reglab/statecodes huggingface dataset:
2023 Revised Code of Washington › Title 48 - Insurance › Chapter 48.43 - Insurance Reform. › 48.43.785 - COVID-19 personal protective equipment expenses—Health care provider reimbursement.

RCW 48.43.785
COVID-19 personal protective equipment expenses—Health care provider reimbursement. (Contingent expiration date.)
(1) For the duration of the federal public health emergency related to COVID-19, a health benefit plan shall reimburse a health care provider who bills for incurred personal protective equipment expenses as a separate expense, using the American medical association's current procedural terminology code 99072 or as subsequently amended, $6.57 for each individual patient encounter.
(2) For purposes of this section, cost sharing is limited to the covered service according to the terms and conditions of the health benefit plan and does not apply to an expense for personal protective equipment.
(3) This section is not intended to apply to health care services that are not provided in person.
[ 2021 c 94 § 2.]
NOTES:
Contingent expiration date—2021 c 94 § 2: "Section 2 of this act expires upon the termination of the federal public health emergency related to COVID-19 as proclaimed by the United States department of health and human services." [ 2021 c 94 § 5.]
Findings—2021 c 94: "(1) The legislature finds that:
(a) The delivery of health care services is essential and maintaining patient safety during the ongoing public health emergency is paramount;
(b) Pursuant to state and federal regulations, and in the interest of minimizing the risk of viral transmission, health care providers have incurred substantially increased costs during the public health emergency associated with the procurement of personal protective equipment;
(c) Costs associated with providing care are typically factored into contracts between a health carrier and a health care provider, but the dramatically increased personal protective equipment costs related to the pandemic, in terms of procurement and increased "per unit" costs, were neither foreseeable nor contemplated in existing contracts; and
(d) Health care providers do not want to bill patients directly for costs associated with personal protective equipment, and in many cases are precluded from doing so pursuant to terms of contract between health care providers and health carriers, so many health care providers currently do not have a mechanism to recoup costs of personal protective equipment.
(2) Therefore, the legislature finds that to help ensure patient safety and continued access to personal protective equipment, it is necessary that health carriers reimburse health care providers for costs associated with personal protective equipment." [ 2021 c 94 § 1.]
Application—2021 c 94: "This act applies prospectively for the duration of the state of emergency related to COVID-19." [ 2021 c 94 § 3.]
Effective date—2021 c 94: "This act is necessary for the immediate preservation of the public peace, health, or safety, or support of the state government and its existing public institutions, and takes effect immediately [April 16, 2021]." [ 2021 c 94 § 4.]
2023 Revised Code of Washington › Title 48 - Insurance › Chapter 48.43 - Insurance Reform. › 48.43.790 - Behavioral services—Next-day appointments.

RCW 48.43.790
Behavioral services—Next-day appointments.
Health plans issued or renewed on or after January 1, 2023, must make next-day appointments available to enrollees experiencing urgent, symptomatic behavioral health conditions to receive covered behavioral health services. The appointment may be with a licensed provider other than a licensed behavioral health professional, as long as that provider is acting within their scope of practice, and may be provided through telemedicine consistent with RCW 48.43.735. Need for urgent symptomatic care is associated with the presentation of behavioral health signs or symptoms that require immediate attention, but are not emergent.
[ 2021 c 302 § 106.]
NOTES:
Findings—Intent—2021 c 302: See note following RCW 71.24.890.
2023 Revised Code of Washington › Title 48 - Insurance › Chapter 48.43 - Insurance Reform. › 48.43.795 - Qualified health plans—Acceptance of premium and cost-sharing assistance.

RCW 48.43.795
Qualified health plans—Acceptance of premium and cost-sharing assistance.
For qualified health plans offered on the exchange, a carrier shall:
(1) Accept payments for enrollee premiums or cost-sharing assistance under RCW 43.71.110 or as part of a sponsorship program under RCW 43.71.030(4). Nothing in this subsection expands or restricts the types of sponsorship programs authorized under state and federal law;
(2) Clearly communicate premium assistance amounts to enrollees as part of the invoicing and payment process; and
(3) Accept and process enrollment and payment data transferred by the exchange in a timely manner.
[ 2021 c 246 § 4.]
2023 Revised Code of Washington › Title 48 - Insurance › Chapter 48.43 - Insurance Reform. › 48.43.800 - Primary care expenditures assessment—Review.

RCW 48.43.800
Primary care expenditures assessment—Review.
The commissioner may include an assessment of carriers' primary care expenditures in the previous plan year or anticipated for the upcoming plan year in its reviews of health plan form or rate filings. In conducting the review, the commissioner must consider any definition of primary care expenditures and any primary care expenditure targets established under RCW 70.390.080. The commissioner may determine the form and content of carrier primary care expenditure reporting.
[ 2022 c 155 § 2.]
2023 Revised Code of Washington › Title 48 - Insurance › Chapter 48.43 - Insurance Reform. › 48.43.805 - Prescription drug upper payment limit—Rules.

RCW 48.43.805
Prescription drug upper payment limit—Rules.
(1) For health plans issued or renewed on or after January 1, 2024, if the prescription drug affordability board, as established in chapter 70.405 RCW, establishes an upper payment limit for a prescription drug pursuant to RCW 70.405.050, a carrier must provide sufficient information, as determined by the commissioner, to indicate that reimbursement for a claim for that prescription drug will not exceed the upper payment limit for the drug established by the board.
(2) The commissioner may adopt any rules necessary to implement this section.
[ 2022 c 153 § 10.]
2023 Revised Code of Washington › Title 48 - Insurance › Chapter 48.43 - Insurance Reform. › 48.43.810 - Biomarker testing—Standards—Construction.

RCW 48.43.810
Biomarker testing—Standards—Construction.
(1) Health plans issued or renewed on or after January 1, 2023, shall exempt an enrollee from prior authorization requirements for coverage of biomarker testing for either of the following:
(a) Stage 3 or 4 cancer; or
(b) Recurrent, relapsed, refractory, or metastatic cancer.
(2) For purposes of this section, "biomarker test" means a single or multigene diagnostic test of the cancer patient's biospecimen, such as tissue, blood, or other bodily fluids, for DNA, RNA, or protein alterations, including phenotypic characteristics of a malignancy, to identify an individual with a subtype of cancer, in order to guide patient treatment.
(3) For purposes of this section, biomarker testing must be:
(a) Recommended in the latest version of nationally recognized guidelines or biomarker compendia, such as those published by the national comprehensive cancer network;
(b) Approved by the United States food and drug administration or a validated clinical laboratory test performed in a clinical laboratory certified under the clinical laboratory improvement amendments or in an alternative laboratory program approved by the centers for medicare and medicaid services;
(c) A covered service; and
(d) Prescribed by an in-network provider.
(4) This section does not limit, prohibit, or modify an enrollee's rights to biomarker testing as part of an approved clinical trial under chapter 69.77 RCW.
(5) Nothing in this section may be construed to mandate coverage of a health care service.
(6) Nothing in this section prohibits a health plan from requiring a biomarker test prior to approving a drug or treatment.
(7) This section does not limit an enrollee's rights to access individual gene tests.
[ 2022 c 123 § 1.]
2023 Revised Code of Washington › Title 48 - Insurance › Chapter 48.43 - Insurance Reform. › 48.43.815 - Donor human milk—Standards.

RCW 48.43.815
Donor human milk—Standards.
(1) For group health plans other than small group health plans issued or renewed on or after January 1, 2023, a health carrier shall provide coverage for medically necessary donor human milk for inpatient use when ordered by a licensed health care provider with prescriptive authority or an international board certified lactation consultant certified by the international board of lactation consultant examiners for an infant who is medically or physically unable to receive maternal human milk or participate in chest feeding or whose parent is medically or physically unable to produce maternal human milk in sufficient quantities or caloric density or participate in chest feeding, if the infant meets at least one of the following criteria:
(a) An infant birth weight of below 2,500 grams;
(b) An infant gestational age equal to or less than 34 weeks;
(c) Infant hypoglycemia;
(d) A high risk for development of necrotizing enterocolitis, bronchopulmonary dysplasia, or retinopathy of prematurity;
(e) A congenital or acquired gastrointestinal condition with long-term feeding or malabsorption complications;
(f) Congenital heart disease requiring surgery in the first year of life;
(g) An organ or bone marrow transplant;
(h) Sepsis;
(i) Congenital hypotonias associated with feeding difficulty or malabsorption;
(j) Renal disease requiring dialysis in the first year of life;
(k) Craniofacial anomalies;
(l) An immunologic deficiency;
(m) Neonatal abstinence syndrome;
(n) Any other serious congenital or acquired condition for which the use of pasteurized donor human milk and donor human milk derived products is medically necessary and supports the treatment and recovery of the child; or
(o) Any baby still inpatient within 72 hours of birth without sufficient human milk available.
(2) Donor human milk covered under this section must be obtained from a milk bank that meets minimum standards adopted by the department of health pursuant to RCW 43.70.645.
(3) For purposes of this section:
(a) "Donor human milk" means human milk that has been contributed to a milk bank by one or more donors.
(b) "Milk bank" means an organization that engages in the procurement, processing, storage, distribution, or use of human milk contributed by donors.
(4) The commissioner may adopt any rules necessary to implement this section.
[ 2022 c 236 § 1.]
2023 Revised Code of Washington › Title 48 - Insurance › Chapter 48.43 - Insurance Reform. › 48.43.820 - Consolidated appropriations act enforcement—Implementation of federal regulations.

RCW 48.43.820
Consolidated appropriations act enforcement—Implementation of federal regulations.
The commissioner is authorized to enforce provisions of P.L. 116-260 (enacted December 27, 2020, as the consolidated appropriations act of 2021) and implementing federal regulations in effect on March 31, 2022, that are applicable to or regulate the conduct of carriers issuing health plans or grandfathered health plans to residents of Washington state on or after January 1, 2022. In addition to the enforcement actions authorized under RCW 48.02.080, the commissioner may impose a civil monetary penalty in an amount not to exceed $100 for each day for each individual with respect to which a failure to comply with these provisions occurs.
[ 2022 c 263 § 5.]
NOTES:
Effective date—2022 c 263: See note following RCW 43.371.100.
2023 Revised Code of Washington › Title 48 - Insurance › Chapter 48.43 - Insurance Reform. › 48.43.825 - Certified peer specialist services—Network access standards.

RCW 48.43.825
Certified peer specialist services—Network access standards.
By July 1, 2026, each carrier shall provide access to services provided by certified peer specialists and certified peer specialist trainees in a manner sufficient to meet the network access standards set forth in rules established by the office of the insurance commissioner.
[ 2023 c 469 § 16.]
2023 Revised Code of Washington › Title 48 - Insurance › Chapter 48.43 - Insurance Reform. › 48.43.300 - Definitions.

RCW 48.43.300
Definitions.
The definitions in this section apply throughout RCW 48.43.300 through 48.43.370 unless the context clearly requires otherwise.
(1) "Adjusted RBC report" means an RBC report that has been adjusted by the commissioner in accordance with RCW 48.43.305(4).
(2) "Corrective order" means an order issued by the commissioner specifying corrective actions that the commissioner has determined are required.
(3) "Domestic carrier" means any carrier domiciled in this state, or any person or entity subject to chapter 48.42 RCW domiciled in this state.
(4) "Foreign or alien carrier" means any carrier that is licensed to do business in this state but is not domiciled in this state, or any person or entity subject to chapter 48.42 RCW not domiciled in this state.
(5) "NAIC" means the national association of insurance commissioners.
(6) "Negative trend" means, with respect to a carrier, a negative trend over a period of time, as determined in accordance with the "trend test calculation" included in the RBC instructions.
(7) "RBC" means risk-based capital.
(8) "RBC instructions" means the RBC report including risk-based capital instructions adopted by the NAIC, as such RBC instructions may be amended by the NAIC from time to time in accordance with the procedures adopted by the NAIC.
(9) "RBC level" means a carrier's company action level RBC, regulatory action level RBC, authorized control level RBC, or mandatory control level RBC where:
(a) "Company action level RBC" means, with respect to any carrier, the product of 2.0 and its authorized control level RBC;
(b) "Regulatory action level RBC" means the product of 1.5 and its authorized control level RBC;
(c) "Authorized control level RBC" means the number determined under the risk-based capital formula in accordance with the RBC instructions;
(d) "Mandatory control level RBC" means the product of .70 and the authorized control level RBC.
(10) "RBC plan" means a comprehensive financial plan containing the elements specified in RCW 48.43.310(2). If the commissioner rejects the RBC plan, and it is revised by the carrier, with or without the commissioner's recommendation, the plan shall be called the "revised RBC plan."
(11) "RBC report" means the report required in RCW 48.43.305.
(12) "Total adjusted capital" means the sum of:
(a) Either a carrier's statutory capital and surplus or net worth, or both, as determined in accordance with statutory accounting applicable to the annual financial statements required to be filed with the commissioner; and
(b) Other items, if any, as the RBC instructions may provide.
[ 1998 c 241 § 1.]
2023 Revised Code of Washington › Title 48 - Insurance › Chapter 48.43 - Insurance Reform. › 48.43.305 - Report of RBC levels—Distribution of report—Formula for determination—Commissioner may make adjustments.

RCW 48.43.305
Report of RBC levels—Distribution of report—Formula for determination—Commissioner may make adjustments.
(1) Every domestic carrier shall, on or prior to the filing date of March 1st, prepare and submit to the commissioner a report of its RBC levels as of the end of the calendar year just ended, in a form and containing such information as is required by the RBC instructions. In addition, every domestic carrier shall file its RBC report:
(a) With the NAIC in accordance with the RBC instructions; and
(b) With the insurance commissioner in any state in which the carrier is authorized to do business, if the insurance commissioner has notified the carrier of its request in writing, in which case the carrier shall file its RBC report not later than the later of:
(i) Fifteen days from the receipt of notice to file its RBC report with that state; or
(ii) The filing date.
(2) A carrier's RBC shall be determined in accordance with the formula set forth in the RBC instructions. The formula shall take into account (and may adjust for the covariance between):
(a) The risk with respect to the carrier's assets;
(b) The risk of adverse insurance experience with respect to the carrier's liabilities and obligations;
(c) The interest rate risk with respect to the carrier's business; and
(d) All other business risks and such other relevant risks as are set forth in the RBC instructions; determined in each case by applying the factors in the manner set forth in the RBC instructions.
(3) An excess of capital over the amount produced by the risk-based capital requirements contained in RCW 48.43.300 through 48.43.370 and the formulas, schedules, and instructions referenced in RCW 48.43.300 through 48.43.370 is desirable in the business of insurance. Accordingly, carriers should seek to maintain capital above the RBC levels required by RCW 48.43.300 through 48.43.370. Additional capital is used and useful in the insurance business and helps to secure a carrier against various risks inherent in, or affecting, the business of insurance and not accounted for or only partially measured by the risk-based capital requirements contained in RCW 48.43.300 through 48.43.370.
(4) If a domestic carrier files an RBC report that in the judgment of the commissioner is inaccurate, then the commissioner shall adjust the RBC report to correct the inaccuracy and shall notify the carrier of the adjustment. The notice shall contain a statement of the reason for the adjustment.
[ 1998 c 241 § 2.]
2023 Revised Code of Washington › Title 48 - Insurance › Chapter 48.43 - Insurance Reform. › 48.43.320 - Authorized control level event—Commissioner's options.

RCW 48.43.320
Authorized control level event—Commissioner's options.
(1) "Authorized control level event" means any of the following events:
(a) The filing of an RBC report by the carrier which indicates that the carrier's total adjusted capital is greater than or equal to its mandatory control level RBC but less than its authorized control level RBC;
(b) The notification by the commissioner to the carrier of an adjusted RBC report that indicates the event in (a) of this subsection, provided the carrier does not challenge the adjusted RBC report under RCW 48.43.330;
(c) If, under RCW 48.43.330, the carrier challenges an adjusted RBC report that indicates the event in (a) of this subsection, notification by the commissioner to the carrier that the commissioner has, after a hearing, rejected the carrier's challenge;
(d) The failure of the carrier to respond, in a manner satisfactory to the commissioner, to a corrective order, provided the carrier has not challenged the corrective order under RCW 48.43.330; or
(e) If the carrier has challenged a corrective order under RCW 48.43.330 and the commissioner has, after a hearing, rejected the challenge or modified the corrective order, the failure of the carrier to respond, in a manner satisfactory to the commissioner, to the corrective order subsequent to rejection or modification by the commissioner.
(2) In the event of an authorized control level event with respect to a carrier, the commissioner shall:
(a) Take those actions required under RCW 48.43.315 regarding a carrier with respect to which a regulatory action level event has occurred; or
(b) If the commissioner deems it to be in the best interests of either the policyholders or subscribers, or both, and creditors of the carrier and of the public, take those actions necessary to cause the carrier to be placed under regulatory control under chapter 48.31 RCW. In the event the commissioner takes such actions, the authorized control level event is sufficient grounds for the commissioner to take action under chapter 48.31 RCW, and the commissioner shall have the rights, powers, and duties with respect to the carrier as are set forth in chapter 48.31 RCW. In the event the commissioner takes actions under this subsection (2)(b) pursuant to an adjusted RBC report, the carrier is entitled to those protections afforded to carriers under the provisions of RCW 48.31.121 pertaining to summary proceedings.
[ 1998 c 241 § 5.]
2023 Revised Code of Washington › Title 48 - Insurance › Chapter 48.43 - Insurance Reform. › 48.43.325 - Mandatory control level event—Commissioner's duty—Regulatory control.

RCW 48.43.325
Mandatory control level event—Commissioner's duty—Regulatory control.
(1) "Mandatory control level event" means any of the following events:
(a) The filing of an RBC report which indicates that the carrier's total adjusted capital is less than its mandatory control level RBC;
(b) Notification by the commissioner to the carrier of an adjusted RBC report that indicates the event in (a) of this subsection, provided the carrier does not challenge the adjusted RBC report under RCW 48.43.330; or
(c) If, under RCW 48.43.330, the carrier challenges an adjusted RBC report that indicates the event in (a) of this subsection, notification by the commissioner to the carrier that the commissioner has, after a hearing, rejected the carrier's challenge.
(2) In the event of a mandatory control level event, with respect to a carrier, the commissioner shall take those actions necessary to place the carrier under regulatory control under chapter 48.31 RCW. In that event, the mandatory control level event is sufficient grounds for the commissioner to take action under chapter 48.31 RCW, and the commissioner shall have the rights, powers, and duties with respect to the carrier as are set forth in chapter 48.31 RCW. If the commissioner takes actions pursuant to an adjusted RBC report, the carrier is entitled to the protections of RCW 48.31.121 pertaining to summary proceedings. However, the commissioner may forego action for up to ninety days after the mandatory control level event if the commissioner finds there is a reasonable expectation that the mandatory control level event may be eliminated within the ninety-day period.
[ 1998 c 241 § 6.]
2023 Revised Code of Washington › Title 48 - Insurance › Chapter 48.43 - Insurance Reform. › 48.43.330 - Carrier's right to hearing—Request by carrier—Date set by commissioner.

RCW 48.43.330
Carrier's right to hearing—Request by carrier—Date set by commissioner.
(1) Upon notification to a carrier by the commissioner of any of the following, the carrier shall have the right to a hearing, in accordance with chapters 48.04 and 34.05 RCW, at which the carrier may challenge any determination or action by the commissioner:
(a) Of an adjusted RBC report; or
(b)(i) That the carrier's RBC plan or revised RBC plan is unsatisfactory; and
(ii) The notification constitutes a regulatory action level event with respect to such carrier; or
(c) That the carrier has failed to adhere to its RBC plan or revised RBC plan and that such failure has a substantial adverse effect on the ability of the carrier to eliminate the company action level event with respect to the carrier in accordance with its RBC plan or revised RBC plan; or
(d) Of a corrective order with respect to the carrier.
(2) The carrier shall notify the commissioner of its request for a hearing within five days after the notification by the commissioner under this section. Upon receipt of the carrier's request for a hearing, the commissioner shall set a date for the hearing. The date shall be no less than ten nor more than thirty days after the date of the carrier's request.
[ 1998 c 241 § 7.]
2023 Revised Code of Washington › Title 48 - Insurance › Chapter 48.43 - Insurance Reform. › 48.43.340 - Powers or duties of commissioner not limited—Rules.

RCW 48.43.340
Powers or duties of commissioner not limited—Rules.
(1) The provisions of RCW 48.43.300 through 48.43.370 are supplemental to any other provisions of the laws and rules of this state, and shall not preclude or limit any other powers or duties of the commissioner under such laws and rules, including, but not limited to, chapter 48.31 RCW.
(2) The commissioner may adopt reasonable rules necessary for the implementation of RCW 48.43.300 through 48.43.370.
[ 1998 c 241 § 9.]
2023 Revised Code of Washington › Title 48 - Insurance › Chapter 48.43 - Insurance Reform. › 48.43.345 - Foreign or alien carriers—Required RBC report—Commissioner may require RBC plan—Mandatory control level event.

RCW 48.43.345
Foreign or alien carriers—Required RBC report—Commissioner may require RBC plan—Mandatory control level event.
(1) Any foreign or alien carrier shall, upon the written request of the commissioner, submit to the commissioner an RBC report as of the end of the calendar year just ended by the later of:
(a) The date an RBC report would be required to be filed by a domestic carrier under RCW 48.43.300 through 48.43.370; or
(b) Fifteen days after the request is received by the foreign or alien carrier. Any foreign or alien carrier shall, at the written request of the commissioner, promptly submit to the commissioner a copy of any RBC plan that is filed with the insurance commissioner of any other state.
(2) In the event of a company action level event, regulatory action level event, or authorized control level event with respect to any foreign or alien carrier as determined under the RBC statute applicable in the state of domicile of the carrier or, if no RBC statute is in force in that state, under the provisions of RCW 48.43.300 through 48.43.370, if the insurance commissioner of the state of domicile of the foreign or alien carrier fails to require the foreign or alien carrier to file an RBC plan in the manner specified under that state's RBC statute or, if no RBC statute is in force in that state, under RCW 48.43.310, the commissioner may require the foreign or alien carrier to file an RBC plan with the commissioner. In this event, the failure of the foreign or alien carrier to file an RBC plan with the commissioner is grounds to order the carrier to cease and desist from writing new insurance business in this state.
(3) In the event of a mandatory control level event with respect to any foreign or alien carrier, if no domiciliary receiver has been appointed with respect to the foreign or alien carrier under the rehabilitation and liquidation statute applicable in the state of domicile of the foreign or alien carrier, the commissioner may apply for an order under RCW 48.31.080 or 48.31.090 to conserve the assets within this state of foreign or alien carriers, and the occurrence of the mandatory control level event is considered adequate grounds for the application.
[ 1998 c 241 § 10.]
2023 Revised Code of Washington › Title 48 - Insurance › Chapter 48.43 - Insurance Reform. › 48.43.350 - No liability or cause of action against commissioner or department.

RCW 48.43.350
No liability or cause of action against commissioner or department.
There is no liability on the part of, and no cause of action shall arise against, the commissioner or insurance department or its employees or agents for any action taken by them in the performance of their powers and duties under RCW 48.43.300 through 48.43.370.
[ 1998 c 241 § 11.]
2023 Revised Code of Washington › Title 48 - Insurance › Chapter 48.43 - Insurance Reform. › 48.43.355 - Notice by commissioner to carrier—When effective.

RCW 48.43.355
Notice by commissioner to carrier—When effective.
All notices by the commissioner to a carrier that may result in regulatory action are effective upon dispatch if transmitted by registered or certified mail, or in the case of any other transmission, are effective upon the carrier's receipt of such notice.
[ 1998 c 241 § 12.]
2023 Revised Code of Washington › Title 48 - Insurance › Chapter 48.43 - Insurance Reform. › 48.43.360 - Initial RBC reports—Calculation of initial RBC levels—Subsequent reports.

RCW 48.43.360
Initial RBC reports—Calculation of initial RBC levels—Subsequent reports.
For RBC reports to be filed by carriers commencing operations after June 11, 1998, those carriers shall calculate the initial RBC levels using financial projections, considering managed care arrangements, for its first full year in operation. Such projections, including the risk-based capital requirement, must be included as part of a comprehensive business plan that is submitted as part of the application for registration under RCW 48.44.040 and 48.46.030. The resulting RBC requirement shall be reported in the first RBC report submitted under RCW 48.43.305. For subsequent reports, the RBC results using actual financial data shall be included.
[ 1998 c 241 § 13.]
2023 Revised Code of Washington › Title 48 - Insurance › Chapter 48.43 - Insurance Reform. › 48.43.366 - Self-funded multiple employer welfare arrangements.

RCW 48.43.366
Self-funded multiple employer welfare arrangements.
A self-funded multiple employer welfare arrangement, as defined in RCW 48.125.010, is subject to the same RBC reporting requirements as a domestic carrier under RCW 48.43.300 through 48.43.370.
[ 2004 c 260 § 19.]
NOTES:
Effective date—2004 c 260: See RCW 48.125.901.
2023 Revised Code of Washington › Title 48 - Insurance › Chapter 48.43 - Insurance Reform. › 48.43.370 - RBC standards not applicable to certain carriers.

RCW 48.43.370
RBC standards not applicable to certain carriers.
RCW 48.43.300 through 48.43.370 shall not apply to a carrier which is subject to the provisions of RCW 48.05.430 through * 48.05.490.
[ 1998 c 241 § 15.]
NOTES:
*Reviser's note: RCW 48.05.490 was repealed by 2006 c 25 § 11.
2023 Revised Code of Washington › Title 48 - Insurance › Chapter 48.43 - Insurance Reform. › 48.43.400 - Prescription drug utilization management—Definitions.

RCW 48.43.400
Prescription drug utilization management—Definitions.
The definitions in this section apply throughout this section and RCW 48.43.410 and 48.43.420 unless the context clearly requires otherwise.
(1) "Clinical practice guidelines" means a systemically developed statement to assist decision making by health care providers and patients about appropriate health care for specific clinical circumstances and conditions.
(2) "Clinical review criteria" means the written screening procedures, decision rules, medical protocols, and clinical practice guidelines used by a health carrier or prescription drug utilization management entity as an element in the evaluation of medical necessity and appropriateness of requested prescription drugs under a health plan.
(3) "Emergency fill" means a limited dispensed amount of medication that allows time for the processing of prescription drug utilization management.
(4) "Medically appropriate" means prescription drugs that under the applicable standard of care are appropriate: (a) To improve or preserve health, life, or function; (b) to slow the deterioration of health, life, or function; or (c) for the early screening, prevention, evaluation, diagnosis, or treatment of a disease, condition, illness, or injury.
(5) "Prescription drug utilization management" means a set of formal techniques used by a health carrier or prescription drug utilization management entity, that are designed to monitor the use of or evaluate the medical necessity, appropriateness, efficacy, or efficiency of prescription drugs including, but not limited to, prior authorization and step therapy protocols.
(6) "Prescription drug utilization management entity" means an entity affiliated with, under contract with, or acting on behalf of a health carrier to perform prescription drug utilization management.
(7) "Prior authorization" means a mandatory process that a carrier or prescription drug utilization management entity requires a provider or facility to follow to determine if a service is a benefit and meets the requirements for medical necessity, clinical appropriateness, level of care, or effectiveness in relation to the applicable plan.
(8) "Step therapy protocol" means a protocol or program that establishes the specific sequence in which prescription drugs for a specified medical condition will be covered by a health carrier.
[ 2019 c 171 § 1.]
NOTES:
Rules—2019 c 171: See note following RCW 48.43.420.
2023 Revised Code of Washington › Title 48 - Insurance › Chapter 48.43 - Insurance Reform. › 48.43.410 - Prescription drug utilization management—Clinical review criteria—Requirement to be evidence-based and updated regularly.

RCW 48.43.410
Prescription drug utilization management—Clinical review criteria—Requirement to be evidence-based and updated regularly.
For health plans delivered, issued for delivery, or renewed on or after January 1, 2021, clinical review criteria used to establish a prescription drug utilization management protocol must be evidence-based and updated on a regular basis through review of new evidence, research, and newly developed treatments.
[ 2019 c 171 § 2.]
NOTES:
Rules—2019 c 171: See note following RCW 48.43.420.
2023 Revised Code of Washington › Title 48 - Insurance › Chapter 48.43 - Insurance Reform. › 48.43.430 - Prescription medication—Maximum charge at point of sale—Requirements.

RCW 48.43.430
Prescription medication—Maximum charge at point of sale—Requirements.
(1) Beginning January 1, 2021, the maximum amount a health carrier or pharmacy benefit manager may require a person to pay at the point of sale for a covered prescription medication is the lesser of:
(a) The applicable cost sharing for the prescription medication; or
(b) The amount the person would pay for the prescription medication if the person purchased the prescription medication without using a health plan.
(2) A health carrier or pharmacy benefit manager may not require a pharmacist to dispense a brand name prescription medication when a less expensive therapeutically equivalent generic prescription medication is available.
(3) For purposes of this section, "pharmacy benefit manager" has the same meaning as in *RCW 19.340.010.
[ 2020 c 116 § 1.]
NOTES:
*Reviser's note: RCW 19.340.010 was repealed by 2020 c 240 § 19, effective January 1, 2022. For later enactment, see RCW 48.200.020.
2023 Revised Code of Washington › Title 48 - Insurance › Chapter 48.43 - Insurance Reform. › 48.43.435 - Prescription medication—Cost-sharing calculation—Application—Rules.

RCW 48.43.435
Prescription medication—Cost-sharing calculation—Application—Rules.
(1)(a) Except as provided in (b) of this subsection, when calculating an enrollee's contribution to any applicable cost-sharing or out-of-pocket maximum, a health carrier offering a nongrandfathered health plan with a pharmacy benefit, or a health care benefit manager administering benefits for the health carrier, shall include any cost-sharing amounts paid by the enrollee directly or on behalf of the enrollee by another person for a covered prescription drug that is:
(i) Without a generic equivalent or a therapeutic equivalent preferred under the health plan's formulary;
(ii) With a generic equivalent or a therapeutic equivalent preferred under the health plan's formulary where the enrollee has obtained access to the drug through:
(A) Prior authorization;
(B) Step therapy; or
(C) The prescription drug exception request process under RCW 48.43.420; or
(iii) With a generic equivalent or therapeutic equivalent preferred under the health plan's formulary, throughout an exception request process under RCW 48.43.420, including any appeal of a denial of an exception request. If the health carrier utilizes a health care benefit manager to approve or deny exception requests, the exception request process for the purposes of this subsection (1)(a)(iii) also includes any time between the completion of the exception request process, including any appeal of a denial, and when the health care benefit manager communicates the status of the request to the health carrier.
(b) When calculating an enrollee's contribution to any applicable deductible, any amount paid on behalf of the enrollee by another person for a prescription drug that is not subject to payment of a deductible need not be included in the calculation, unless the terms of the enrollee's health plan require inclusion.
(2) Any cost-sharing amounts paid directly by or on behalf of the enrollee by another person for a covered prescription drug under subsection (1) of this section shall be applied towards the enrollee's applicable cost-sharing or out-of-pocket maximum in full at the time it is rendered.
(3) The commissioner may adopt any rules necessary to implement this section.
(4) This section applies to nongrandfathered health plans issued or renewed on or after January 1, 2023.
(5) This section does not apply to a qualifying health plan for a health savings account to the extent necessary to preserve the enrollee's ability to claim tax exempt contributions and withdrawals from the enrollee's health savings account under internal revenue service laws, regulations, and guidance.
(6) For purposes of this section:
(a) "Health care benefit manager" has the same meaning as in RCW 48.200.020.
(b) "Person" has the same meaning as in RCW 48.01.070.
[ 2022 c 228 § 1.]
2023 Revised Code of Washington › Title 48 - Insurance › Chapter 48.43 - Insurance Reform. › 48.43.500 - Intent—Purpose—2000 c 5.

RCW 48.43.500
Intent—Purpose—2000 c 5.
It is the intent of the legislature that enrollees covered by health plans receive quality health care designed to maintain and improve their health. The purpose of chapter 5, Laws of 2000 is to ensure that health plan enrollees:
(1) Have improved access to information regarding their health plans;
(2) Have sufficient and timely access to appropriate health care services, and choice among health care providers;
(3) Are assured that health care decisions are made by appropriate medical personnel;
(4) Have access to a quick and impartial process for appealing plan decisions;
(5) Are protected from unnecessary invasions of health care privacy; and
(6) Are assured that personal health care information will be used only as necessary to obtain and pay for health care or to improve the quality of care.
[ 2000 c 5 § 1.]
NOTES:
Application—2000 c 5: "This act applies to: Health plans as defined in RCW 48.43.005 offered, renewed, or issued by a carrier; medical assistance provided under RCW 74.09.522; the basic health plan offered under chapter 70.47 RCW; and health benefits provided under chapter 41.05 RCW." [ 2000 c 5 § 19.]
Short title—2000 c 5: "This act may be known and cited as the health care patient bill of rights." [ 2000 c 5 § 22.]
Captions not law—2000 c 5: "Captions used in this act are not any part of the law." [ 2000 c 5 § 24.]
Construction—2000 c 5: "To the extent permitted by law, if any provision of this act conflicts with state or federal law, such provision must be construed in a manner most favorable to the enrollee." [ 2000 c 5 § 26.]
Severability—2000 c 5: "If any provision of this act or its application to any person or circumstance is held invalid, the remainder of the act or the application of the provision to other persons or circumstances is not affected." [ 2000 c 5 § 27.]
Application to contracts—Effective dates—2000 c 5: "(1) Except as provided in subsections (2) and (3) of this section, this act applies to contracts entered into or renewing after June 30, 2001.
(2) Sections 13, 14, 15, and 16 of this act take effect January 1, 2001.
(3) Section 29 of this act takes effect July 1, 2001." [ 2000 c 5 § 28.]
2023 Revised Code of Washington › Title 48 - Insurance › Chapter 48.43 - Insurance Reform. › 48.43.5051 - Requests for confidential communications—Monitoring and ensuring compliance—Standardized form for submission of requests—Rules.

RCW 48.43.5051
Requests for confidential communications—Monitoring and ensuring compliance—Standardized form for submission of requests—Rules.
(1) The commissioner shall:
(a) Develop a process for the regular collection of information from carriers on requests for confidential communications pursuant to RCW 48.43.505 for the purposes of monitoring compliance, including monitoring:
(i) The effectiveness of the process described in RCW 48.43.505 in allowing protected individuals to redirect insurance communications, the extent to which protected individuals are using the process, and whether the process is working properly; and
(ii) The education and outreach activities conducted by carriers to inform enrollees about their right to confidential communications;
(b) Establish a process for ensuring compliance; and
(c) Develop rules necessary to implement chapter 56, Laws of 2019.
(2) The commissioner shall work with stakeholders to develop and make available to the public a standardized form that a protected individual may submit to a carrier to make a confidential communications request. At minimum, this form must:
(a) Inform a protected individual about the protected individual's right to confidential communications;
(b) Allow a protected individual to indicate where to redirect communications, including a specified physical or email address or specified telephone number; and
(c) Include a disclaimer that it may take up to three business days from the date of receipt for a carrier to process the form.
[ 2019 c 56 § 4.]
NOTES:
Findings—Declarations—2019 c 56: "The legislature finds and declares:
(1) All people deserve the right to choose the health services that are right for them, and the right to confidential access to those health services.
(2) When people are assured of the ability to confidentially access health care services, they are more likely to seek health services, disclose health risk behaviors to a clinician, and return for follow-up care.
(3) When denied confidential access to needed care, people may delay or forgo care, leading to higher rates of unprotected sex, unintended pregnancy, untreated sexually transmitted infections, and mental health issues, or they may turn to public health safety net funds or free clinics to receive confidential care—important resources that should be reserved for people who do not have insurance coverage." [ 2019 c 56 § 1.]
Effective date—2019 c 56: "This act takes effect January 1, 2020." [ 2019 c 56 § 8.]
2023 Revised Code of Washington › Title 48 - Insurance › Chapter 48.43 - Insurance Reform. › 48.43.517 - Enrollment of child participating in medical assistance program—Employer-sponsored health plan.

RCW 48.43.517
Enrollment of child participating in medical assistance program—Employer-sponsored health plan.
When the health care authority has determined that it is cost-effective to enroll a child participating in a medical assistance program under chapter 74.09 RCW in an employer-sponsored health plan, the carrier shall permit the enrollment of the participant who is otherwise eligible for coverage in the health plan without regard to any open enrollment restrictions. The request for special enrollment shall be made by the authority or participant within sixty days of the authority's determination that the enrollment would be cost-effective.
[ 2011 1st sp.s. c 15 § 78; 2007 c 5 § 7.]
NOTES:
Effective date—Findings—Intent—Report—Agency transfer—References to head of health care authority—Draft legislation—2011 1st sp.s. c 15: See notes following RCW 74.09.010.
2023 Revised Code of Washington › Title 48 - Insurance › Chapter 48.43 - Insurance Reform. › 48.43.520 - Requirement to maintain a documented utilization review program description and written utilization review criteria—Rules.

RCW 48.43.520
Requirement to maintain a documented utilization review program description and written utilization review criteria—Rules.
(1) Carriers that offer a health plan shall maintain a documented utilization review program description and written utilization review criteria based on reasonable medical evidence. The program must include a method for reviewing and updating criteria. Carriers shall make clinical protocols, medical management standards, and other review criteria available upon request to participating providers.
(2) The commissioner shall adopt, in rule, standards for this section after considering relevant standards adopted by national managed care accreditation organizations and state agencies that purchase managed health care services.
(3) A carrier shall not be required to use medical evidence or standards in its utilization review of religious nonmedical treatment or religious nonmedical nursing care.
[ 2000 c 5 § 8.]
NOTES:
Application—Short title—Captions not law—Construction—Severability—Application to contracts—Effective dates—2000 c 5: See notes following RCW 48.43.500.
2023 Revised Code of Washington › Title 48 - Insurance › Chapter 48.43 - Insurance Reform. › 48.43.525 - Prohibition against retrospective denial of health plan coverage—Rules.

RCW 48.43.525
Prohibition against retrospective denial of health plan coverage—Rules.
(1) A health carrier that offers a health plan shall not retrospectively deny coverage for emergency and nonemergency care that had prior authorization under the plan's written policies at the time the care was rendered.
(2) The commissioner shall adopt, in rule, standards for this section after considering relevant standards adopted by national managed care accreditation organizations and state agencies that purchase managed health care services.
[ 2000 c 5 § 9.]
NOTES:
Application—Short title—Captions not law—Construction—Severability—Application to contracts—Effective dates—2000 c 5: See notes following RCW 48.43.500.
2023 Revised Code of Washington › Title 48 - Insurance › Chapter 48.43 - Insurance Reform. › 48.43.540 - Requirement to designate a licensed medical director—Exemption.

RCW 48.43.540
Requirement to designate a licensed medical director—Exemption.
Any carrier that offers a health plan and any self-insured health plan subject to the jurisdiction of Washington state shall designate a medical director who is licensed under chapter 18.57 or 18.71 RCW. However, a naturopathic or complementary alternative health plan, which provides solely complementary alternative health care to individuals, groups, or health plans, may have a medical director licensed under chapter 18.36A RCW. A carrier that offers dental only coverage shall designate a dental director who is licensed under chapter 18.32 RCW, or licensed in a state that has been determined by the dental quality assurance commission to have substantially equivalent licensing standards to those of Washington. A health plan or self-insured health plan that offers only religious nonmedical treatment or religious nonmedical nursing care shall not be required to have a medical director.
[ 2002 c 103 § 1; 2000 c 5 § 13.]
NOTES:
Application—Short title—Captions not law—Construction—Severability—Application to contracts—Effective dates—2000 c 5: See notes following RCW 48.43.500.
2023 Revised Code of Washington › Title 48 - Insurance › Chapter 48.43 - Insurance Reform. › 48.43.550 - Delegation of duties—Carrier accountability.

RCW 48.43.550
Delegation of duties—Carrier accountability.
Each carrier is accountable for and must oversee any activities required by chapter 5, Laws of 2000 that it delegates to any subcontractor. No contract with a subcontractor executed by the health carrier or the subcontractor may relieve the health carrier of its obligations to any enrollee for the provision of health care services or of its responsibility for compliance with statutes or rules.
[ 2000 c 5 § 18.]
NOTES:
Application—Short title—Captions not law—Construction—Severability—Application to contracts—Effective dates—2000 c 5: See notes following RCW 48.43.500.
2023 Revised Code of Washington › Title 48 - Insurance › Chapter 48.43 - Insurance Reform. › 48.43.904 - Construction—Chapter applicable to state registered domestic partnerships—2009 c 521.

RCW 48.43.904
Construction—Chapter applicable to state registered domestic partnerships—2009 c 521.
For the purposes of this chapter, the terms spouse, marriage, marital, husband, wife, widow, widower, next of kin, and family shall be interpreted as applying equally to state registered domestic partnerships or individuals in state registered domestic partnerships as well as to marital relationships and married persons, and references to dissolution of marriage shall apply equally to state registered domestic partnerships that have been terminated, dissolved, or invalidated, to the extent that such interpretation does not conflict with federal law. Where necessary to implement chapter 521, Laws of 2009, gender-specific terms such as husband and wife used in any statute, rule, or other law shall be construed to be gender neutral, and applicable to individuals in state registered domestic partnerships.
[ 2009 c 521 § 125.]