
(f) Skilled nursing facility;
(g) Home or any location determined by the individual receiving the service; or
(h) Renal dialysis center, except an independent renal dialysis center.
(4) Except for subsection (3)(g) of this section, any originating site under subsection (3) of this section may charge a facility fee for infrastructure and preparation of the patient. Reimbursement for a facility fee must be subject to a negotiated agreement between the originating site and the health plan. A distant site, a hospital that is an originating site for audio-only telemedicine, or any other site not identified in subsection (3) of this section may not charge a facility fee.
(5) The plan may not distinguish between originating sites that are rural and urban in providing the coverage required in subsection (1) of this section.
(6) The plan may subject coverage of a telemedicine or store and forward technology health service under subsection (1) of this section to all terms and conditions of the plan including, but not limited to, utilization review, prior authorization, deductible, copayment, or coinsurance requirements that are applicable to coverage of a comparable health care service provided in person.
(7) This section does not require the plan to reimburse:
(a) An originating site for professional fees;
(b) A provider for a health care service that is not a covered benefit under the plan; or
(c) An originating site or health care provider when the site or provider is not a contracted provider under the plan.
(8)(a) If a provider intends to bill a patient or the patient's health plan for an audio-only telemedicine service, the provider must obtain patient consent for the billing in advance of the service being delivered.
(b) If the health care authority has cause to believe that a provider has engaged in a pattern of unresolved violations of this subsection (8), the health care authority may submit information to the appropriate disciplining authority, as defined in RCW 18.130.020, for action. Prior to submitting information to the appropriate disciplining authority, the health care authority may provide the provider with an opportunity to cure the alleged violations or explain why the actions in question did not violate this subsection (8).
(c) If the provider has engaged in a pattern of unresolved violations of this subsection (8), the appropriate disciplining authority may levy a fine or cost recovery upon the provider in an amount not to exceed the applicable statutory amount per violation and take other action as permitted under the authority of the disciplining authority. Upon completion of its review of any potential violation submitted by the health care authority or initiated directly by an enrollee, the disciplining authority shall notify the health care authority of the results of the review, including whether the violation was substantiated and any enforcement action taken as a result of a finding of a substantiated violation.
(9) For purposes of this section:
(a)(i) "Audio-only telemedicine" means the delivery of health care services through the use of audio-only technology, permitting real-time communication between the patient at the originating site and the provider, for the purpose of diagnosis, consultation, or treatment.
(ii) For purposes of this section only, "audio-only telemedicine" does not include:
(A) The use of facsimile or email; or
(B) The delivery of health care services that are customarily delivered by audio-only technology and customarily not billed as separate services by the provider, such as the sharing of laboratory results;
(b) "Disciplining authority" has the same meaning as in RCW 18.130.020
;
(c) "Distant site" means the site at which a physician or other licensed provider, delivering a professional service, is physically located at the time the service is provided through telemedicine;
(d) "Established relationship" means the provider providing audio-only telemedicine has access to sufficient health records to ensure safe, effective, and appropriate care services and:
(i) The covered person has had, within the past three years, at least one in-person appointment, or at least one real-time interactive appointment using both audio and video technology, with the provider providing audio-only telemedicine or with a provider employed at the same medical group, at the same clinic, or by the same integrated delivery system operated by a carrier licensed under chapter
48.44
or
48.46
RCW as the provider providing audio-only telemedicine; or
(ii) The covered person was referred to the provider providing audio-only telemedicine by another provider who has had, within the past three years, at least one in-person appointment, or at least one real-time interactive appointment using both audio and video technology, with the covered person and has provided relevant medical information to the provider providing audio-only telemedicine;
(e) "Health care service" has the same meaning as in RCW 48.43.005
;
(f) "Hospital" means a facility licensed under chapter
70.41, 71.12, or
72.23
RCW;
(g) "Originating site" means the physical location of a patient receiving health care services through telemedicine;
(h) "Provider" has the same meaning as in RCW 48.43.005
;
(i) "Store and forward technology" means use of an asynchronous transmission of a covered person's medical information from an originating site to the health care provider at a distant site which results in medical diagnosis and management of the covered person, and does not include the use of audio-only telephone, facsimile, or email; and
(j) "Telemedicine" means the delivery of health care services through the use of interactive audio and video technology, permitting real-time communication between the patient at the originating site and the provider, for the purpose of diagnosis, consultation, or treatment. For purposes of this section only, "telemedicine" includes audio-only telemedicine, but does not include facsimile or email.
[
2024 c 215 s 1
;
2023 c 8 s 1
;
2022 c 213 s 1
;
2021 c 157 s 1
;
2020 c 92 s 2
;
2018 c 260 s 30
;
2017 c 219 s 2
;
2016 c 68 s 4
;
2015 c 23 s 2
.]
NOTES:
Conflict with federal requirements
—
2022 c 213:
"If any part of this act is found to be in conflict with federal requirements that are a prescribed condition to the allocation of federal funds to the state, the conflicting part of this act is inoperative solely to the extent of the conflict and with respect to the agencies directly affected, and this finding does not affect the operation of the remainder of this act in its application to the agencies concerned. Rules adopted under this act must meet federal requirements that are a necessary condition to the receipt of federal funds by the state." [
2022 c 213 s 6
.]
Conflict with federal requirements
—
2021 c 157:
See note following RCW 74.09.327
.
Effective date
—
2020 c 92:
See note following RCW 48.43.735
.
Effective date
—
2017 c 219:
See note following RCW 48.43.735
.
Effective date
—
Intent
—
2016 c 68:
See notes following RCW 48.43.735
.
Effective date
—
2015 c 23 ss 2-4:
"Sections 2 through 4 of this act take effect January 1, 2017." [
2015 c 23 s 7
.]
Adoption of sections
—
2015 c 23 ss 2-4:
"The legislature encourages health plans to adopt the requirements of sections 2 through 4 of this act prior to January 1, 2017. Therefore, nothing in this act prohibits a plan from adopting the requirements of sections 2 through 4 of this act prior to January 1, 2017." [
2015 c 23 s 8
.]
Intent
—
2015 c 23:
"It is the intent of the legislature to recognize the application of telemedicine as a reimbursable service by which an individual receives medical services from a health care provider without in-person contact with the provider. It is also the intent of the legislature to reduce the compliance requirements on hospitals when granting privileges or associations to telemedicine physicians." [
2015 c 23 s 1
.]
RCW 41.05.730
Ground emergency medical transportation services
—
Medicaid reimbursement
—
Calculation
—
Federal approval
—
Department's duties.
(1) An eligible provider, as described in subsection (2) of this section, must, in addition to the rate of payment that the provider would otherwise receive for medicaid ground emergency medical transportation services, receive supplemental medicaid reimbursement to the extent provided by law.
(2) A provider is eligible for supplemental reimbursement only if the provider has all of the following characteristics continuously during a state fiscal year:
(a) Provides ground emergency medical transportation services to medicaid beneficiaries:
(b) Is a provider that is enrolled as a medicaid provider for the period being claimed;
(c) Is owned or operated by the state, a city, county, fire protection district, community services district, health care district, federally recognized Indian tribe or any unit of government as defined in 42 C.F.R. Sec. 433.50;
(3) An eligible provider's supplemental reimbursement pursuant to this section must be calculated and paid as follows:
(a) The supplemental reimbursement to an eligible provider, as described in subsection (2) of this section, must be equal to the amount of federal financial participation received as a result of the claims submitted pursuant to subsection (6)(b) of this section;
(b) In no instance may the amount certified pursuant to subsection (5)(a) of this section, when combined with the amount received from all other sources of reimbursement from the medicaid program, exceed one hundred percent of actual costs, as determined pursuant to the medicaid state plan, for ground emergency medical transportation services;
(c) The supplemental medicaid reimbursement provided by this section must be distributed exclusively to eligible providers under a payment methodology based on ground emergency medical transportation services provided to medicaid beneficiaries by eligible providers on a per-transport basis or other federally permissible basis. The authority shall obtain approval from the federal centers for medicare and medicaid services for the payment methodology to be utilized, and may not make any payment pursuant to this section prior to obtaining that approval.
(4)(a) It is the legislature's intent in enacting this section to provide the supplemental reimbursement described in this section without any expenditure from the general fund. An eligible provider, as a condition of receiving supplemental reimbursement pursuant to this section, shall enter into, and maintain, an agreement with the authority for the purposes of implementing this section and reimbursing the department for the costs of administering this section.
(b) The nonfederal share of the supplemental reimbursement submitted to the federal centers for medicare and medicaid services for purposes of claiming federal financial participation shall be paid only with funds from the governmental entities described in subsection (2)(c) of this section and certified to the state as provided in subsection (5) of this section.
(5) Participation in the program by an eligible provider described in this section is voluntary. If an applicable governmental entity elects to seek supplemental reimbursement pursuant to this section on behalf of an eligible provider owned or operated by the entity, as described in subsection (2)(c) of this section, the governmental entity shall do all of the following:
(a) Certify, in conformity with the requirements of 42 C.F.R. Sec. 433.51, that the claimed expenditures for the ground emergency medical transportation services are eligible for federal financial participation;
(b) Provide evidence supporting the certification as specified by the department;
(c) Submit data as specified by the department to determine the appropriate amounts to claim as expenditures qualifying for federal financial participation;
(d) Keep, maintain, and have readily retrievable, any records specified by the department to fully disclose reimbursement amounts to which the eligible provider is entitled, and any other records required by the federal centers for medicare and medicaid services.
(6) The department shall promptly seek any necessary federal approvals for the implementation of this section. The department may limit the program to those costs that are allowable expenditures under Title XIX of the federal social security act (42 U.S.C. Sec. 1396 et seq.). If federal approval is not obtained for implementation of this section, this section may not be implemented.
(a) The department shall submit claims for federal financial participation for the expenditures for the services described in subsection (5) of this section that are allowable expenditures under federal law.
(b) The department shall, on an annual basis, submit any necessary materials to the federal government to provide assurances that claims for federal financial participation will include only those expenditures that are allowable under federal law.
(7) If either a final judicial determination is made by any court of appellate jurisdiction or a final determination is made by the administrator of the federal centers for medicare and medicaid services that the supplemental reimbursement provided for in this section must be made to any provider not described in this section, the director shall execute a declaration stating that the determination has been made and on that date this section becomes inoperative.
[
2015 c 147 s 1
.]
RCW 41.05.735
Ground emergency medical transportation services
—
Medicaid reimbursement
—
Intergovernmental transfer program
—
Federal approval
—
Authority's duties.
(1) The authority shall design and implement, in consultation with eligible providers as described in subsection (2) of this section, an intergovernmental transfer program relating to medicaid managed care, ground emergency medical transport services including those services provided by emergency medical technicians at the basic, advanced, and paramedic levels in the prestabilization and preparation for transport in order to increase capitation payments for the purpose of increasing reimbursement to eligible providers.
(2) A provider is eligible for increased reimbursement pursuant to this section only if the provider meets both of the following conditions in an applicable state fiscal year:
(a) Provides ground emergency medical transport services to medicaid managed care enrollees pursuant to a contract or other arrangement with a medicaid managed care plan.
(b) Is owned or operated by the state, a city, county, fire protection district, special district, community services district, health care district, federally recognized Indian tribe or unit of government as defined in 42 C.F.R. Sec. 433.50.
(3) To the extent intergovernmental transfers are voluntarily made by, and accepted from, an eligible provider described in subsection (2) of this section, or a governmental entity affiliated with an eligible provider, the department shall make increased capitation payments to applicable medicaid managed care plans for covered ground emergency medical transportation services.
(a) The increased capitation payments made pursuant to this section must be in amounts at least actuarially equivalent to the supplemental fee-for-service payments available for eligible providers to the extent permissible under federal law.
(b) Except as provided in subsection (6) of this section, all funds associated with intergovernmental transfers made and accepted pursuant to this section must be used to fund additional payments to eligible providers.
(c) Medicaid managed care plans shall pay one hundred percent of any amount of increased capitation payments made pursuant to this section to eligible providers for providing and making available ground emergency medical transportation and paramedical services pursuant to a contract or other arrangement with a medicaid managed care plan.
(4) The intergovernmental transfer program developed pursuant to this section must be implemented on the date federal approval was obtained, and only to the extent intergovernmental transfers from the eligible provider, or the governmental entity with which it is affiliated, are provided for this purpose. To the extent permitted by federal law, the department may implement the intergovernmental transfer program and increased capitation payments pursuant to this section on a retroactive basis as needed.
(5) Participation in the intergovernmental transfers under this section is voluntary on the part of the transferring entities for purposes of all applicable federal laws.
(6) This section must be implemented without any additional expenditure from the state general fund. As a condition of participation under this section, each eligible provider as described in subsection (2) of this section, or the governmental entity affiliated with an eligible provider, shall agree to reimburse the department for any costs associated with implementing this section. Intergovernmental transfers described in this section are subject to a twenty percent administration fee of the nonfederal share paid to the department and is allowed to count as a cost of providing the services.
(7) As a condition of participation under this section, medicaid managed care plans, eligible providers as described in subsection (2) of this section, and governmental entities affiliated with eligible providers shall agree to comply with any requests for information or similar data requirements imposed by the department for purposes of obtaining supporting documentation necessary to claim federal funds or to obtain federal approvals.
(8) This section must be implemented only if and to the extent federal financial participation is available and is not otherwise jeopardized, and any necessary federal approvals have been obtained.
(9) To the extent that the director determines that the payments made pursuant to this section do not comply with federal medicaid requirements, the director retains the discretion to return or not accept an intergovernmental transfer, and may adjust payments pursuant to this section as necessary to comply with federal medicaid requirements.
(10) To the extent federal approval is obtained, the increased capitation payments under this section may commence for dates of service on or after January 1, 2015.
[
2015 c 147 s 2
.]
RCW 41.05.740
School employees' benefits board.
(1) The school employees' benefits board is created within the authority. The function of the school employees' benefits board is to design and approve insurance benefit plans for school employees and to establish eligibility criteria for participation in insurance benefit plans.
(2) By September 30, 2017, the governor shall appoint the following voting members to the school employees' benefits board as follows:
(a) Two members from associations representing certificated employees;
(b) Two members from associations representing classified employees;
(c) Four members with expertise in employee health benefits policy and administration, one of which is nominated by an association representing school business officials; and
(d) The director of the authority or his or her designee.
(3) Initial members of the school employees' benefits board shall serve staggered terms not to exceed four years. Members appointed thereafter shall serve two-year terms.
(4) Compensation and reimbursement related to school employees' benefits board member service are as follows:
(a) Members of the school employees' benefits board must be compensated in accordance with RCW 43.03.250
and must be reimbursed for their travel expenses while on official business in accordance with RCW 43.03.050
and
43.03.060
.
(b) While school employees' benefits board members are carrying out their powers and duties under this chapter, if the service of any certificated or classified employee results in a need for a school employees' benefits board organization to employ a substitute for such certificated or classified employee during such service, payment for such a substitute may be made by the authority from funds appropriated by the legislature for the school employees' benefits board program. If such substitute is paid by the authority, no deduction shall be made from the salary of the certificated or classified employee. In no event shall a school employees' benefits board organization deduct from the salary of a certificated or classified employee serving on the school employees' benefits board more than the amount paid the substitute employed by the school employees' benefits board organization.
(5) The director of the authority or his or her designee shall be the chair and another member shall be selected by the school employees' benefits board as vice chair. The chair shall conduct meetings of the school employees' benefits board. The vice chair shall preside over meetings in the absence of the chair. The school employees' benefits board shall develop bylaws for the conduct of its business.
(6) The school employees' benefits board shall:
(a) Study all matters connected with the provision of health care coverage, life insurance, liability insurance, accidental death and dismemberment, and disability insurance, or any of, or combination of, the enumerated types of insurance for eligible school employees and their dependents on the best basis possible with relation both to the welfare of the school employees and the state. However, liability insurance should not be made available to dependents;
(b) Develop school employee benefit plans that include comprehensive, evidence-based health care benefits for school employees. In developing these plans, the school employees' benefits board shall consider the following elements:
(i) Methods of maximizing cost containment while ensuring access to quality health care;
(ii) Development of provider arrangements that encourage cost containment and ensure access to quality care including, but not limited to, prepaid delivery systems and prospective payment methods;
(iii)(A) Wellness, preventive care, chronic disease management, and other initiatives that focus on proven strategies.
(B)(I) As of January 1, 2028, the school employees' benefits board shall no longer offer the smart health program, which includes the wellness incentive and the smart health online portal.
(II) Employees who have met the eligibility requirements to receive a wellness incentive by December 31, 2027, will still receive the wellness incentive in plan year 2028.
(III) Employees are not eligible to earn a wellness incentive as of January 1, 2028;
(iv) Utilization review procedures to support cost-effective benefits delivery;
(v) Ways to leverage efficient purchasing by coordinating with the public employees' benefits board;
(vi) Effective coordination of benefits; and
(vii) Minimum standards for insuring entities;
(c) Authorize premium contributions for a school employee and the employee's dependents in a manner that encourages the use of cost-efficient health care systems. For participating school employees, the required school employee share of the cost for family coverage premiums may not exceed three times the premiums for a school employee purchasing single coverage for the same coverage plan;
(d) Determine the terms and conditions of school employee and dependent eligibility criteria, enrollment policies, and scope of coverage. Employer groups obtaining benefits through contractual agreement with the authority for school employees defined in RCW 41.05.011
(6)(b)(iv) may contractually agree with the authority to benefits eligibility criteria which differs from that determined by the school employees' benefits board. At a minimum, the eligibility criteria established by the school employees' benefits board shall address the following:
(i) The effective date of coverage following hire;
(ii) The benefits eligibility criteria, but the school employees' benefits board's criteria shall be no more restrictive than requiring that a school employee be anticipated to work at least six hundred thirty hours per school year to be benefits eligible; and
(iii) Coverage for dependents, including criteria for legal spouses; children up to age twenty-six; children of any age with disabilities, mental illness, or intellectual or other developmental disabilities; and state registered domestic partners, as defined in RCW 26.60.020, and others authorized by the legislature;
(e) Establish terms and conditions for a school employees' benefits board organization to have the ability to locally negotiate eligibility criteria for a school employee who is anticipated to work less than six hundred thirty hours in a school year. A school employees' benefits board organization that elects to use a lower threshold of hours for benefits eligibility must use benefits authorized by the school employees' benefits board and shall do so as an enrichment to the state's definition of basic education;
(f) Establish penalties to be imposed when a school employees' benefits board organization fails to comply with established participation criteria; and
(g) Participate with the authority in the preparation of specifications and selection of carriers contracted for school employee benefit plan coverage of eligible school employees in accordance with the criteria set forth in rules. To the extent possible, the school employees' benefits board shall leverage efficient purchasing by coordinating with the public employees' benefits board.
(7) School employees shall choose participation in one of the health care benefit plans developed by the school employees' benefits board. Individual school employees eligible for benefits under subsection (6)(d) of this section may be permitted to waive coverage under terms and conditions established by the school employees' benefits board.
(8) By November 30, 2021, the authority shall review the benefit plans provided through the school employees' benefits board, complete an analysis of the benefits provided and the administration of the benefits plans, and determine whether provisions in chapter 13, Laws of 2017 3rd sp. sess. have resulted in cost savings to the state. The authority shall submit a report to the relevant legislative policy and fiscal committees summarizing the results of the review and analysis.
[
2025 c 396 s 2
;
2023 c 13 s 7
;
2018 c 260 s 1
;
2017 3rd sp.s. c 13 s 801
.]
NOTES:
Finding
—
Intent
—
2023 c 13:
See note following RCW 41.05.011
.
Effective date
—
2017 3rd sp.s. c 13 ss 102, 505, and 801:
See note following RCW 28A.400.205
.
Intent
—
2017 3rd sp.s. c 13:
See note following RCW 28A.150.410
.
Collective bargaining agreements not impaired
—
2017 3rd sp.s. c 13:
See note following RCW 41.56.139
.
RCW 41.05.742
Single enrollment requirement.
Beginning with the 2022 plan year, individuals are limited to a single enrollment in medical, dental, and vision plans in either the school employees' benefits board or the public employees' benefits board. The school employees' benefits board and the public employees' benefits board shall adopt policies to reflect this single enrollment requirement.
[
2021 c 18 s 1
;
2020 c 8 s 4
.]
NOTES:
Effective date
—
2020 c 8:
See note following RCW 41.05.744
.
RCW 41.05.743
School board members
—
Eligibility for health benefits.
(1) For purposes of this section, "school board member" means the board of directors of a school district as governed by chapter
28A.343
RCW or the board of directors of an educational service district as governed by chapter
28A.310
RCW.
(2) As of January 1, 2024, a school board member may participate in the benefit plans offered by and subject to the terms and conditions determined by the school employees' benefits board. A school board member may enroll in medical, dental, and vision benefits and shall be responsible for premium rates developed by the authority. A school board member shall be responsible for submitting the full self-pay premium amount for the benefits the member elects to enroll in for each month the member is covered.
(3) A school board member may participate in the school employees' benefits board program for the duration of the member's elected term as a school board member and may renew the member's participation at the start of each subsequent term as a school board member.
(4) If a school board member voluntarily ends the member's enrollment in the school employees' benefits board program prior to the end of their elected term, the member is no longer eligible under this section to participate in the school employees' benefits board program for the remainder of the member's elected term.
(5) This section does not create any eligibility for school board members to participate in retiree benefits provided by the public employees' benefits board program.
[
2023 c 13 s 8
.]
NOTES:
Finding
—
Intent
—
2023 c 13:
See note following RCW 41.05.011
.
RCW 41.05.744
School employee eligibility during COVID-19 state of emergency.
(1) A school employee eligible as of February 29, 2020, for the employer contribution towards benefits offered by the school employees' benefits board shall maintain their eligibility for the employer contribution under the following circumstances directly related or in response to the governor's February 29, 2020, proclamation of a state of emergency existing in all counties in the state of Washington related to the novel coronavirus (COVID-19):
(a) During any school closures or changes in school operations for the school employee;
(b) While the school employee is quarantined or required to care for a family member, as defined by RCW 49.46.210
(2), who is quarantined; and
(c) In order to take care of a child as defined by RCW 49.46.210
(2), when the child's:
(i) School is closed;
(ii) Regular day care facility is closed; or
(iii) Regular child care provider is unable to provide services.
(2) Requirements in subsection (1) of this section expires when the governor's state of emergency related to the novel coronavirus (COVID-19) ends.
(3) When regular school operations resume, school employees shall continue to maintain their eligibility for the employer contribution for the remainder of the school year so long as their work schedule returns to the schedule in place before February 29, 2020, or, if there is a change in schedule, so long as the new schedule, had it been in effect at the start of the school year, would have resulted in the employee being anticipated to work the minimum hours to meet benefits eligibility.
(4) Quarantine, as used in subsection (1)(b) [of this section] includes only periods of isolation required by the federal government, a foreign national government, a state or local public health official, a health care provider, or an employer.
[
2020 c 8 s 5
.]
NOTES:
Effective date
—
2020 c 8:
"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 17, 2020]." [
2020 c 8 s 6
.]
RCW 41.05.745
School employees' benefits board
—
Employee-paid, voluntary benefits
—
Optional benefits.
(1) In addition to the benefits offering authority under this chapter, the school employees' benefits board may study and, subject to the availability of funding, offer the following employee-paid, voluntary benefits:
(a) Emergency transportation;
(b) Identity protection;
(c) Legal aid;
(d) Long-term care insurance;
(e) Noncommercial personal automobile insurance;
(f) Personal homeowner's or renter's insurance;
(g) Pet insurance;
(h) Specified disease or illness-triggered fixed payment insurance, hospital confinement fixed payment insurance, or other fixed payment insurance offered as an independent, noncoordinated benefit regulated by the office of the insurance commissioner;
(i) Travel insurance; and
(j) Voluntary employees' beneficiary association accounts.
(2) The health care authority, in consultation with the school employees' benefits board, shall review the optional benefits reported by school districts as required in RCW 28A.400.280
and determine if the optional benefits are in competition with benefits currently offered under either the authority's or the board's authorities. If a school district benefit offering is determined to be in competition with the benefits offered under either the authority's or the board's authorities, the health care authority must inform the school district of the benefits conflict and work with the school district, and the applicable carrier, to either modify and remove competing components of the district-based benefit or end the district-based offering. If a carrier is in the process of modifying benefits, including seeking any required regulatory approval, a school district may continue to offer the original benefit.
(3) Specified disease or illness-triggered fixed payment insurance, hospital confinement fixed payment insurance, or other fixed payment insurance offered pursuant to this section as an independent, noncoordinated benefit is not a health plan as defined in RCW 48.43.005
.
[
2020 c 231 s 3
.]
RCW 41.05.750
Problem gambling and gambling disorder treatment program.
(1) A program for (a) year-round integrated problem gambling prevention efforts that include community engagement and the treatment of problem gambling and gambling disorder; and (b) the support, certification, and training of professionals in the identification and treatment of problem gambling and gambling disorder is established within the authority. The department of health may license or certify behavioral health agencies for problem gambling treatment. The authority may contract for any services provided under the program. The authority shall conduct a program evaluation, including tracking program participation and evaluating outcomes.
(2) To receive treatment under subsection (1) of this section, a person must:
(a) Need treatment for problem gambling or gambling disorder, or be impacted by a loved one experiencing problem gambling or gambling disorder;
(b) Be identified by the authority as being most amenable to and likely to benefit from treatment; and
(c) Be unable to afford treatment.
(3) Treatment under this section is available only to the extent of the funds appropriated or otherwise made available to the authority for this purpose. The authority may solicit and accept for use any gift of money or property made by will or otherwise, and any grant of money, services, or property from the federal government, any tribal government, the state, or any political subdivision thereof or any private source, and do all things necessary to cooperate with the federal government or any of its agencies or any tribal government in making an application for any grant.
(4)(a) The authority shall establish and facilitate an ongoing advisory committee that will hold quarterly meetings to:
(i) Track progress of recommendations from the 2022 legislative problem gambling task force final report;
(ii) Provide advice and feedback on the state problem gambling program upon request by the authority; and
(iii) Discuss emerging issues related to problem gambling and identify possible strategies for improvement.
(b) The advisory committee membership must include, at a minimum, at least one representative from each of the following:
(i) The Washington state gambling commission;
(ii) The Washington state lottery commission;
(iii) The Washington state horse racing commission;
(iv) The Washington state health care authority;
(v) The tribal gaming industry;
(vi) An established business primarily engaged in the selling of food or drink for consumption on the premises and that offers punchboards, pull-tabs, and social card games as a commercial stimulant;
(vii) The gambling counselor certification committee;
(viii) A nonprofit problem gambling organization; and
(ix) The recovery community including at least one member with lived experience of problem gambling.
[
2023 c 284 s 2
;
2018 c 201 s 2004
;
2010 c 171 s 1
;
2005 c 369 s 2
;
2002 c 349 s 4
. Formerly RCW 43.20A.890, 67.70.350
.]
NOTES:
Findings
—
Intent
—
2023 c 284:
"(1) The legislature finds that:
(a) The costs to society of problem gambling and gambling disorder include family disintegration, criminal activity, and financial insolvencies;
(b) Individuals experiencing problem gambling and gambling disorder are at significantly increased risks for other co-occurring disorders, including substance use disorder and mental health issues such as depression, anxiety, or other behavioral health concerns;
(c) Residents of Washington may participate in a variety of legal gaming activities such as the state-run lottery, tribal gaming by federally recognized Indian tribes, certain fund-raisers offered by bona fide charitable and nonprofit organizations, and punchboards, pull-tabs, and social card games approved as a commercial stimulant at established businesses primarily engaged in the selling of food or drink for consumption on the premises;
(d) A 2021 prevalence study found that among all adults, 1.5 percent are at a moderate-to-severe risk for developing a gambling disorder, and among adults who gamble, 3.5 percent are at a moderate-to-severe risk of a gambling disorder; and
(e) The 2022 problem gambling task force final report, delivered to the legislature in December 2022, determined there are critical gaps in providing state-funded comprehensive problem gambling services to Washington residents, including:
(i) Prevention efforts not coordinated with other behavioral health and substance abuse prevention initiatives;
(ii) Problem gambling treatment coverage is not available across the state; and
(iii) No state-supported residential treatment services are available in Washington state.
(2) The legislature intends to provide long-term, dedicated funding for prevention, public awareness efforts, and education regarding problem gambling disorder, clinical training, workforce development, and accessible treatment services for individuals impacted by problem gambling or gambling disorders as well as after-care support." [
2023 c 284 s 1
.]
Effective date
—
2023 c 284:
"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, 2023." [
2023 c 284 s 8
.]
Findings
—
Intent
—
Effective date
—
2018 c 201:
See notes following RCW 41.05.018
.
Findings
—
Intent
—
2005 c 369:
"(1) The legislature finds that:
(a) The costs to society of problem and pathological gambling include family disintegration, criminal activity, and financial insolvencies;
(b) Problem and pathological gamblers suffer a higher incidence of addictive disorders such as alcohol and substance abuse;
(c) Residents of Washington have the opportunity to participate in a variety of legal gambling activities operated by the state, by federally recognized tribes, and by private businesses and nonprofit organizations; and
(d) A 1999 study found that five percent of adult Washington residents and eight percent of adolescents could be classified as problem gamblers during their lifetimes, and that more than one percent of adults have been afflicted with pathological gambling.
(2) The legislature intends to provide long-term, dedicated funding for public awareness and education regarding problem and pathological gambling, training in its identification and treatment, and treatment services for problem and pathological gamblers and, as clinically appropriate, members of their families." [
2005 c 369 s 1
.]
Severability
—
2005 c 369:
"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." [
2005 c 369 s 10
.]
Effective date
—
2005 c 369:
"This act is necessary for the immediate preservation of the public peace, health, or safety, or support of the state government and its existing public institutions, and takes effect July 1, 2005." [
2005 c 369 s 11
.]
RCW 41.05.751
Problem gambling account.
The problem gambling account is created in the state treasury. Money in the account may be spent only after appropriation. Expenditures from the account may be used only for the purposes of the program established under RCW 41.05.750
.
[
2018 c 201 s 2005
;
2005 c 369 s 3
. Formerly RCW 43.20A.892
.]
NOTES:
Findings
—
Intent
—
Effective date
—
2018 c 201:
See notes following RCW 41.05.018
.
Findings
—
Intent
—
Severability
—
Effective date
—
2005 c 369:
See notes following RCW 41.05.750
.
RCW 41.05.760
Recovery residences
—
Registry.
(1) The authority shall establish and maintain a registry of approved recovery residences. The authority may contract with a nationally recognized recovery residence certification organization based in Washington to establish and maintain the registry.
(2) The authority or the contracted entity described in subsection (1) of this section shall determine that a recovery residence is approved for inclusion in the registry if the recovery residence has been certified by a nationally recognized recovery residence certification organization based in Washington that is approved by the authority or if the recovery residence is a chapter of a national recovery residence organization with peer-run homes that is approved by the authority as meeting the following standards in its certification process:
(a) Peers are required to be involved in the governance of the recovery residence;
(b) Recovery support is integrated into the daily activities;
(c) The recovery residence must be maintained as a home-like environment that promotes healthy recovery;
(d) Resident activities are promoted within the recovery residence and in the community through work, education, community engagement, or other activities; and
(e) The recovery residence maintains an environment free from alcohol and illicit drugs.
(3) Nothing in this section requires that a recovery residence become certified by the certifying organization approved by the authority in subsection (2) of this section or be included in the registry, unless the recovery residence decides to participate in the recovery residence program activities established in this chapter.
(4) For the purposes of this section, "recovery residence" means a home-like environment that promotes healthy recovery from a substance use disorder and supports persons recovering from a substance use disorder through the use of peer recovery support.
[
2019 c 264 s 2
.]
NOTES:
Findings
—
2019 c 264:
"(1) The legislature finds that substance use disorder is a disease impacting the whole family and the whole society and requires a system of care that includes prevention, treatment, and recovery services that support and strengthen impacted individuals, families, and the community at large.
(2) The legislature further finds that access to quality recovery housing is crucial for helping individuals remain in recovery from substance use disorder beyond treatment. Furthermore, recovery housing serves to preserve the state's financial investment in a person's treatment. Without access to quality recovery housing, individuals are much less likely to recover from substance use disorder and more likely to face continued issues that impact their well-being, their families, and their communities. These issues include death by overdose or other substance use disorder-related medical complications; higher health care costs; high use of emergency departments and public health care systems; higher risk for involvement with law enforcement and incarceration; and an inability to obtain and maintain employment. These challenges are compounded by an overall lack of affordable housing nationwide.
(3) The legislature recognizes that recovery is a long-term process and requires a comprehensive approach. Recognizing the potential for fraudulent and unethical recovery housing operators, this act is designed to address the quality of recovery housing in the state of Washington." [
2019 c 264 s 1
.]
RCW 41.05.810
Prenatal substance exposure treatment
—
Contracting.
(1) By January 1, 2024, the authority, on behalf of clients or potential clients of the department of children, youth, and families as described in this subsection, shall contract with a provider with expertise in comprehensive prenatal substance exposure treatment and family supports to offer services to children over the age of three and families who are or have been involved in the child welfare system or who are at risk of becoming involved in the child welfare system. This contract shall maximize the number of families that can be served through referrals by authority employees and other community partners in order to keep families together, reduce the number of placements, and prevent adverse outcomes for impacted children.
(2) By January 1, 2025, the authority, on behalf of clients or potential clients of the department of children, youth, and families as described in this subsection, shall contract with up to three providers across the state, in addition to the contracted provider in subsection (1) of this section, to offer comprehensive treatment services for prenatal substance exposure and family supports for children who were prenatally exposed to substances and who are, or have been, involved in the child welfare system.
(3) Comprehensive treatment and family supports must be trauma-informed and may include:
(a) Occupational, speech, and language therapy;
(b) Behavioral health counseling and caregiver counseling;
(c) Sensory processing support;
(d) Educational advocacy, psychoeducation, social skills support, and groups;
(e) Linkages to community resources; and
(f) Family supports and education, including the programs for parents, caregivers, and families recommended by the federal centers for disease control and prevention.
(4) The authority shall contract with the provider referenced in subsection (1) of this section to support the providers under contract in subsection (2) of this section by:
(a) Creating education and training programs for providers working with children who had prenatal substance exposure; and
(b) Offering ongoing coaching and support in creating a safe and healing environment, free from judgment, where families are supported through the challenges of care for children with prenatal substance exposure.
(5) The authority, in collaboration with the department of children, youth, and families, shall work with the contracted providers and families to collect relevant outcome data and provide a report on the expansion of services under the contracts and the outcomes experienced by persons receiving services under this section. The authority shall submit the report to the legislature with any recommendations related to improving availability of and access to services and ways to improve outcomes by June 1, 2028.
[
2023 c 288 s 2
.]
NOTES:
Findings
—
2023 c 288:
"The legislature finds that:
(1) Fetal alcohol spectrum disorders are lifelong physical, developmental, behavioral, and intellectual disabilities caused by prenatal alcohol exposure;
(2) According to the federal centers for disease control and prevention, fetal alcohol spectrum disorders affect as many as one in 20 people in the United States;
(3) The health care authority estimates that one percent of births, or approximately 870 children each year, are born with fetal alcohol spectrum disorders;
(4) In addition to alcohol use, other substances consumed during pregnancy may result in prenatal substance exposure affecting the physical, developmental, behavioral, and intellectual abilities of the exposed child;
(5) Washington has limited diagnostic capacity and currently lacks the capacity to diagnose and treat every child who needs support and treatment due to prenatal substance exposure;
(6) Without appropriate treatment and supports, children born with fetal alcohol spectrum disorders and other prenatal substance disorders are likely to experience adverse outcomes. According to current statistics, these children face adverse outcomes such as:
(a) 61 percent of children with fetal alcohol spectrum disorders are suspended or expelled from school by age 12;
(b) 90 percent of persons with fetal alcohol spectrum disorders develop comorbid mental health conditions; and
(c) 60 percent of youth with fetal alcohol spectrum disorders are involved in the justice system;
(7) Untreated and unsupported prenatal substance exposure results in higher costs for the state and worse outcomes for children and their families;
(8) Investing in prevention and earlier intervention, including diagnostic capacity, treatment, and services for children and supports for families and caregivers will improve school outcomes; and
(9) Effective prenatal substance exposure response requires effective and ongoing cross-agency strategic planning and coordination." [
2023 c 288 s 1
.]
RCW 41.05.812
Prenatal substance exposure
—
Expanded treatment and services.
(1) Subject to the availability of amounts appropriated for this specific purpose, the authority shall expand specific treatment and services to children and youth with prenatal substance exposure who would benefit from evidence-based services impacting their behavioral and physical health.
(2) The authority shall contract for the services authorized in this section with behavioral health entities in a manner that allows leveraging of federal medicaid funds to pay for a portion of the costs.
(3) The authority shall consult with the department of children, youth, and families in the implementation of the program and services authorized under this section.
[
2024 c 328 s 203
.]
NOTES:
Findings
—
Intent
—
2024 c 328:
See note following RCW 13.34.050
.
RCW 41.05.820
Qualified requirement for health carrier in insurance holding company to offer silver and gold health plans.
(1) For plan years beginning January 1, 2020, at least one health carrier in an insurance holding company system must offer in the exchange at least one silver and one gold qualified health plan in any county in which any health carrier in that insurance holding company system offers a fully insured health plan that was approved, on or after June 7, 2018, by the school employees' benefits board or the public employees' benefits board to be offered to employees and their covered dependents under this chapter.
(2) The rates for a health plan approved by the school employees' benefits board or the public employees' benefits board may not include the administrative costs or actuarial risks associated with a qualified health plan offered under subsection (1) of this section.
(3) The authority shall perform an actuarial review during the annual rate setting process for plans approved by the school employees' benefits board or the public employees' benefits board to ensure compliance with subsection (2) of this section.
(4) For purposes of this section, "exchange" and "health carrier" have the same meaning as in RCW 48.43.005
.
(5) For purposes of this section, "insurance holding company system" has the same meaning as in RCW 48.31B.005
.
[
2018 c 219 s 2
.]
NOTES:
Findings
—
Intent
—
2018 c 219:
"(1) The legislature finds that:
(a) Access to health care is fundamental to the health and safety of the citizens of Washington state;
(b) Health insurance coverage is necessary for most people to access health care;
(c) Due to uncertainty in the health insurance marketplace, volatility in the current federal regulatory environment, and rising health care costs, ensuring access to the private health insurance market in every county in Washington state is becoming more difficult;
(d) The consequences of losing private health insurance coverage in a county would be catastrophic, leading to deteriorating health outcomes, lost productivity, and lower quality of life; and
(e) If the private market fails to provide coverage in a county, the state must intervene.
(2) The legislature therefore intends to:
(a) Leverage the provider networks used by private insurers offering coverage to state and school employees to ensure private insurance coverage is available in all counties where those insurers offer coverage to state and school employees; and
(b) Until such coverage is available, make coverage in the Washington state health insurance pool more affordable to persons residing in counties where no private insurance is available." [
2018 c 219 s 1
.]
RCW 41.05.831
Coverage for hearing instruments.
A health plan offered to public employees and their covered dependents under this chapter issued or renewed on or after January 1, 2024, is subject to RCW 48.43.135
.
[
2023 c 245 s 3
.]
RCW 41.05.840
Universal health care commission.
(1) The universal health care commission is established to create immediate and impactful changes in the health care access and delivery system in Washington and to prepare the state for the creation of a health care system that provides coverage and access for all Washington residents through a unified financing system once the necessary federal authority has become available. The authority must begin any necessary federal application process within 60 days of its availability.
(2) The commission includes the following voting members:
(a) One member from each of the two largest caucuses of the house of representatives, appointed by the speaker of the house of representatives;
(b) One member from each of the two largest caucuses of the senate, appointed by the president of the senate;
(c) The secretary of the department of health, or the secretary's designee;
(d) The director of the health care authority, or the director's designee;
(e) The chief executive officer of the Washington health benefit exchange, or the chief executive officer's designee;
(f) The insurance commissioner, or the commissioner's designee;
(g) The director of the office of equity, or the director's designee; and
(h) Six members appointed by the governor, using an equity lens, with knowledge and experience regarding health care coverage, access, and financing, or other relevant expertise, including at least one consumer representative and at least one invitation to an individual representing tribal governments with knowledge of the Indian health care delivery in the state.
(3)(a) The governor must appoint the chair of the commission from any of the members identified in subsection (2) of this section for a term of no more than three years. A majority of the voting members of the commission shall constitute a quorum for any votes of the commission.
(b) The commission's meetings shall be open to the public pursuant to chapter
42.30
RCW. The authority must publish on its website the dates and locations of commission meetings, agendas of prior and upcoming commission meetings, and meeting materials for prior and upcoming commission meetings.
(4) The health care authority shall staff the commission.
(5) Members of the commission shall serve without compensation but must be reimbursed for their travel expenses while on official business in accordance with RCW 43.03.050
and
43.03.060
.
(6) The commission may establish advisory committees that include members of the public with knowledge and experience in health care, in order to support stakeholder engagement and an analytical process by which key design options are developed. A member of an advisory committee need not be a member of the commission.
(7) By November 1, 2022, the commission shall submit a baseline report to the legislature and the governor, and post it on the authority's website. The report must include:
(a) A complete synthesis of analyses done on Washington's existing health care finance and delivery system, including cost, quality, workforce, and provider consolidation trends and how they impact the state's ability to provide all Washingtonians with timely access to high quality, affordable health care;
(b) A strategy for developing implementable changes to the state's health care financing and delivery system to increase access to health care services and health coverage, reduce health care costs, reduce health disparities, improve quality, and prepare for the transition to a unified health care financing system by actively examining data and reports from sources that are monitoring the health care system. Such sources shall include data or reports from the health care cost transparency board under RCW 70.390.070, the public health advisory board, the governor's interagency coordinating council on health disparities under RCW 43.20.275, the all-payer health care claims database established under chapter
43.371
RCW, prescription drug price data, performance measure data under chapter
70.320
RCW, and other health care cost containment programs;
(c) An inventory of the key design elements of a universal health care system including:
(i) A unified financing system including, but not limited to, a single-payer financing system;
(ii) Eligibility and enrollment processes and requirements;
(iii) Covered benefits and services;
(iv) Provider participation;
(v) Effective and efficient provider payments, including consideration of global budgets and health plan payments;
(vi) Cost containment and savings strategies that are designed to assure that total health care expenditures do not exceed the health care cost growth benchmark established under chapter
70.390
RCW;
(vii) Quality improvement strategies;
(viii) Participant cost sharing, if appropriate;
(ix) Quality monitoring and disparities reduction;
(x) Initiatives for improving culturally appropriate health services within public and private health-related agencies;
(xi) Strategies to reduce health disparities including, but not limited to, mitigating structural racism and other determinants of health as set forth by the office of equity;
(xii) Information technology systems and financial management systems;
(xiii) Data sharing and transparency; and
(xiv) Governance and administration structure, including integration of federal funding sources;
(d) An assessment of the state's current level of preparedness to meet the elements of (c) of this subsection and steps Washington should take to prepare for a just transition to a unified health care financing system, including a single-payer financing system. Recommendations must include, but are not limited to, administrative changes, reorganization of state programs, retraining programs for displaced workers, federal waivers, and statutory and constitutional changes;
(e) Recommendations for implementing reimbursement rates for health care providers serving medical assistance clients who are enrolled in programs under chapter
74.09
RCW at a rate that is no less than 80 percent of the rate paid by medicare for similar services;
(f) Recommendations for coverage expansions to be implemented prior to and consistent with a universal health care system, including potential funding sources; and
(g) Recommendations for the creation of a finance committee to develop a financially feasible model to implement universal health care coverage using state and federal funds.
(8) Following the submission of the baseline report on November 1, 2022, the commission must structure its work to continue to further identify opportunities to implement reforms consistent with subsection (7)(b) of this section and to implement structural changes to prepare the state for a transition to a unified health care financing system. The commission must submit annual reports to the governor and the legislature each November 1st, beginning in 2023. The reports must detail the work of the commission, the opportunities identified to advance the goals under subsection (7) of this section, which, if any, of the opportunities a state agency is implementing, which, if any, opportunities should be pursued with legislative policy or fiscal authority, and which opportunities have been identified as beneficial, but lack federal authority to implement.
(9) Subject to sufficient existing agency authority, state agencies may implement specific elements of any report issued under this section. This section shall not be construed to authorize the commission to implement a universal health care system through a unified financing system until there is further action by the legislature and the governor.
(10) The commission must hold its first meeting within 90 days of July 25, 2021.
[
2021 c 309 s 2
.]
NOTES:
Findings
—
Intent
—
2021 c 309:
"(1) The legislature finds that:
(a) Healthy Washingtonians contribute to the economic well-being of their families and communities, and access to appropriate health services and improved health outcomes allow all Washingtonian families to enjoy productive and satisfying lives;
(b) Washington and the United States are experiencing the deepest economic crisis since the Great Depression, caused by a public health crisis;
(c) Skyrocketing unemployment rates due to COVID-19 have exposed the frailties and inequalities of the current health care system while causing unsustainable strain to the state's medicaid system;
(d) Thousands of union and nonunion workers are unemployed and without health insurance;
(e) Approximately 125,000 undocumented people live in the state with no access to health care during a global pandemic;
(f) Multiple economic analyses show that a universal system is less expensive, more equitable, and will produce billions in savings per year; and
(g) While a unified health care financing system can provide universal coverage, increase access to care, decrease costs, and improve quality, implementing such a system in the state is dependent on foundational legal, financial, and programmatic changes from the federal government.
(2) The legislature intends to create a permanent universal health care commission to:
(a) Implement immediate and impactful changes in the state's current health care system to increase access to quality, affordable health care by streamlining access to coverage, reducing fragmentation of health care financing across multiple public and private health insurance entities, reducing unnecessary administrative costs, reducing health disparities, and establishing mechanisms to expeditiously link residents with their chosen providers; and
(b) Establish the preliminary infrastructure to create a universal health system, including a unified financing system, that controls health care spending so that the system is affordable to the state, employers, and individuals, once the necessary federal authorities have been realized.
(3) The legislature further intends that the state, in collaboration with all communities, health plans, and providers, should take steps to improve health outcomes for all residents of the state." [
2021 c 309 s 1
.]
RCW 41.05.845
Prior authorization.
(1) A health plan offered to public employees, retirees, and their covered dependents under this chapter issued or renewed on or after January 1, 2024, shall comply with the following standards related to prior authorization for health care services and prescription drugs:
(a) The health plan shall meet the following time frames for prior authorization determinations and notifications to a participating provider or facility that submits the prior authorization request through an electronic prior authorization process:
(i) For electronic standard prior authorization requests, the health plan shall make a decision and notify the provider or facility of the results of the decision within three calendar days, excluding holidays, of submission of an electronic prior authorization request by the provider or facility that contains the necessary information to make a determination. If insufficient information has been provided to the health plan to make a decision, the health plan shall request any additional information from the provider or facility within one calendar day of submission of the electronic prior authorization request.
(ii) For electronic expedited prior authorization requests, the health plan shall make a decision and notify the provider or facility of the results of the decision within one calendar day of submission of an electronic prior authorization request by the provider or facility that contains the necessary information to make a determination. If insufficient information has been provided to the health plan to make a decision, the health plan shall request any additional information from the provider or facility within one calendar day of submission of the electronic prior authorization request.
(b) The health plan shall meet the following time frames for prior authorization determinations and notifications to a participating provider or facility that submits the prior authorization request through a process other than an electronic prior authorization process described in subsection (2) of this section:
(i) For nonelectronic standard prior authorization requests, the health plan shall make a decision and notify the provider or facility of the results of the decision within five calendar days of submission of a nonelectronic prior authorization request by the provider or facility that contains the necessary information to make a determination. If insufficient information has been provided to the health plan to make a decision, the health plan shall request any additional information from the provider or facility within five calendar days of submission of the nonelectronic prior authorization request.
(ii) For nonelectronic expedited prior authorization requests, the health plan shall make a decision and notify the provider or facility of the results of the decision within two calendar days of submission of a nonelectronic prior authorization request by the provider or facility that contains the necessary information to make a determination. If insufficient information has been provided to the health plan to make a decision, the health plan shall request any additional information from the provider or facility within one calendar day of submission of the nonelectronic prior authorization request.
(c) In any instance in which the health plan has determined that a provider or facility has not provided sufficient information for making a determination under (a) and (b) of this subsection, the health plan may establish a specific reasonable time frame for submission of the additional information. This time frame must be communicated to the provider and enrollee with the health plan's request for additional information.
(d) The prior authorization requirements of the health plan must be described in detail and written in easily understandable language. The health plan shall make its most current prior authorization requirements and restrictions, including the written clinical review criteria, available to providers and facilities in an electronic format upon request. The prior authorization requirements must be based on peer-reviewed clinical review criteria. The clinical review criteria must be evidence-based criteria and must accommodate new and emerging information related to the appropriateness of clinical criteria with respect to black and indigenous people, other people of color, gender, and underserved populations. The clinical review criteria must be evaluated and updated, if necessary, at least annually.
(2)(a) Each health plan offered to public employees, retirees, and their covered dependents under this chapter shall establish and maintain a prior authorization application programming interface that is consistent with final rules issued by the federal centers for medicare and medicaid services and published in the federal register, and that indicates that a prior authorization denial or authorization of a service less intensive than that included in the original request is an adverse benefit determination and is subject to the health plan's grievance and appeal process under RCW 48.43.535
.
(b) Each health plan offered to public employees, retirees, and their covered dependents under this chapter shall establish and maintain an interoperable electronic process or application programming interface that automates the process for in-network providers to determine whether a prior authorization is required for a covered prescription drug. The interoperable electronic process or application programming interface must support the exchange of prior authorization requests and determinations for prescription drugs, including information on covered alternative prescription drugs, beginning January 1, 2027, and must:
(i) Allow providers to identify prior authorization information and documentation requirements;
(ii) Facilitate the exchange of prior authorization requests and determinations from its electronic health records or practice management system; and
(iii) Indicate that a prior authorization denial or authorization of a drug other than the one included in the original prior authorization request is an adverse benefit determination and is subject to the health plan's grievance and appeal process under RCW 48.43.535
.
(c) Regardless of whether federal rules related to standards for using an application programming interface to communicate prior authorization status to providers are revoked, delayed, suspended, or not finalized by the federal centers for medicare and medicaid services after February 8, 2024, the requirements of (a) of this subsection shall be enforced beginning January 1, 2027.
(3) Nothing in this section applies to prior authorization determinations made pursuant to RCW 41.05.526
.
(4) For the purposes of this section:
(a) "Expedited prior authorization request" means a request by a provider or facility for approval of a health care service or prescription drug where:
(i) The passage of time:
(A) Could seriously jeopardize the life or health of the enrollee;
(B) Could seriously jeopardize the enrollee's ability to regain maximum function; or
(C) In the opinion of a provider or facility with knowledge of the enrollee's medical condition, would subject the enrollee to severe pain that cannot be adequately managed without the health care service or prescription drug that is the subject of the request; or
(ii) The enrollee is undergoing a current course of treatment using a nonformulary drug.
(b) "Standard prior authorization request" means a request by a provider or facility for approval of a health care service or prescription drug where the request is made in advance of the enrollee obtaining a health care service that is not required to be expedited.
(5) This section shall not apply to coverage provided under the medicare part C or part D programs set forth in Title XVIII of the social security act of 1965, as amended.
[
2025 c 25 s 2
;
2023 c 382 s 2
.]
RCW 41.05.850
Abortion coverage
—
Cost sharing.
(1) Except as provided in subsection (2) of this section, a health plan offered to public employees and their covered dependents under this chapter issued or renewed on or after January 1, 2024, that provides coverage for abortion may not impose cost sharing for the abortion of a pregnancy.
(2) 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 plan 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.
[
2023 c 194 s 2
.]
RCW 41.05.890
Certain health care and financial related data provided to authority
—
Exempt from disclosure.
(1) All health care and financial related data as required by section 4, chapter 3, Laws of 2012 2nd sp. sess. that was sent by school districts and their benefits providers to the office of the insurance commissioner for plan years ending in 2012 through 2016 for the purposes of studying health benefits provided to school employees must be provided to the authority by March 15, 2018.
(2) All claims data, including health care and financial related data received by the authority under subsection (1) of this section, is the property of the state and is exempt from disclosure and not subject to chapter
42.56
RCW.
[
2018 c 260 s 31
.]
NOTES:
Effective date
—
2018 c 260 ss 14, 22, 23, 31, and 32:
See note following RCW 41.05.075
.
RCW 41.05.900
Short title.
This chapter shall be known as the Washington state health care reform act of 1988.
[
1988 c 107 s 1
.]
RCW 41.05.901
Implementation
—
Effective dates
—
1988 c 107.
(1) The state health care authority shall be established and shall take such steps as are necessary to ensure that this act is fully implemented on October 1, 1988.
There is hereby appropriated for the biennium ending June 30, 1989, the sum of one million three hundred thousand dollars, or as much thereof as is necessary, to the office of the governor from the state employees' insurance administrative account, for the purposes of implementing this subsection.
(2) Subsection (1) of this section, RCW 48.14.027
and
82.04.4331, and sections 13 and 31, chapter 107, Laws of 1988 are necessary for the immediate preservation of the public peace, health, and safety, the support of the state government and its existing public institutions, and shall take effect March 16, 1988.
(3) The remainder of this act shall take effect on October 1, 1988.
[
1988 c 107 s 36
.]
RCW 41.05.950
Retired or disabled public employees
—
Special health coverage enrollment opportunity.
(1) A retired or disabled employee who: (a) Is receiving a retirement allowance under chapters [chapter] 41.32, 41.35, 41.37, or
41.40
RCW; (b) was previously denied coverage solely for failure to timely notify the authority of their plan to defer coverage; and (c) appealed the denial of benefits to the authority on or before December 31, 2022, may enroll in medical and dental plans under the authority, provided they apply no later than the end of the open enrollment period for the plan year beginning January 1, 2024.
(2) A retired or disabled employee enrolling in benefits under this section may only enroll in a fully insured medicare advantage or medicare supplement plan.
(3) Retired or disabled employees and their dependents are responsible for payment of rates developed by the authority, and must include any amounts necessary for administration in accordance with this chapter. Premium rates charged to retired or disabled employees and their dependents shall be based on the experience of the community-rated risk pools established under RCW 41.05.022
and
41.05.080
and must be reduced by the amount of the subsidy provided under RCW 41.05.085
.
(4) The authority may establish rules to implement the enrollment opportunity under this section.
[
2023 c 15 s 1
.]
NOTES:
Effective date
—
2023 c 15:
"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 30, 2023]." [
2023 c 15 s 2
.]
RCW 41.05.951
Retired or disabled employees of employer groups
—
Return following termination of employer's agreement
—
2023 c 312.
Any retired or disabled employee whose participation in insurance plans or contracts under RCW 41.05.080
(1)(a)(i) ended due to the termination of the contractual agreement between the authority and an employer group on or before January 1, 2023, must be allowed to return and participate in insurance plans and contracts as described in RCW 41.05.080
(1)(a)(ii) so long as the retired or disabled employee notifies the health care authority in writing by December 31, 2023, after which participation will begin on the first day of the month following the date the authority receives the retired or disabled employee's written notice.
[
2023 c 312 s 3
.]
NOTES:
Effective date
—
2023 c 312:
See note following RCW 41.05.083
.