reglab/statecodes huggingface dataset:
2023 Revised Code of Washington › Title 48 - Insurance › Chapter 48.43 - Insurance Reform. › 48.43.043 - Colorectal cancer examinations and laboratory tests—Required benefits or coverage.

RCW 48.43.043
Colorectal cancer examinations and laboratory tests—Required benefits or coverage.
(1) Health plans issued or renewed on or after July 1, 2008, must provide benefits or coverage for colorectal cancer examinations and laboratory tests consistent with the guidelines or recommendations of the United States preventive services task force or the federal centers for disease control and prevention. Benefits or coverage must be provided:
(a) For any of the colorectal screening examinations and tests in the selected guidelines or recommendations, at a frequency identified in such guidelines or recommendations, as deemed appropriate by the patient's physician after consultation with the patient; and
(b) To a covered individual who is:
(i) At least fifty years old; or
(ii) Less than fifty years old and at high risk or very high risk for colorectal cancer according to such guidelines or recommendations.
(2) To encourage colorectal cancer screenings, patients and health care providers must not be required to meet burdensome criteria or overcome significant obstacles to secure such coverage. An individual may not be required to pay an additional deductible or coinsurance for testing that is greater than an annual deductible or coinsurance established for similar benefits. If the health plan does not cover a similar benefit, a deductible or coinsurance may not be set at a level that materially diminishes the value of the colorectal cancer benefit required.
(3)(a) A health carrier is not required under this section to provide for a referral to a nonparticipating health care provider, unless the carrier does not have an appropriate health care provider that is available and accessible to administer the screening exam and that is a participating health care provider with respect to such treatment.
(b) If a health carrier refers an individual to a nonparticipating health care provider pursuant to this section, screening exam services or resulting treatment, if any, must be provided at no additional cost to the individual beyond what the individual would otherwise pay for services provided by a participating health care provider.
[ 2007 c 23 § 1.]
2023 Revised Code of Washington › Title 48 - Insurance › Chapter 48.43 - Insurance Reform. › 48.43.045 - Health plan requirements—Annual reports—Exemptions.

RCW 48.43.045
Health plan requirements—Annual reports—Exemptions.
(1) Every health plan delivered, issued for delivery, or renewed by a health carrier on and after January 1, 1996, shall:
(a) Permit every category of health care provider to provide health services or care included in the basic essential health benefits benchmark plan established by the commissioner consistent with RCW 48.43.715, to the extent that:
(i) The provision of such health services or care is within the health care providers' permitted scope of practice;
(ii) The providers agree to abide by standards related to:
(A) Provision, utilization review, and cost containment of health services;
(B) Management and administrative procedures; and
(C) Provision of cost-effective and clinically efficacious health services; and
(iii) The plan covers such services or care in the essential health benefits benchmark plan. The reference to the essential health benefits does not create a mandate to cover a service that is otherwise not a covered benefit.
(b) Annually report the names and addresses of all officers, directors, or trustees of the health carrier during the preceding year, and the amount of wages, expense reimbursements, or other payments to such individuals, unless substantially similar information is filed with the commissioner or the national association of insurance commissioners. This requirement does not apply to a foreign or alien insurer regulated under chapter 48.20 or 48.21 RCW that files a supplemental compensation exhibit in its annual statement as required by law.
(2) The requirements of subsection (1)(a) of this section do not apply to a licensed health care profession regulated under Title 18 RCW when the licensing statute for the profession states that such requirements do not apply.
[ 2015 c 237 § 2; 2007 c 253 § 12; 2007 c 98 § 18; 2006 c 25 § 7; 1997 c 231 § 205; 1995 c 265 § 8.]
NOTES:
Effective date—Implementation—2007 c 253: See RCW 18.250.901 and 18.250.902.
Effective dates—2007 c 98: See RCW 18.74.912.
Short title—Part headings and captions not law—Severability—Effective dates—1997 c 231: See notes following RCW 48.43.005.
Captions not law—Effective dates—Savings—Severability—1995 c 265: See notes following RCW 70.47.015.
2023 Revised Code of Washington › Title 48 - Insurance › Chapter 48.43 - Insurance Reform. › 48.43.047 - Health plans—Minimum coverage for preventative services—No cost-sharing requirements.

RCW 48.43.047
Health plans—Minimum coverage for preventative services—No cost-sharing requirements.
(1) A health plan issued on or after June 7, 2018, must, at a minimum, provide coverage for the same preventive services required to be covered under 42 U.S.C. Sec. 300gg-13 (2016) and any federal rules or guidance in effect on December 31, 2016, implementing 42 U.S.C. Sec. 300gg-13.
(2) The health plan may not impose cost-sharing requirements for the preventive services required to be covered under subsection (1) of this section.
(3) The insurance commissioner shall enforce this section consistent with federal rules, guidance, and case law in effect on December 31, 2016, applicable to 42 U.S.C. 300gg-13 (2016).
[ 2018 c 14 § 1.]
2023 Revised Code of Washington › Title 48 - Insurance › Chapter 48.43 - Insurance Reform. › 48.43.055 - Procedures for review and adjudication of health care provider complaints—Requirements.

RCW 48.43.055
Procedures for review and adjudication of health care provider complaints—Requirements.
(1) Except as provided by subsection (2) of this section, each health carrier as defined under RCW 48.43.005 shall file with the commissioner its procedures for review and adjudication of complaints initiated by health care providers. Procedures filed under this section shall provide a fair review for consideration of complaints. Every health carrier shall provide reasonable means allowing any health care provider aggrieved by actions of the health carrier to be heard after submitting a written request for review. If the health carrier fails to grant or reject a request within thirty days after it is made, the complaining health care provider may proceed as if the complaint had been rejected. A complaint that has been rejected by the health carrier may be submitted to nonbinding mediation. Mediation shall be conducted under chapter 7.07 RCW, or any other rules of mediation agreed to by the parties. This section is solely for resolution of provider complaints. Complaints by, or on behalf of, a covered person are subject to the grievance processes in RCW 48.43.530.
(2) For purposes of out-of-network payment disputes between a health carrier and health care provider covered under the provisions of chapter 48.49 RCW, the arbitration provisions of chapter 48.49 RCW apply.
[ 2019 c 427 § 28; 2005 c 172 § 19; 2002 c 300 § 6; 1995 c 265 § 20.]
NOTES:
Findings—Intent—Effective date—2019 c 427: See RCW 48.49.003 and 48.49.900.
Short title—Effective date—2005 c 172: See RCW 7.07.900 and 7.07.904.
Captions not law—Effective dates—Savings—Severability—1995 c 265: See notes following RCW 70.47.015.
2023 Revised Code of Washington › Title 48 - Insurance › Chapter 48.43 - Insurance Reform. › 48.43.059 - Payments made by a second-party payment process—Definition.

RCW 48.43.059
Payments made by a second-party payment process—Definition.
(1) For the purposes of this section, "second-party payment process" means a process in which: (a) An individual has an account under his or her name maintained with a financial institution and is either managed by the financial institution or an entity that, with the express agreement with the individual, has established the account on behalf of the individual with a financial institution; (b) the account is funded with funds from the individual or his or her family members or in a manner otherwise consistent with federal law including, but not limited to, federal guidance implementing the federal patient protection and affordable care act; and (c) the account is under the control of the covered person, such that the covered person may authorize payments from the account.
(2) All issuers must accept any payments made by a second-party payment process; however, no issuer need accept payment by a second-party payment process if the second-party payer is controlled by or receives funding from any entity where such entity may be reimbursed by an issuer for providing health care services or if the account under the control of the covered person is funded by any such entity, except those third-party entities from whom federal law requires such issuer to accept payment.
(3) Payments made under subsection (2) of this section may be made with any legal tender denominated in United States dollars.
[ 2015 c 284 § 2.]
NOTES:
Recognition—Intent—2015 c 284: "(1) The legislature recognizes that under regulations implementing the federal patient protection and affordable care act, issuers offering individual market qualified health plans are required to accept third-party premium and cost-sharing payments from the Ryan White HIV/AIDS program under Title XXVI of the public health service act, Indian tribes, tribal organizations or urban Indian organizations, and state and federal government programs. However, federal regulators have stated that they have serious concerns about payments made on a third-party basis by hospitals, health care providers, and other commercial entities using their own funds because of the potential that such payments could cause distortions in the insurance market.
(2) The legislature intends to clarify that an entity that makes premium payments from accounts that are owned and controlled by the covered person do not constitute a third party for the purposes of acceptance of premium payments by an issuer. The legislature does not intend to impact third-party payment programs required under federal law , including, but not limited to, federal guidance implementing the federal patient protection and affordable care act." [ 2015 c 284 § 1.]
2023 Revised Code of Washington › Title 48 - Insurance › Chapter 48.43 - Insurance Reform. › 48.43.071 - Health care information—Requirement to provide free copy to covered person appealing denial of social security benefits—Exceptions.

RCW 48.43.071
Health care information—Requirement to provide free copy to covered person appealing denial of social security benefits—Exceptions.
Upon request of a covered person or a covered person's personal representative, an issuer shall provide the covered person or representative with one copy of the covered person's health care information free of charge if the covered person is appealing the denial of federal supplemental security income or social security disability benefits. The issuer may provide the health care information in either paper or electronic format. An issuer is not required to provide a covered person or a covered person's personal representative with a free copy of health care information that has previously been provided free of charge pursuant to a request within the preceding two years. For purposes of this section, "health care information" has the same meaning as in RCW 70.02.010.
[ 2018 c 87 § 4.]
2023 Revised Code of Washington › Title 48 - Insurance › Chapter 48.43 - Insurance Reform. › 48.43.0725 - Reproductive health plan coverage—Immediate postpartum contraception devices.

RCW 48.43.0725
Reproductive health plan coverage—Immediate postpartum contraception devices.
(1) For births taking place in a licensed hospital or birthing center, a health plan must allow a provider to separately bill for devices, implants, professional services, or a combination thereof, associated with immediate postpartum contraception and may not consider such devices, implants, services, or combinations thereof to be part of any payments for general obstetric procedures.
(2) For purposes of this section, "immediate postpartum contraception" means the postpartum insertion of intrauterine devices or contraceptive implants performed before the patient is discharged from the hospital or birthing center and includes the devices or implants themselves.
(3) This section does not apply to facility services associated with immediate postpartum contraception.
(4) Nothing in this section affects an enrollee's right to directly access women's health care services, including contraceptive services.
(5) This section applies to health plans issued or renewed on or after January 1, 2023.
[ 2022 c 122 § 3.]
NOTES:
Findings—Intent—2022 c 122: See note following RCW 41.05.430.
2023 Revised Code of Washington › Title 48 - Insurance › Chapter 48.43 - Insurance Reform. › 48.43.074 - Qualified health plans—Single invoice billing—Certification of compliance required in the segregation plan for premium amounts attributable to coverage of abortion services.

RCW 48.43.074
Qualified health plans—Single invoice billing—Certification of compliance required in the segregation plan for premium amounts attributable to coverage of abortion services.
(1) The legislature intends to codify the state's current practice of requiring health carriers to bill enrollees with a single invoice and to segregate into a separate account the premium attributable to abortion services for which federal funding is prohibited. Washington has achieved full compliance with section 1303 of the federal patient protection and affordable care act by requiring health carriers to submit a single invoice to enrollees and to segregate into a separate account the premium amounts attributable to coverage of abortion services for which federal funding is prohibited. Further, section 1303 states that the act does not preempt or otherwise have any effect on state laws regarding the prohibition of, or requirement of, coverage, funding, or procedural requirements on abortions.
(2) In accordance with RCW 48.43.073 related to requirements for coverage and funding of abortion services, an issuer offering a qualified health plan must:
(a) Bill enrollees and collect payment through a single invoice that includes all benefits and services covered by the qualified health plan; and
(b) Include in the segregation plan required under applicable federal and state law a certification that the issuer's billing and payment processes meet the requirements of this section.
[ 2019 c 399 § 5.]
NOTES:
Effective date—2019 c 399 § 5: "Section 5 of this act is necessary for the immediate preservation of the public peace, health, or safety, or support of the state government and its existing public institutions, and takes effect immediately [May 13, 2019]." [ 2019 c 399 § 10.]
Findings—Short title—2019 c 399: See notes following RCW 74.09.875.
Recommendations—Preexposure and postexposure prophylaxis financial support awareness—2019 c 399: See note following RCW 48.43.072.
2023 Revised Code of Washington › Title 48 - Insurance › Chapter 48.43 - Insurance Reform. › 48.43.078 - Digital breast tomosynthesis—Intent to ensure women with access—Commissioner's and health care authority's duty to clarify mandates.

RCW 48.43.078
Digital breast tomosynthesis—Intent to ensure women with access—Commissioner's and health care authority's duty to clarify mandates.
(1) Digital breast tomosynthesis, also called three-dimensional mammography, is the latest advancement in breast imaging. Studies indicate that digital breast tomosynthesis can result in a forty-one percent increase in invasive cancer detection, a fifteen percent decrease in the recall rate from screening mammography, and a twenty-nine percent increase in the detection of all breast cancers. In addition, the American college of radiology has indicated that tomosynthesis is no longer investigational. Therefore, it is the intent of the legislature to ensure women have access to the most effective breast imaging and to clarify that the existing mandate for mammography must include tomosynthesis.
(2) The legislature directs the office of the insurance commissioner to clarify that the existing mandates for mammography in RCW 48.20.393, 48.21.225, 48.44.325, and 48.46.275 include coverage for tomosynthesis under the same terms and conditions currently allowed for mammography. The application of a deductible and cost sharing is prohibited, consistent with 42 U.S.C. Sec. 300-gg-13.
(3) The legislature also directs the health care authority to clarify that the existing mandate for mammography in RCW 41.05.180 includes coverage for tomosynthesis under the same terms and conditions currently allowed for mammography. The application of a deductible and cost sharing is prohibited, consistent with 42 U.S.C. Sec. 300-gg-13.
[ 2018 c 115 § 1.]
2023 Revised Code of Washington › Title 48 - Insurance › Chapter 48.43 - Insurance Reform. › 48.43.083 - Chiropractor services—Participating provider agreement—Health carrier reimbursement.

RCW 48.43.083
Chiropractor services—Participating provider agreement—Health carrier reimbursement.
(1) A health carrier must reimburse a chiropractor who has signed a participating provider agreement for services determined by the carrier to be medically necessary if:
(a) The service is:
(i) Covered chiropractic health care, as defined in RCW 48.43.515, by the health plan under which the enrollee received the services; and
(ii) Provided by the chiropractor, or the chiropractor's employee specified in RCW 18.25.190 (2) or (3) who works in the same location as the chiropractor and to whom the chiropractor, pursuant to rules adopted by the Washington state chiropractic quality assurance commission, has delegated the service. The employee must meet the health carrier's reasonable qualifications for all such providers in the relevant class, including but not limited to standards for education and background checks, as applicable; and
(b) The chiropractor complies with the terms and conditions of the participating provider agreement. Violations of the participating provider agreement by an employee of the chiropractor to whom he or she has delegated a service may be deemed by the carrier to have been committed by the chiropractor.
(2) If a health carrier offers a participating provider agreement to a chiropractor within a single practice organized as a sole proprietorship, partnership, or corporation, the carrier must offer the same participating provider agreement to any other chiropractor within that practice providing services at the same location. The agreement may allow either party to terminate it without cause.
[ 2007 c 502 § 1.]
NOTES:
Savings—2007 c 502: "This act does not affect any existing right acquired or liability or obligation incurred prior to January 1, 2008." [ 2007 c 502 § 3.]
Severability—2007 c 502: "If any provision of this act or its application to any person or circumstance is held invalid, the remainder of the act or the application of the provision to other persons or circumstances is not affected." [ 2007 c 502 § 4.]
Effective date—2007 c 502: "This act takes effect January 1, 2008." [ 2007 c 502 § 5.]
2023 Revised Code of Washington › Title 48 - Insurance › Chapter 48.43 - Insurance Reform. › 48.43.085 - Health carrier may not prohibit its enrollees from contracting for services outside the health care plan.

RCW 48.43.085
Health carrier may not prohibit its enrollees from contracting for services outside the health care plan.
Notwithstanding any other provision of law, no health carrier subject to the jurisdiction of the state of Washington may prohibit directly or indirectly its enrollees from freely contracting at any time to obtain any health care services outside the health care plan on any terms or conditions the enrollees choose. Nothing in this section shall be construed to bind a carrier for any services delivered outside the health plan. The provisions of this section shall be disclosed pursuant to *RCW 48.43.095(2). The insurance commissioner is prohibited from adopting rules regarding this section.
[ 1996 c 312 § 3.]
NOTES:
*Reviser's note: RCW 48.43.095 was repealed by 2000 c 5 § 29, effective July 1, 2001.
2023 Revised Code of Washington › Title 48 - Insurance › Chapter 48.43 - Insurance Reform. › 48.43.087 - Contracting for services at enrollee's expense—Mental health care practitioner—Conditions—Exception.

RCW 48.43.087
Contracting for services at enrollee's expense—Mental health care practitioner—Conditions—Exception.
(1) For purposes of this section:
(a) "Health carrier" includes disability insurers regulated under chapter 48.20 or 48.21 RCW, health care services contractors regulated under chapter 48.44 RCW, plans operating under the health care authority under chapter 41.05 RCW, the basic health plan operating under chapter 70.47 RCW, the state health insurance pool operating under chapter 48.41 RCW, insuring entities regulated under this chapter, and health maintenance organizations regulated under chapter 48.46 RCW.
(b) "Intermediary" means a person duly authorized to negotiate and execute provider contracts with health carriers on behalf of mental health care practitioners.
(c) Consistent with their lawful scopes of practice, "mental health care practitioners" includes only the following: Any generally recognized medical specialty of practitioners licensed under chapter 18.57 or 18.71 RCW who provide mental health services, advanced practice psychiatric nurses as authorized by the *nursing care quality assurance commission under chapter 18.79 RCW, psychologists licensed under chapter 18.83 RCW, and mental health counselors, marriage and family therapists, and social workers licensed under chapter 18.225 RCW.
(d) "Mental health services" means outpatient services.
(2) Consistent with federal and state law and rule, no contract between a mental health care practitioner and an intermediary or between a mental health care practitioner and a health carrier that is written, amended, or renewed after June 6, 1996, may contain a provision prohibiting a practitioner and an enrollee from agreeing to contract for services solely at the expense of the enrollee as follows:
(a) On the exhaustion of the enrollee's mental health care coverage;
(b) During an appeal or an adverse certification process;
(c) When an enrollee's condition is excluded from coverage; or
(d) For any other clinically appropriate reason at any time.
(3) If a mental health care practitioner provides services to an enrollee during an appeal or adverse certification process, the practitioner must provide to the enrollee written notification that the enrollee is responsible for payment of these services, unless the health carrier elects to pay for services provided.
(4) This section does not apply to a mental health care practitioner who is employed full time on the staff of a health carrier.
[ 2001 c 251 § 33; 1996 c 304 § 1.]
NOTES:
*Reviser's note: The reference to "nursing care quality assurance commission" was changed to "board of nursing" by 2023 c 123.
Severability—2001 c 251: See RCW 18.225.900.
2023 Revised Code of Washington › Title 48 - Insurance › Chapter 48.43 - Insurance Reform. › 48.43.091 - Health carrier coverage of outpatient mental health services—Requirements.

RCW 48.43.091
Health carrier coverage of outpatient mental health services—Requirements.
Every health carrier that provides coverage for any outpatient mental health service shall comply with the following requirements:
(1) In performing a utilization review of mental health services for a specific enrollee, the utilization review is limited to accessing only the specific health care information contained in the enrollee's record.
(2) In performing an audit of a provider that has furnished mental health services to a carrier's enrollees, the audit is limited to accessing only the records of enrollees covered by the specific health carrier for which the audit is being performed, except as otherwise permitted by RCW 70.02.050 and * 71.05.630.
[ 1999 c 87 § 1.]
NOTES:
*Reviser's note: RCW 71.05.630 was repealed by 2013 c 200 § 34, effective July 1, 2014.
2023 Revised Code of Washington › Title 48 - Insurance › Chapter 48.43 - Insurance Reform. › 48.43.093 - Health carrier coverage of emergency medical services—Requirements—Conditions.

RCW 48.43.093
Health carrier coverage of emergency medical services—Requirements—Conditions.
(1)(a) A health carrier shall cover emergency services provided to a covered person if a prudent layperson acting reasonably would have believed that an emergency medical condition existed. In addition, a health carrier shall not require prior authorization of emergency services if a prudent layperson acting reasonably would have believed that an emergency medical condition existed. With respect to care obtained from a nonparticipating hospital emergency department or behavioral health emergency services provider, a health carrier shall cover emergency services. In addition, a health carrier shall not require prior authorization of emergency services.
(b) A health carrier shall cover emergency services without limiting what constitutes an emergency medical condition solely on the basis of diagnosis codes. Any determination of whether the prudent layperson standard has been met must be based on all pertinent documentation and be focused on the presenting symptoms and not solely on the final diagnosis.
(2) Coverage of emergency services may be subject to applicable in-network copayments, coinsurance, and deductibles, as provided in chapter 48.49 RCW.
(3) Nothing in this section is to be construed as prohibiting a health carrier from:
(a) Requiring notification of stabilization or inpatient admission within the time frame specified in its contract with the hospital or behavioral health emergency services provider or as soon thereafter as medically possible but no less than twenty-four hours; or
(b) Requiring a hospital or emergency behavioral health emergency services provider to make a documented good faith effort to notify the covered person's health carrier within 48 hours of stabilization, or by the end of the business day following the day the stabilization occurs, whichever is later, if the covered person needs to be stabilized. If a health carrier requires such notification, the health carrier shall provide access to an authorized representative seven days a week to receive notifications.
(4) Except to the extent provided otherwise in this section, follow-up care that is a direct result of the emergency must be obtained in accordance with the health plan's usual terms and conditions of coverage. All other terms and conditions of coverage may be applied to emergency services.
[ 2022 c 263 § 3; 2019 c 427 § 3; 1997 c 231 § 301.]
NOTES:
Effective date—2022 c 263: See note following RCW 43.371.100.
Findings—Intent—Effective date—2019 c 427: See RCW 48.49.003 and 48.49.900.
Short title—Part headings and captions not law—Severability—Effective dates—1997 c 231: See notes following RCW 48.43.005.
2023 Revised Code of Washington › Title 48 - Insurance › Chapter 48.43 - Insurance Reform. › 48.43.096 - Medication synchronization policy required for health plans covering prescription drugs—Requirements—Definitions.

RCW 48.43.096
Medication synchronization policy required for health plans covering prescription drugs—Requirements—Definitions.
(1) A health benefit plan issued or renewed after December 31, 2015, that provides coverage for prescription drugs must implement a medication synchronization policy for the dispensing of prescription drugs to the plan's enrollees.
(a) If an enrollee requests medication synchronization for a new prescription, the health plan must permit filling the drug: (i) For less than a one-month supply of the drug if synchronization will require more than a fifteen-day supply of the drug; or (ii) for more than a one-month supply of the drug if synchronization will require a fifteen-day supply of the drug or less.
(b) The health benefit plan shall adjust the enrollee cost-sharing for a prescription drug subject to coinsurance that is dispensed for less than the standard refill amount for the purpose of synchronizing the medications.
(c) The health benefit plan shall adjust the enrollee cost-sharing for a prescription drug with a copayment that is dispensed for less than the standard refill amount for the purpose of synchronizing the medications by:
(i) Discounting the copayment rate by fifty percent;
(ii) Discounting the copayment rate based on fifteen-day increments; or
(iii) Any other method that meets the intent of this section and is approved by the office of the insurance commissioner.
(2) Upon request of an enrollee, the prescribing provider or pharmacist shall:
(a) Determine that filling or refilling the prescription is in the best interest of the enrollee, taking into account the appropriateness of synchronization for the drug being dispensed;
(b) Inform the enrollee that the prescription will be filled to less than the standard refill amount for the purpose of synchronizing his or her medications; and
(c) Deny synchronization on the grounds of threat to patient safety or suspected fraud or abuse.
(3) For purposes of this section, the following terms have the following meanings unless the context clearly requires otherwise:
(a) "Medication synchronization" means the coordination of medication refills for a patient taking two or more medications for a chronic condition such that the patient's medications are refilled on the same schedule for a given time period.
(b) "Prescription" has the same meaning as in RCW 18.64.011.
[ 2015 c 213 § 1.]
2023 Revised Code of Washington › Title 48 - Insurance › Chapter 48.43 - Insurance Reform. › 48.43.0961 - Continuity of coverage for health plans covering prescription drugs for behavioral health.

RCW 48.43.0961
Continuity of coverage for health plans covering prescription drugs for behavioral health.
(1) Except as provided in subsection (2) of this section, for health plans that include prescription drug coverage issued or renewed on or after January 1, 2025, a health carrier or its health care benefit manager may not require the substitution of a nonpreferred drug with a preferred drug in a given therapeutic class, or increase an enrollee's cost-sharing obligation mid-plan year for the drug, if the prescription is for a refill of an antipsychotic, antidepressant, antiepileptic, or other drug prescribed to the enrollee to treat a serious mental illness, the enrollee is medically stable on the drug, and a participating provider continues to prescribe the drug.
(2) Nothing in this section prohibits:
(a) The carrier from requiring generic substitution during the current plan year;
(b) The carrier from adding new drugs to its formulary during the current plan year;
(c) The carrier from removing a drug from its formulary for reasons of patient safety concerns, drug recall or removal from the market, or medical evidence indicating no therapeutic effect of the drug; or
(d) A participating provider from prescribing a different drug that is covered by the plan and medically appropriate for the enrollee.
(3) For the purposes of this section:
(a) "Refill" means a second or subsequent filling of a previously issued prescription.
(b) "Serious mental illness" means a mental disorder, as defined in the most recent edition of the diagnostic and statistical manual of mental disorders published by the American psychiatric association, that results in serious functional impairment that substantially interferes with or limits one or more major life activities.
[ 2023 c 325 § 1.]
2023 Revised Code of Washington › Title 48 - Insurance › Chapter 48.43 - Insurance Reform. › 48.43.097 - Filing of financial statements—Every health carrier.

RCW 48.43.097
Filing of financial statements—Every health carrier.
Every health carrier holding a registration from the commissioner shall file its financial statements as required by this code and by the commissioner in accordance with the accounting practices and procedures manuals as adopted by the national association of insurance commissioners, unless otherwise provided by law.
[ 1999 c 33 § 3.]
2023 Revised Code of Washington › Title 48 - Insurance › Chapter 48.43 - Insurance Reform. › 48.43.105 - Preparation of documents that compare health carriers—Immunity—Due diligence.

RCW 48.43.105
Preparation of documents that compare health carriers—Immunity—Due diligence.
(1) A public or private entity who exercises due diligence in preparing a document of any kind that compares health carriers of any kind is immune from civil liability from claims based on the document and the contents of the document.
(2)(a) There is absolute immunity to civil liability from claims based on such a comparison document and its contents if the information was provided by the carrier, was substantially accurately presented, and contained the effective date of the information that the carrier supplied, if any.
(b) Where due diligence efforts to obtain accurate information have been taken, there is immunity from claims based on such a comparison document and its contents if the publisher of the comparison document asked for such information from the carrier, was refused, and relied on any usually reliable source for the information including, but not limited to, carrier enrollees, customers, insurance producers, or providers. The carrier enrollees, customers, insurance producers, or providers are likewise immune from civil liability on claims based on information they provided if they believed the information to be accurate and had exercised due diligence in their efforts to confirm the accuracy of the information provided.
(3) The immunity from liability contained in this section applies only if the comparison document contains the following in a conspicuous place and in easy to read typeface:
This comparison is based on information believed to be reliable by its publisher, but the accuracy of the information cannot be guaranteed. Caution is suggested to all readers who are encouraged to confirm data of importance to the reader before any purchasing or other decisions are made.
(4) The insurance commissioner is prohibited from adopting rules regarding this section.
[ 2008 c 217 § 48; 1996 c 312 § 5.]
NOTES:
Severability—Effective date—2008 c 217: See notes following RCW 48.03.020.
2023 Revised Code of Washington › Title 48 - Insurance › Chapter 48.43 - Insurance Reform. › 48.43.125 - Coverage at a long-term care facility following hospitalization—Definition.

RCW 48.43.125
Coverage at a long-term care facility following hospitalization—Definition.
(1) A carrier that provides coverage for a person at a long-term care facility following the person's hospitalization shall, upon the request of the person or his or her legal representative as authorized in RCW 7.70.065, provide such coverage at the facility in which the person resided immediately prior to the hospitalization if:
(a) The person's primary care physician determines that the medical care needs of the person can be met at the requested facility;
(b) The requested facility has all applicable licenses and certifications, and is not under a stop placement order that prevents the person's readmission;
(c) The requested facility agrees to accept payment from the carrier for covered services at the rate paid to similar facilities that otherwise contract with the carrier to provide such services; and
(d) The requested facility, with regard to the following, agrees to abide by the standards, terms, and conditions required by the carrier of similar facilities with which the carrier otherwise contracts: (i) Utilization review, quality assurance, and peer review; and (ii) management and administrative procedures, including data and financial reporting that may be required by the carrier.
(2) For purposes of this section, "long-term care facility" or "facility" means a nursing facility licensed under chapter 18.51 RCW, continuing care retirement community defined under RCW 70.38.025, or assisted living facility licensed under chapter 18.20 RCW.
[ 2012 c 10 § 43; 1999 c 312 § 2.]
NOTES:
Application—2012 c 10: See note following RCW 18.20.010.
Findings—1999 c 312: "The legislature finds that a long-term care facility is home for any individual who resides there, and the individual has the right to receive services in his or her own home and to be cared for by the organization with which he or she has a contractual agreement to provide housing and related services. The legislature further finds that restricting individuals from returning to the long-term care facility in which they were residing prior to hospitalization may detrimentally impact the health and well-being of frail individuals and their families." [ 1999 c 312 § 1.]
Short title—1999 c 312: "This act may be known and cited as the Kitson act." [ 1999 c 312 § 3.]
2023 Revised Code of Washington › Title 48 - Insurance › Chapter 48.43 - Insurance Reform. › 48.43.135 - Hearing instruments—Coverage.

RCW 48.43.135
Hearing instruments—Coverage.
(1) For nongrandfathered group health plans other than small group health plans issued or renewed on or after January 1, 2024, a health carrier shall include coverage for hearing instruments, including bone conduction hearing devices. This section does not include coverage of over-the-counter hearing instruments.
(2) Coverage shall also include the initial assessment, fitting, adjustment, auditory training, and ear molds as necessary to maintain optimal fit. Coverage of the services in this subsection shall include services for enrollees who intend to obtain or have already obtained any hearing instrument, including an over-the-counter hearing instrument.
(3) A health carrier shall provide coverage for hearing instruments as provided in subsection (1) of this section at no less than $3,000 per ear with hearing loss every 36 months.
(4) The services and hearing instruments covered under this section are not subject to the enrollee's deductible unless the health plan is offered as a qualifying health plan for a health savings account. For such a qualifying health plan, the carrier may apply a deductible to coverage of the services covered under this section only at the minimum level necessary to preserve the enrollee's ability to claim tax exempt contributions and withdrawals from the enrollee's health savings account under internal revenue service laws and regulations.
(5) Coverage for a minor under 18 years of age shall be available under this section only after the minor has received medical clearance within the preceding six months from:
(a) An otolaryngologist for an initial evaluation of hearing loss; or
(b) A licensed physician, which indicates there has not been a substantial change in clinical status since the initial evaluation by an otolaryngologist.
(6) For the purposes of this section:
(a) "Hearing instrument" has the same meaning as defined in RCW 18.35.010.
(b) "Over-the-counter hearing instrument" has the same meaning as "over-the-counter hearing aid" in 21 C.F.R. Sec. 800.30 as of December 28, 2022.
[ 2023 c 245 § 1.]
2023 Revised Code of Washington › Title 48 - Insurance › Chapter 48.43 - Insurance Reform. › 48.43.176 - Eosinophilic gastrointestinal associated disorder—Elemental formula.

RCW 48.43.176
Eosinophilic gastrointestinal associated disorder—Elemental formula.
(1) Each health benefit plan issued or renewed after December 31, 2015, must offer benefits or coverage for medically necessary elemental formula, regardless of delivery method, when a licensed physician or other health care provider with prescriptive authority:
(a) Diagnoses a patient with an eosinophilic gastrointestinal associated disorder; and
(b) Orders and supervises the use of the elemental formula.
(2) Nothing in this section prohibits a health benefit plan from requiring prior authorization or imposing other appropriate utilization controls in approving coverage for medically necessary elemental formula.
[ 2014 c 115 § 2.]
2023 Revised Code of Washington › Title 48 - Insurance › Chapter 48.43 - Insurance Reform. › 48.43.180 - Denturist services.

RCW 48.43.180
Denturist services.
Notwithstanding any provision of any certified health plan covering dental care as provided for in this chapter, effective January 1, 1995, benefits shall not be denied thereunder for any service performed by a denturist licensed under chapter 18.30 RCW if (1) the service performed was within the lawful scope of such person's license, and (2) such plan would have provided benefits if such service had been performed by a dentist licensed under chapter 18.32 RCW.
[ 1995 c 1 § 23 (Initiative Measure No. 607, approved November 8, 1994).]
NOTES:
Short title—1995 c 1 (Initiative Measure No. 607): See RCW 18.30.900.
2023 Revised Code of Washington › Title 48 - Insurance › Chapter 48.43 - Insurance Reform. › 48.43.185 - General anesthesia services for dental procedures.

RCW 48.43.185
General anesthesia services for dental procedures.
(1) Each group health benefit plan that provides coverage for hospital, medical, or ambulatory surgery center services must cover general anesthesia services and related facility charges in conjunction with any dental procedure performed in a hospital or ambulatory surgical center if such anesthesia services and related facility charges are medically necessary because the covered person:
(a) Is under the age of seven, or physically or developmentally disabled, with a dental condition that cannot be safely and effectively treated in a dental office; or
(b) Has a medical condition that the person's physician determines would place the person at undue risk if the dental procedure were performed in a dental office. The procedure must be approved by the person's physician.
(2) Each group health benefit plan or group dental plan that provides coverage for dental services must cover medically necessary general anesthesia services in conjunction with any covered dental procedure performed in a dental office if the general anesthesia services are medically necessary because the covered person is under the age of seven or physically or developmentally disabled.
(3) This section does not prohibit a group health benefit plan or group dental plan from:
(a) Applying cost-sharing requirements, maximum annual benefit limitations, and prior authorization requirements to the services required under this section; or
(b) Covering only those services performed by a health care provider, or in a health care facility, that is part of its provider network; nor does it limit the health carrier in negotiating rates and contracts with specific providers.
(4) This section does not apply to medicare supplement policies, or supplemental contracts covering a specified disease or other limited benefits.
(5) For the purpose of this section, "general anesthesia services" means services to induce a state of unconsciousness accompanied by a loss of protective reflexes, including the ability to maintain an airway independently and respond purposefully to physical stimulation or verbal command.
(6) This section applies to group health benefit plans and group dental plans issued or renewed on or after January 1, 2002.
[ 2001 c 321 § 2.]
2023 Revised Code of Washington › Title 48 - Insurance › Chapter 48.43 - Insurance Reform. › 48.43.190 - Payment of chiropractic services—Parity.

RCW 48.43.190
Payment of chiropractic services—Parity.
(1)(a) A health carrier may not pay a chiropractor less for a service or procedure identified under a particular physical medicine and rehabilitation code, evaluation and management code, or spinal manipulation code, as listed in a nationally recognized services and procedures code book such as the American medical association current procedural terminology code book, than it pays any other type of provider licensed under Title 18 RCW for a service or procedure under the same or substantially similar code, except as provided in (b) of this subsection. A carrier may not circumvent this requirement by creating a chiropractor-specific code not listed in the nationally recognized code book otherwise used by the carrier for provider payment.
(b) This section does not affect a health carrier's:
(i) Implementation of a health care quality improvement program to promote cost-effective and clinically efficacious health care services, including but not limited to pay-for-performance payment methodologies and other programs fairly applied to all health care providers licensed under Title 18 RCW that are designed to promote evidence-based and research-based practices;
(ii) Health care provider contracting to comply with the network adequacy standards;
(iii) Authority to pay in-network providers differently than out-of-network providers; and
(iv) Authority to pay a chiropractor less than another provider for procedures or services under the same or a substantially similar code based upon differences in the cost of maintaining a practice or carrying malpractice insurance, as recognized by a nationally accepted reimbursement methodology.
(c) This section does not, and may not be construed to:
(i) Require the payment of provider billings that do not meet the definition of a clean claim as set forth in rules adopted by the commissioner;
(ii) Require any health plan to include coverage of any condition; or
(iii) Expand the scope of practice for any health care provider.
(2) This section applies only to payments made on or after January 1, 2009.
[ 2018 c 181 § 1; 2008 c 304 § 1.]
NOTES:
Rules—2018 c 181 § 1: "The office of the insurance commissioner may adopt any rules necessary to implement section 1 of this act." [ 2018 c 181 § 2.]
Effective date—2018 c 181 § 1: "Section 1 of this act takes effect January 1, 2019." [ 2018 c 181 § 3.]
2023 Revised Code of Washington › Title 48 - Insurance › Chapter 48.43 - Insurance Reform. › 48.43.195 - Contraceptive drugs—Twelve-month refill coverage.

RCW 48.43.195
Contraceptive drugs—Twelve-month refill coverage.
(1) A health benefit plan issued or renewed on or after January 1, 2018, that includes coverage for contraceptive drugs must provide reimbursement for a twelve-month refill of contraceptive drugs obtained at one time by the enrollee, unless the enrollee requests a smaller supply or the prescribing provider instructs that the enrollee must receive a smaller supply. The health plan must allow enrollees to receive the contraceptive drugs on-site at the provider's office, if available. Any dispensing practices required by the plan must follow clinical guidelines for appropriate prescribing and dispensing to ensure the health of the patient while maximizing access to effective contraceptive drugs.
(2) Nothing in this section prohibits a health plan from limiting refills that may be obtained in the last quarter of the plan year if a twelve-month supply of the contraceptive drug has already been dispensed during the plan year.
(3) For purposes of this section, "contraceptive drugs" means all drugs approved by the United States food and drug administration that are used to prevent pregnancy, including, but not limited to, hormonal drugs administered orally, transdermally, and intravaginally.
[ 2017 c 293 § 2.]
NOTES:
Finding—Intent—2017 c 293: "The legislature finds that a significant percentage of pregnancies are unintended and could be averted with broader access to health care and effective contraception. Research suggests that moving from twenty-eight day dispensing of contraceptive drugs to twelve-month dispensing improves adherence to maintenance of the drugs and effective use of the contraceptives. It is therefore the intent of the legislature to require private health insurers to require dispensing of contraceptive drugs with up to a twelve-month supply provided at one time." [ 2017 c 293 § 1.]