reglab/statecodes huggingface dataset:
2023 Revised Code of Washington › Title 48 - Insurance › Chapter 48.46 - Health Maintenance Organizations. › 48.46.070 - Governing body.

RCW 48.46.070
Governing body.
(1) The members of the governing body of a health maintenance organization shall be nominated by the voting members or by the enrolled participants and providers, and shall be elected by the enrolled participants or voting members pursuant to the provisions of their bylaws, which shall not be restricted to providers. At least one-third of such body shall consist of consumers who are substantially representative of the enrolled population of such organization: PROVIDED, HOWEVER, That any organization that is a qualified health maintenance organization under P.L. 93-222 (Title XIII, section 1310(d) of the public health services [service] act) is deemed to have satisfied these governing body requirements and the requirements of RCW 48.46.030(2).
(2) For health maintenance organizations formed by public institutions of higher education or public hospital districts, the governing body shall be advised by an advisory board consisting of at least two-thirds consumers who are elected by the voting members or the enrolled participants and are substantially representative of the enrolled population.
[ 1985 c 320 § 3; 1983 c 106 § 5; 1975 1st ex.s. c 290 § 8.]
2023 Revised Code of Washington › Title 48 - Insurance › Chapter 48.46 - Health Maintenance Organizations. › 48.46.090 - Standard of services provided.

RCW 48.46.090
Standard of services provided.
A health maintenance organization, and the health care facilities and providers with which such organization has entered into contracts to provide health care services to its enrolled participants, shall provide such services in a manner consistent with the dignity of each enrolled participant as a human being.
[ 1975 1st ex.s. c 290 § 10.]
2023 Revised Code of Washington › Title 48 - Insurance › Chapter 48.46 - Health Maintenance Organizations. › 48.46.100 - Grievance procedure.

RCW 48.46.100
Grievance procedure.
A health maintenance organization shall establish and maintain a grievance procedure, approved by the commissioner, to provide reasonable and effective resolution of complaints initiated by enrolled participants concerning any matter relating to the interpretation of any provision of such enrolled participants' health maintenance contracts, including, but not limited to, claims regarding the scope of coverage for health care services; denials, cancellations, or nonrenewals of enrolled participants' coverage; and the quality of the health care services rendered, and which may include procedures for arbitration.
[ 1975 1st ex.s. c 290 § 11.]
2023 Revised Code of Washington › Title 48 - Insurance › Chapter 48.46 - Health Maintenance Organizations. › 48.46.110 - Name restrictions—Discrimination—Recovery of costs of health care services participant not entitled to.

RCW 48.46.110
Name restrictions—Discrimination—Recovery of costs of health care services participant not entitled to.
(1) No health maintenance organization may refer to itself in its name or advertising with any of the words: "insurance", "casualty", "surety", "mutual", or any other words descriptive of the insurance, casualty, or surety business, or deceptively similar to the name or description of any insurance or surety corporation or health care service contractor or other health maintenance organization doing business in this state.
(2) No health maintenance organization, nor any health care facility or provider with which such organization has contracted to provide health care services, shall discriminate against any person from whom or on whose behalf, payment to meet the required charge is available, with regard to enrollment, disenrollment, or the provision of health care services, on the basis of such person's race, color, sex, religion, place of residence if there is reasonable access to the facility of the health maintenance organization, socioeconomic status, or status as a recipient of medicare under Title XVIII of the Social Security Act, 42 U.S.C. section 1396, et seq.
(3) Where a health maintenance organization determines that an enrolled participant has received health care services to which such enrolled participant is not entitled under the terms of his or her health maintenance agreement, neither such organization, nor any health care facility or provider with which such organization has contracted to provide health care services, shall have recourse against such enrolled participant for any amount above the actual cost of providing such service, if any, specified in such agreement, unless the enrolled participant or a member of his or her family has given or withheld information to the health maintenance organization, the effect of which is to mislead or misinform the health maintenance organization as to the enrolled participant's right to receive such services.
[ 2009 c 549 § 7151; 1983 c 202 § 11; 1975 1st ex.s. c 290 § 12.]
2023 Revised Code of Washington › Title 48 - Insurance › Chapter 48.46 - Health Maintenance Organizations. › 48.46.120 - Examination of health maintenance organizations—Duties of organizations, powers of commissioner—Independent audit reports.

RCW 48.46.120
Examination of health maintenance organizations—Duties of organizations, powers of commissioner—Independent audit reports.
(1) The commissioner may make an examination of the operations of any health maintenance organization as often as he or she deems necessary in order to carry out the purposes of this chapter.
(2) Every health maintenance organization shall submit its books and records relating its operation for financial condition and market conduct examinations and in every way facilitate them. The quality or appropriateness of medical services or systems shall not be examined except to the extent that such items are incidental to an examination of the financial condition or the market conduct of a health maintenance organization. For the purpose of examinations, the commissioner may issue subpoenas, administer oaths, and examine the officers and principals of the health maintenance organization and the principals of such providers concerning their business.
(3) The commissioner may elect to accept and rely on audit reports made by an independent certified public accountant for the health maintenance organization in the course of that part of the commissioner's examination covering the same general subject matter as the audit. The commissioner may incorporate the audit report in his or her report of the examination.
[ 2009 c 549 § 7152; 2007 c 468 § 2; 1987 c 83 § 1; 1986 c 296 § 9; 1985 c 7 § 115; 1983 c 63 § 2; 1975 1st ex.s. c 290 § 13.]
NOTES:
Severability—Effective date—1986 c 296: See notes following RCW 48.14.020.
2023 Revised Code of Washington › Title 48 - Insurance › Chapter 48.46 - Health Maintenance Organizations. › 48.46.135 - Fine in addition to or in lieu of suspension, revocation, or refusal.

RCW 48.46.135
Fine in addition to or in lieu of suspension, revocation, or refusal.
After hearing or upon stipulation by the registrant and in addition to or in lieu of the suspension, revocation, or refusal to renew any registration of a health maintenance organization, the commissioner may levy a fine against the party involved for each offense in an amount not less than fifty dollars and not more than ten thousand dollars. The order levying such fine shall specify the period within which the fine shall be fully paid and which period shall not be less than fifteen nor more than thirty days from the date of such order. Upon failure to pay any such fine when due the commissioner shall revoke the registration of the registrant, if not already revoked, and the fine shall be recovered in a civil action brought on behalf of the commissioner by the attorney general. Any fine so collected shall be paid by the commissioner to the state treasurer for the account of the general fund.
[ 1983 c 202 § 15.]
2023 Revised Code of Washington › Title 48 - Insurance › Chapter 48.46 - Health Maintenance Organizations. › 48.46.140 - Fees.

RCW 48.46.140
Fees.
Every organization subject to this chapter shall pay to the commissioner the following fees:
(1) For filing a copy of its application for a certificate of registration or amendment thereto, one hundred dollars;
(2) For filing each annual report pursuant to RCW 48.46.080, ten dollars.
[ 1975 1st ex.s. c 290 § 15.]
2023 Revised Code of Washington › Title 48 - Insurance › Chapter 48.46 - Health Maintenance Organizations. › 48.46.170 - Effect of chapter as to other laws—Construction.

RCW 48.46.170
Effect of chapter as to other laws—Construction.
(1) Solicitation of enrolled participants by a health maintenance organization granted a certificate of registration, or its appointed insurance producers or representatives, does not violate any provision of law relating to solicitation or advertising by health professionals.
(2) Any health maintenance organization authorized under this chapter is not violating any law prohibiting the practice by unlicensed persons of podiatric medicine and surgery, chiropractic, dental hygiene, opticianry, dentistry, optometry, osteopathic medicine and surgery, pharmacy, medicine and surgery, physical therapy, nursing, or psychology. This subsection does not expand a health professional's scope of practice or allow employees of a health maintenance organization to practice as a health professional unless licensed.
(3) This chapter does not alter any statutory obligation, or rule adopted thereunder, in chapter 70.38 RCW.
(4) Any health maintenance organization receiving a certificate of registration pursuant to this chapter is exempt from chapter 48.05 RCW.
[ 2008 c 217 § 55; 2003 c 248 § 17; 1996 c 178 § 13; 1983 c 106 § 7; 1975 1st ex.s. c 290 § 18.]
NOTES:
Severability—Effective date—2008 c 217: See notes following RCW 48.03.020.
Effective date—1996 c 178: See note following RCW 18.35.110.
2023 Revised Code of Washington › Title 48 - Insurance › Chapter 48.46 - Health Maintenance Organizations. › 48.46.180 - Duty of employer to inform and make available to employees option of enrolling in health maintenance organization.

RCW 48.46.180
Duty of employer to inform and make available to employees option of enrolling in health maintenance organization.
(1) The state government, or any political subdivision thereof, which offers its employees a health benefits plan shall make available to and inform its employees or members of the option to enroll in at least one health maintenance organization holding a valid certificate of authority which provides health care services in the geographic areas in which such employees or members reside.
(2) Each employer, public or private, having more than fifty employees in this state which offers its employees a health benefits plan, and each employee benefits fund in this state having more than fifty members which offers its members any form of health benefits shall make available to and inform its employees or members of the option to enroll in at least one health maintenance organization holding a valid certificate of authority which provides health care services in the geographic areas in which a substantial number of such employees or members reside: PROVIDED, That unless at least twenty-five employees agree to participate in a health maintenance organization the employer need not provide such an option: PROVIDED FURTHER, That where such employees are members of a bona fide bargaining unit covered by a labor-management collective bargaining agreement, the selection of the options required by this section may be specified in such agreement: AND PROVIDED FURTHER, That the provisions of this section shall not be mandatory where such members are covered by a Taft-Hartley health care trust, except that the labor-management trustees may contract with a health maintenance organization if a feasibility study determines it is to the advantage of the members to so contract.
(3) Subsections (1) and (2) of this section shall impose no responsibilities or duties upon state government or any political subdivision thereof or any other employer, either public or private, to provide health maintenance organization coverage when no health maintenance organization exists for the purpose of providing health care services in the geographic areas in which the employees or members reside.
(4) No employer in this state shall in any way be required to pay more for health benefits as a result of the application of this section than would otherwise be required by any prevailing collective bargaining agreement or other legally enforceable contract of obligation for the provision of health benefits between such employer and its employees.
[ 1975 1st ex.s. c 290 § 19.]
2023 Revised Code of Washington › Title 48 - Insurance › Chapter 48.46 - Health Maintenance Organizations. › 48.46.200 - Rules and regulations.

RCW 48.46.200
Rules and regulations.
The commissioner may, in accordance with the provisions of the administrative procedure act, chapter 34.05 RCW, promulgate rules and regulations as necessary or proper to carry out the provisions of this chapter. Nothing in this chapter shall be construed to prohibit the commissioner from requiring changes in procedures previously approved by him or her.
[ 2009 c 549 § 7153; 1975 1st ex.s. c 290 § 21.]
2023 Revised Code of Washington › Title 48 - Insurance › Chapter 48.46 - Health Maintenance Organizations. › 48.46.210 - Compliance with federal funding requirements—Construction.

RCW 48.46.210
Compliance with federal funding requirements—Construction.
Nothing in this chapter shall prohibit any health maintenance organization from meeting the requirements of any federal law which would authorize such health maintenance organization to receive federal financial assistance or enroll beneficiaries assisted by federal funds.
[ 1975 1st ex.s. c 290 § 22.]
2023 Revised Code of Washington › Title 48 - Insurance › Chapter 48.46 - Health Maintenance Organizations. › 48.46.220 - Review of administrative action.

RCW 48.46.220
Review of administrative action.
Any party aggrieved by a decision, order, or regulation made under this chapter by the commissioner shall have the right to have such reviewed pursuant to the provisions of the administrative procedure act, chapter 34.05 RCW.
[ 1975 1st ex.s. c 290 § 23.]
2023 Revised Code of Washington › Title 48 - Insurance › Chapter 48.46 - Health Maintenance Organizations. › 48.46.225 - Financial failure—Supervision of commissioner—Priority of distribution of assets.

RCW 48.46.225
Financial failure—Supervision of commissioner—Priority of distribution of assets.
(1) Any rehabilitation, liquidation, or conservation of a health maintenance organization is the same as the rehabilitation, liquidation, or conservation of an insurance company and must be conducted under the supervision of the commissioner pursuant to the law governing the rehabilitation, liquidation, or conservation of insurance companies. The commissioner may apply for an order directing the commissioner to rehabilitate, liquidate, or conserve a health maintenance organization upon any one or more grounds set out in RCW 48.31.030, 48.31.050, and 48.31.080. Enrolled participants have the same priority in the event of liquidation or rehabilitation as the law provides to policyholders of an insurer.
(2) For purposes of determining the priority of distribution of general assets, claims of enrolled participants and enrolled participants' beneficiaries have the same priority as established by RCW 48.31.280 for policyholders and beneficiaries of insureds of insurance companies. If an enrolled participant is liable to any provider for services provided pursuant to and covered by the health maintenance agreement, that liability has the status of an enrolled participant claim for distribution of general assets.
(3) A provider who is obligated by statute or agreement to hold enrolled participants harmless from liability for services provided pursuant to and covered by a health care plan has a priority of distribution of the general assets immediately following that of enrolled participants and enrolled participants' beneficiaries under this section.
[ 2003 c 248 § 18; 1990 c 119 § 4.]
2023 Revised Code of Washington › Title 48 - Insurance › Chapter 48.46 - Health Maintenance Organizations. › 48.46.235 - Minimum net worth—Requirement to maintain—Determination of amount.

RCW 48.46.235
Minimum net worth—Requirement to maintain—Determination of amount.
(1) Except as provided in subsection (2) of this section, every health maintenance organization must have and maintain a minimum net worth equal to the greater of:
(a) Three million dollars; or
(b) Two percent of annual premium earned as reported on the most recent annual financial statement filed with the commissioner on the first one hundred fifty million dollars of premium and one percent of annual premium on the premium in excess of one hundred fifty million dollars; or
(c) An amount equal to the sum of three months' uncovered expenditures as reported on the most recent financial statement filed with the commissioner.
(2) A health maintenance organization registered before July 27, 1997, that, on July 27, 1997, has a minimum net worth equal to or greater than that required by subsection (1) of this section must continue to have and maintain the minimum net worth required by subsection (1) of this section. A health maintenance organization registered before July 27, 1997, that, on July 27, 1997, does not have the minimum net worth required by subsection (1) of this section must have and maintain a minimum net worth of:
(a) The amount required immediately prior to July 27, 1997, until December 31, 1997;
(b) Fifty percent of the amount required by subsection (1) of this section by December 31, 1997;
(c) Seventy-five percent of the amount required by subsection (1) of this section by December 31, 1998; and
(d) One hundred percent of the amount required by subsection (1) of this section by December 31, 1999.
(3)(a) In determining net worth, no debt shall be considered fully subordinated unless the subordination clause is in a form acceptable to the commissioner. An interest obligation relating to the repayment of a subordinated debt must be similarly subordinated.
(b) The interest expenses relating to the repayment of a fully subordinated debt shall not be considered uncovered expenditures.
(c) A subordinated debt incurred by a note meeting the requirement of this section, and otherwise acceptable to the commissioner, shall not be considered a liability and shall be recorded as equity.
(4) Every health maintenance organization shall, when determining liabilities, include an amount estimated in the aggregate to provide for any unearned premium and for the payment of all claims for health care expenditures that have been incurred, whether reported or unreported, which are unpaid and for which such organization is or may be liable, and to provide for the expense of adjustment or settlement of such claims.
Such liabilities shall be computed in accordance with rules promulgated by the commissioner upon reasonable consideration of the ascertained experience and character of the health maintenance organization.
[ 1997 c 212 § 6; 1990 c 119 § 5.]
2023 Revised Code of Washington › Title 48 - Insurance › Chapter 48.46 - Health Maintenance Organizations. › 48.46.237 - Minimum net worth—Domestic or foreign health maintenance organization.

RCW 48.46.237
Minimum net worth—Domestic or foreign health maintenance organization.
(1) For purposes of this section:
(a) "Domestic health maintenance organization" means a health maintenance organization formed under the laws of this state; and
(b) "Foreign health maintenance organization" means a health maintenance organization formed under the laws of the United States, of a state or territory of the United States other than this state, or of the District of Columbia.
(2) If the minimum net worth of a domestic health maintenance organization falls below the minimum net worth required by this chapter, the commissioner shall at once ascertain the amount of the deficiency and serve notice upon the domestic health maintenance organization to cure the deficiency within ninety days after that service of notice.
(3) If the deficiency is not cured, and proof thereof filed with the commissioner within the ninety-day period, the domestic health maintenance organization shall be declared insolvent and shall be proceeded against as authorized by this code or the commissioner shall, consistent with chapters 48.04 and 34.05 RCW, suspend or revoke the registration of the domestic health maintenance organization as being hazardous to its subscribers and the people in this state.
(4) If the deficiency is not cured the domestic health maintenance organization shall not issue or deliver any health maintenance agreement after the expiration of the ninety-day period.
(5) If the minimum net worth of a foreign health maintenance organization falls below the minimum net worth required by this chapter, the commissioner shall, consistent with chapters 48.04 and 34.05 RCW, suspend or revoke the foreign health maintenance organization's registration as being hazardous to its subscribers, enrollees, or the people in this state.
[ 1997 c 212 § 7.]
2023 Revised Code of Washington › Title 48 - Insurance › Chapter 48.46 - Health Maintenance Organizations. › 48.46.240 - Funded reserve requirements.

RCW 48.46.240
Funded reserve requirements.
(1) Each health maintenance organization obtaining a certificate of registration from the commissioner shall provide and maintain a funded reserve of one hundred fifty thousand dollars. The funded reserve shall be deposited with the commissioner or with any organization/trustee acceptable to him or her in the form of cash, securities eligible for investment by the health maintenance organization pursuant to chapter 48.13 RCW, approved surety bond or any combination of these, and must equal or exceed one hundred fifty thousand dollars. The funded reserve shall be established as an assurance that the uncovered expenditure obligations of the health maintenance organization to the enrolled participants will be performed.
(2) All income from reserves on deposit with the commissioner shall belong to the depositing health maintenance organization and shall be paid to it as it becomes available.
(3) Any funded reserve required by this section shall be considered an asset of the health maintenance organization in determining the organization's net worth.
(4) A health maintenance organization that has made a securities deposit with the commissioner may, at its option, withdraw the securities deposit or any part of the deposit after first having deposited or provided in lieu thereof an approved surety bond, a deposit of cash or securities, or any combination of these or other deposits of equal amount and value to that withdrawn. Any securities and surety bond shall be subject to approval by the commissioner before being substituted.
[ 2009 c 549 § 7154; 1990 c 119 § 6; 1985 c 320 § 4; 1982 c 151 § 3.]
NOTES:
Effective date—1982 c 151: See note following RCW 48.46.020.
2023 Revised Code of Washington › Title 48 - Insurance › Chapter 48.46 - Health Maintenance Organizations. › 48.46.243 - Contract—Participant liability.

RCW 48.46.243
Contract—Participant liability.
(1) Subject to subsection (2) of this section, every contract between a health maintenance organization and its participating providers of health care services shall be in writing and shall set forth that in the event the health maintenance organization fails to pay for health care services as set forth in the agreement, the enrolled participant shall not be liable to the provider for any sums owed by the health maintenance organization. Every such contract shall provide that this requirement shall survive termination of the contract.
(2) The provisions of subsection (1) of this section shall not apply:
(a) To emergency care from a provider who is not a participating provider;
(b) To out-of-area services;
(c) To the delivery of covered pediatric oral services that are substantially equal to the essential health benefits benchmark plan; or
(d) In exceptional situations approved in advance by the commissioner, if the health maintenance organization is unable to negotiate reasonable and cost-effective participating provider contracts.
(3) No participating provider, or insurance producer, trustee, or assignee thereof, may maintain an action against an enrolled participant to collect sums owed by the health maintenance organization.
[ 2016 c 122 § 3. Prior: 2013 c 325 § 2; 2013 c 277 § 3; 2008 c 217 § 56; 1990 c 119 § 7.]
NOTES:
Intent—2016 c 122: "It is the intent of the legislature to allow certain provider compensation exhibits to remain confidential by making permanent the provisions of chapter 277, Laws of 2013, which currently expire July 1, 2017, thereby maintaining efficient review and approval of health care plans by the insurance commissioner and fostering innovation in the Washington health insurance market." [ 2016 c 122 § 1.]
Severability—Effective date—2008 c 217: See notes following RCW 48.03.020.
2023 Revised Code of Washington › Title 48 - Insurance › Chapter 48.46 - Health Maintenance Organizations. › 48.46.245 - Plan for handling insolvency—Commissioner's review.

RCW 48.46.245
Plan for handling insolvency—Commissioner's review.
Each health maintenance organization shall have a plan for handling insolvency which allows for continuation of benefits for the duration of the agreement period for which premiums have been paid and continuation of benefits to members who are confined on the date of insolvency in an inpatient facility until their discharge or expiration of benefits. The commissioner shall approve such a plan if it includes:
(1) Insurance to cover the expenses to be paid for continued benefits after insolvency;
(2) Provisions in provider contracts that obligate the provider to provide services for the duration of the period after the health maintenance organization's insolvency for which premium payment has been made and until the enrolled participants' discharge from inpatient facilities;
(3) Use of insolvency reserves established under RCW 48.46.240;
(4) Acceptable letters of credit or approved surety bonds; or
(5) Any other arrangements the commissioner and the organization mutually agree are appropriate to assure that benefits are continued.
[ 1990 c 119 § 8.]
2023 Revised Code of Washington › Title 48 - Insurance › Chapter 48.46 - Health Maintenance Organizations. › 48.46.250 - Coverage of dependent children—Newborn infants, congenital anomalies—Notification period.

RCW 48.46.250
Coverage of dependent children—Newborn infants, congenital anomalies—Notification period.
(1) Any health maintenance agreement under this chapter which provides coverage for dependent children of the enrolled participant shall provide the same coverage for newborn infants of the enrolled participant from and after the moment of birth. Coverage provided under this section shall include, but not be limited to, coverage for congenital anomalies of such children from the moment of birth.
(2) If payment of an additional premium is required to provide coverage for a child, the agreement may require that notification of birth of a newly born child and payment of the required premiums must be furnished to the health maintenance organization. The notification period shall be no less than sixty days from the date of birth. This subsection applies to agreements issued or renewed on or after January 1, 1984.
[ 1984 c 4 § 2; 1983 c 202 § 12.]
2023 Revised Code of Washington › Title 48 - Insurance › Chapter 48.46 - Health Maintenance Organizations. › 48.46.260 - Individual health maintenance agreement—Return within ten days of delivery—Refunds—Void from beginning.

RCW 48.46.260
Individual health maintenance agreement—Return within ten days of delivery—Refunds—Void from beginning.
Every subscriber of an individual health maintenance agreement may return the agreement to the health maintenance organization or the insurance producer through whom it was purchased within ten days of its delivery to the subscriber if, after examination of the agreement, the subscriber is not satisfied with it for any reason. The health maintenance organization shall refund promptly any fee paid for the agreement. An additional ten percent penalty shall be added to any premium refund due which is not paid within thirty days of return of the policy to the health maintenance organization or insurance producer. Upon such return of the agreement, it shall be void from the beginning and the parties shall be in the same position as if no agreement had been issued. Notice of the provisions of this section shall be printed on the face of each such agreement or be attached thereto.
[ 2008 c 217 § 57; 1983 c 202 § 13.]
NOTES:
Severability—Effective date—2008 c 217: See notes following RCW 48.03.020.
2023 Revised Code of Washington › Title 48 - Insurance › Chapter 48.46 - Health Maintenance Organizations. › 48.46.270 - Financial interests of health maintenance organization authorities, restricted—Exceptions, regulations.

RCW 48.46.270
Financial interests of health maintenance organization authorities, restricted—Exceptions, regulations.
(1) No person having any authority in the investment or disposition of the funds of a health maintenance organization and no officer or director of a health maintenance organization shall accept, except for the health maintenance organization, or be the beneficiary of any fee, brokerage, gift, commission, or other emolument because of any sale of health care service agreements or any investment, loan, deposit, purchase, sale, payment, or exchange made by or for the health maintenance organization, or be pecuniarily interested therein in any capacity; except, that such a person may procure a loan from the health maintenance organization directly upon approval by two-thirds of its directors and upon the pledge of securities eligible for the investment of the health maintenance organization's funds under this title.
(2) The commissioner may, by regulations, from time to time, define and permit additional exceptions to the prohibition contained in subsection (1) of this section solely to enable payment of reasonable compensation to a director who is not otherwise an officer or employee of the health maintenance organization, or to a corporation or firm in which the director is interested, for necessary services performed or sales or purchases made to or for the health maintenance organization in the ordinary course of the health maintenance organization's business and in the usual private professional or business capacity of the director or the corporation or firm.
[ 1985 c 320 § 5; 1983 c 202 § 14.]
2023 Revised Code of Washington › Title 48 - Insurance › Chapter 48.46 - Health Maintenance Organizations. › 48.46.274 - Prescribed, self-administered anticancer medication.

RCW 48.46.274
Prescribed, self-administered anticancer medication.
(1) Each health plan issued or renewed on or after January 1, 2012, that provides coverage for cancer chemotherapy treatment must provide coverage for prescribed, self-administered anticancer medication that is used to kill or slow the growth of cancerous cells on a basis at least comparable to cancer chemotherapy medications administered by a health care provider or facility as defined in *RCW 48.43.005 (25) and (26).
(2) Nothing in this section may be interpreted to prohibit a health plan from administering a formulary or preferred drug list, requiring prior authorization, or imposing other appropriate utilization controls in approving coverage for any chemotherapy.
[ 2020 c 18 § 22; 2011 c 159 § 6.]
NOTES:
*Reviser's note: RCW 48.43.005 was alphabetized pursuant to RCW 1.08.015(2)(k), changing subsections (25) and (26) to subsections (27) and (28).
Explanatory statement—2020 c 18: See note following RCW 43.79A.040.
Findings—2011 c 159: See note following RCW 41.05.175.
2023 Revised Code of Washington › Title 48 - Insurance › Chapter 48.46 - Health Maintenance Organizations. › 48.46.275 - Mammograms—Insurance coverage.

RCW 48.46.275
Mammograms—Insurance coverage.
Each health maintenance agreement issued or renewed after January 1, 1990, that provides benefits for hospital or medical care shall provide benefits for screening or diagnostic mammography services, provided that such services are delivered upon the recommendation of the patient's physician or advanced registered nurse practitioner as authorized by the *nursing care quality assurance commission pursuant to chapter 18.79 RCW or physician assistant pursuant to chapter 18.71A RCW.
All services must be provided by the health maintenance organization or rendered upon referral by the health maintenance organization. This section shall not be construed to prevent the application of standard agreement provisions, other than the cost-sharing prohibition provided in RCW 48.43.076, that are applicable to other benefits. This section does not limit the authority of a health maintenance organization to negotiate rates and contract with specific providers for the delivery of mammography services. This section shall not apply to medicare supplement policies or supplemental contracts covering a specified disease or other limited benefits.
[ 2023 c 366 § 6; 1994 sp.s. c 9 § 735; 1989 c 338 § 4.]
NOTES:
*Reviser's note: The reference to "nursing care quality assurance commission" was changed to "board of nursing" by 2023 c 123.
Intent—2023 c 366: See note following RCW 48.43.076.
Severability—Headings and captions not law—Effective date—1994 sp.s. c 9: See RCW 18.79.900 through 18.79.902.
2023 Revised Code of Washington › Title 48 - Insurance › Chapter 48.46 - Health Maintenance Organizations. › 48.46.277 - Prostate cancer screening.

RCW 48.46.277
Prostate cancer screening.
(1) Each health maintenance agreement issued or renewed after December 31, 2006, that provides coverage for hospital or medical expenses shall provide coverage for prostate cancer screening, provided that the screening is delivered upon the recommendation of the patient's physician, advanced registered nurse practitioner, or physician assistant.
(2) All services must be provided by the health maintenance organization or rendered upon a referral by the health maintenance organization.
(3) This section shall not be construed to prevent the application of standard policy provisions applicable to other benefits, such as deductible or copayment provisions. This section does not limit the authority of a health maintenance organization to negotiate rates and contract with specific providers for the delivery of prostate cancer screening services. This section shall not apply to medicare supplemental policies or supplemental contracts covering a specified disease or other limited benefits.
[ 2006 c 367 § 5.]
2023 Revised Code of Washington › Title 48 - Insurance › Chapter 48.46 - Health Maintenance Organizations. › 48.46.280 - Reconstructive breast surgery.

RCW 48.46.280
Reconstructive breast surgery.
(1) Any health care service plan issued, amended, or renewed after July 24, 1983, shall provide coverage for reconstructive breast surgery resulting from a mastectomy which resulted from disease, illness, or injury.
(2) Any health care service plan issued, amended, or renewed after January 1, 1986, shall provide coverage for all stages of one reconstructive breast reduction on the nondiseased breast to make it equal in size with the diseased breast after definitive reconstructive surgery on the diseased breast has been performed.
[ 1985 c 54 § 8; 1983 c 113 § 4.]
NOTES:
Effective date—1985 c 54: See note following RCW 48.20.397.
2023 Revised Code of Washington › Title 48 - Insurance › Chapter 48.46 - Health Maintenance Organizations. › 48.46.285 - Mastectomy, lumpectomy.

RCW 48.46.285
Mastectomy, lumpectomy.
No health maintenance organization under this chapter may refuse coverage or cancel or decline coverage solely because of a mastectomy or lumpectomy performed on the insured or prospective insured more than five years previously. The amount of benefits payable, or any term, rate, condition, or type of coverage shall not be restricted, modified, excluded, increased, or reduced solely on the basis of a mastectomy or lumpectomy performed on the insured or prospective insured more than five years previously.
[ 1985 c 54 § 4.]
NOTES:
Effective date—1985 c 54: See note following RCW 48.20.397.
2023 Revised Code of Washington › Title 48 - Insurance › Chapter 48.46 - Health Maintenance Organizations. › 48.46.292 - Mental health treatment—Waiver of preauthorization for persons involuntarily committed.

RCW 48.46.292
Mental health treatment—Waiver of preauthorization for persons involuntarily committed.
A health maintenance organization providing services or benefits for hospital or medical care coverage in this state shall waive a preauthorization from the health maintenance organization before an enrolled participant or the enrolled participant's covered dependents receive mental health treatment rendered by a state hospital as defined in RCW 72.23.010 if the enrolled participant or the enrolled participant's covered dependents are involuntarily committed to a state hospital as defined in RCW 72.23.010.
[ 1993 c 272 § 5.]
NOTES:
Savings—Severability—1993 c 272: See notes following RCW 43.20B.347.
2023 Revised Code of Washington › Title 48 - Insurance › Chapter 48.46 - Health Maintenance Organizations. › 48.46.300 - Future dividends or refunds, restricted—Issuance or sale of securities regulated.

RCW 48.46.300
Future dividends or refunds, restricted—Issuance or sale of securities regulated.
(1) No health maintenance organization nor any individual acting in behalf thereof may guarantee or agree to the payment of future dividends or future refunds of unused charges or savings in any specific or approximate amounts or percentages in respect to any contract being offered to the public, except in a group contract containing an experience refund provision.
(2) The issuance, sale, or offer for sale in this state of securities of its own issue by any health maintenance organization domiciled in this state other than the memberships and bonds of a nonprofit corporation are subject to the provisions of chapter 48.06 RCW relating to obtaining solicitation permits.
[ 1983 c 106 § 8.]
2023 Revised Code of Washington › Title 48 - Insurance › Chapter 48.46 - Health Maintenance Organizations. › 48.46.310 - Registration not endorsement.

RCW 48.46.310
Registration not endorsement.
The granting of a certificate of registration to a health maintenance organization is permissive only, and does not constitute an endorsement by the insurance commissioner of any person or thing related to the health maintenance organization, and no person may advertise or display a certificate of registration for use as an inducement in any solicitation.
[ 1983 c 106 § 9.]
2023 Revised Code of Washington › Title 48 - Insurance › Chapter 48.46 - Health Maintenance Organizations. › 48.46.320 - Dependent children, termination of coverage, conditions.

RCW 48.46.320
Dependent children, termination of coverage, conditions.
Any health maintenance agreement which provides that coverage of a dependent child shall terminate upon attainment of the limiting age for dependent children specified in the agreement shall also provide in substance that attainment of such limiting age shall not operate to terminate the coverage of such child while the child is and continues to be both: (1) Incapable of self-sustaining employment by reason of developmental or physical disability; and (2) chiefly dependent upon the subscriber for support and maintenance, if proof of such incapacity and dependency is furnished to the health maintenance organization by the enrolled participant within thirty-one days of the child's attainment of the limiting age and subsequently as required by the health maintenance organization but not more frequently than annually after the two-year period following the child's attainment of the limiting age.
[ 2020 c 274 § 38; 1985 c 320 § 6; 1983 c 106 § 10.]
2023 Revised Code of Washington › Title 48 - Insurance › Chapter 48.46 - Health Maintenance Organizations. › 48.46.325 - Option to cover child under age twenty-six.

RCW 48.46.325
Option to cover child under age twenty-six.
(1) Each individual health maintenance agreement that is not grandfathered and that provides coverage for a subscriber's child must offer the option of covering any child under the age of twenty-six.
(2) Each group health maintenance agreement that is not grandfathered and that provides coverage for a participating member's child must offer each participating member the option of covering any child under the age of twenty-six.
(3) Each grandfathered individual or group health maintenance agreement that provides coverage for a subscriber's child must offer the option of covering any child under the age of twenty-six, unless that child is eligible to enroll in an eligible health plan sponsored by the child's employer or the child's spouse's employer.
(4) As used in this section, "grandfathered" has the same meaning as "grandfathered health plan" in RCW 48.43.005.
[ 2012 c 211 § 19; 2011 c 314 § 8; 2007 c 259 § 22.]
NOTES:
Effective date—2007 c 259 §§ 18-22: See note following RCW 41.05.095.
Subheadings not law—2007 c 259: See note following RCW 7.70.060.
2023 Revised Code of Washington › Title 48 - Insurance › Chapter 48.46 - Health Maintenance Organizations. › 48.46.340 - Return of agreement within ten days.

RCW 48.46.340
Return of agreement within ten days.
Every subscriber of an individual health maintenance agreement may return the agreement to the health maintenance organization or the insurance producer through whom it was purchased within ten days of its delivery to the subscriber if, after examination of the agreement, the subscriber is not satisfied with it for any reason. The health maintenance organization shall refund promptly any fee paid for the agreement. Upon such return of the agreement, it shall be void from the beginning and the parties shall be in the same position as if no agreement had been issued. Notice of the substance of this section shall be printed on the face of each such agreement or be attached thereto.
[ 2008 c 217 § 58; 1983 c 106 § 12.]
NOTES:
Severability—Effective date—2008 c 217: See notes following RCW 48.03.020.
2023 Revised Code of Washington › Title 48 - Insurance › Chapter 48.46 - Health Maintenance Organizations. › 48.46.350 - Chemical dependency treatment.

RCW 48.46.350
Chemical dependency treatment.
Each group agreement for health care services that is delivered or issued for delivery or renewed on or after January 1, 1988, must contain provisions providing benefits for the treatment of chemical dependency rendered to covered persons by a provider which is an "approved substance use disorder treatment program" under *RCW 70.96A.020(2). However, this section does not apply to any agreement written as supplemental coverage to any federal or state programs of health care including, but not limited to, Title XVIII health insurance for the aged, which is commonly referred to as Medicare, Parts A&B, and amendments thereto. Treatment must be covered under the chemical dependency coverage if treatment is rendered by the health maintenance organization or if the health maintenance organization refers the enrolled participant or the enrolled participant's dependents to a physician licensed under chapter 18.57 or 18.71 RCW, or to a qualified counselor employed by an approved substance use disorder treatment program described in *RCW 70.96A.020(2). In all cases, a health maintenance organization retains the right to diagnose the presence of chemical dependency and select the modality of treatment that best serves the interest of the health maintenance organization's enrolled participant, or the enrolled participant's covered dependent.
[ 2018 c 201 § 8013; 2003 c 248 § 19; 1990 1st ex.s. c 3 § 14; 1987 c 458 § 18; 1983 c 106 § 13.]
NOTES:
*Reviser's note: RCW 70.96A.020 was repealed by 2016 sp.s. c 29 § 301.
Findings—Intent—Effective date—2018 c 201: See notes following RCW 41.05.018.
Effective date—Severability—1987 c 458: See notes following RCW 48.21.160.
Chemical dependency benefits, rules: RCW 48.21.197.
2023 Revised Code of Washington › Title 48 - Insurance › Chapter 48.46 - Health Maintenance Organizations. › 48.46.355 - "Chemical dependency" defined.

RCW 48.46.355
"Chemical dependency" defined.
For the purposes of RCW 48.46.350, "chemical dependency" means an illness characterized by a physiological of psychological dependency, or both, on a controlled substance regulated under chapter 69.50 RCW and/or alcoholic beverages. It is further characterized by a frequent or intense pattern of pathological use to the extent the user exhibits a loss of self-control over the amount and circumstances of use; develops symptoms of tolerance or physiological and/or psychological withdrawal if use of the controlled substance or alcoholic beverage is reduced or discontinued; and the user's health is substantially impaired or endangered or his or her social or economic function is substantially disrupted.
[ 1987 c 458 § 19.]
NOTES:
Effective date—Severability—1987 c 458: See notes following RCW 48.21.160.
2023 Revised Code of Washington › Title 48 - Insurance › Chapter 48.46 - Health Maintenance Organizations. › 48.46.360 - Payment of cost of agreement directly to holder during labor dispute—Changes restricted—Notice to employee.

RCW 48.46.360
Payment of cost of agreement directly to holder during labor dispute—Changes restricted—Notice to employee.
Any employee whose compensation includes a health maintenance agreement, the cost of which is paid in full or in part by an employer including the state of Washington, its political subdivisions, or municipal corporations, or paid by payroll deduction, may pay the cost as it becomes due directly to the agreement holder whenever the employee's compensation is suspended or terminated directly or indirectly as a result of a strike, lockout, or other labor dispute, for a period not exceeding six months and at the rate and coverages as the health maintenance agreement provides. During that period of time, such agreement may not be altered or changed. Nothing in this section impairs the right of the health maintenance organization to make normal decreases or increases in the cost of the health maintenance agreement upon expiration and renewal of the agreement, in accordance with the agreement. Thereafter, if such health maintenance agreement is no longer available, the employee shall be given the opportunity to convert as specified in RCW 48.46.450 and 48.46.460. When the employee's compensation is so suspended or terminated, the employee shall be notified immediately by the agreement holder in writing, by mail addressed to the address last of record with the agreement holder, that the employee may pay the cost of the health maintenance agreement to the agreement holder as it becomes due as provided in this section. Payment must be made when due or the coverage may be terminated by the health maintenance organization.
[ 1985 c 7 § 116; 1983 c 106 § 14.]
2023 Revised Code of Washington › Title 48 - Insurance › Chapter 48.46 - Health Maintenance Organizations. › 48.46.370 - Coverage not denied for disability.

RCW 48.46.370
Coverage not denied for disability.
No health maintenance organization may deny coverage to a person solely on account of the presence of any disability. Nothing in this section may be construed as limiting a health maintenance organization's authority to deny or otherwise limit coverage to a person when the person because of a medical condition does not meet the essential eligibility requirements established by the health maintenance organization for purposes of determining coverage for any person.
[ 2020 c 274 § 39; 1983 c 106 § 15.]