Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-44 - Health care services contractors-Agents-Contract formats-Standards › Section 284-44-045 - Benefits for registered nurses' services

Current through Register Vol. 24-14, July 15, 2024
(1) Every health care service contractor
			 agreement which is entered into initially or renewed after the effective date
			 of this rule, and which provides benefits for any health care service to be
			 performed by doctors of medicine, and every certificate issued thereunder,
			 shall contain the following provision, or a provision which is the substantial
			 equivalent of it:
"Benefits under this contract will not be denied for any health
				care service performed by a registered nurse licensed to practice under chapter
				18.88 RCW, if first, the service performed was within the lawful scope of such
				nurse's license, and second, this contract would have provided benefits if such
				service had been performed by a doctor of medicine licensed to practice under
				chapter
				18.71 RCW."
(2) The provisions of subsection
			 (1) shall apply to all health care service agreements, whether they expressly
			 provide for indemnification benefits for services rendered by health care
			 providers who are not "participants" as defined in
			 RCW
			  48.44.010(4), or whether
			 they provide only for benefits in the form of services rendered by health care
			 providers who are "participants" for the purpose of such contracts.
(3) To comply with
			 RCW
			  48.44.290, benefits must not be denied to a
			 person covered by a health care service agreement by reason of his choice to
			 obtain health care services from a registered nurse. A unilaterally imposed
			 contract provision which requires or permits an artificial reduction in the
			 level of an indemnification benefit based on such a choice to obtain health
			 care services from a registered nurse will be held to violate
			 RCW
			  48.44.290, and will be the basis for
			 disapproval of such agreement pursuant to
			 RCW
			  48.44.020(2)(f). An example
			 of such an impermissible provision would be one which unilaterally sets the
			 level of reimbursement for nurse-provided service at a fixed, less-than-100%
			 percentage of the benefit which would be paid for participant-doctor-provided
			 services, if any, or other doctor-provided services, if the contractor has no
			 participant doctors. An example of a permissible provision would be one which
			 was based on some percentage of the usual, customary, and reasonable (UCR) fee
			 charged by the particular provider of health care service, and which applied
			 the same percentage to the UCR fees of medical doctors and registered nurses
			 alike. The latter provision would be permissible even if it resulted in lower
			 actual dollar amounts for benefits for nurse-provided services than for
			 doctor-provided services, since the difference would result from the disparity
			 of fees actually charged by medical doctors and registered nurses rather than
			 from an arbitrary formula based on assumptions concerning the relative worth of
			 doctor-provided services versus nurse-provided services. A contract provision
			 is not unilaterally imposed and is permissible, if it sets the benefit level in
			 accord with an agreement between the health care service contractor and the
			 particular registered nurse for whose services the benefits are
			 provided.
(4) To comply with
			 RCW
			  48.44.290, no health care service contractor
			 agreement may contain a provision which places restrictions or limitations on
			 benefits for nurse-provided health care services which are not also placed on
			 benefits for doctor-provided health care services. An example of an
			 impermissible provision would be one which limited the number of office calls
			 made to a registered nurse to a number less than the limit for office calls
			 made to a medical doctor. A contract provision which places such a limitation
			 or restriction on benefits for nurse-provided health care services will be held
			 to violate
			 RCW
			  48.44.290, and will be the basis for
			 disapproval of such agreement pursuant to
			 RCW
			  48.44.020(2)(f).
Statutory Authority:
				  RCW
				  48.44.050. 82-02-004 (Order R 81-8), §
										284-44-045, filed
				  12/28/81.