reglab/statecodes huggingface dataset:
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter L - REPRODUCTIVE HEALTH CARE AND CONTRACEPTION › Section 284-43-7220 - Coverage required

Current through Register Vol. 24-14, July 15, 2024
A health plan must provide coverage for all services and
				  supplies required under
				  RCW
				   48.43.072 and
				  48.43.073. A student health plan
				  must also provide coverage for all services and supplies required under
				  RCW
				   48.43.072 and
				  48.43.073.
(1) Required coverage of contraceptive
				services and supplies includes, but is not limited to:
(a) All prescription and over-the-counter
				contraceptive drugs, devices, and other products approved by the Federal Food
				and Drug Administration;
(b)
				Voluntary sterilization procedures; and
(c) The consultations, examinations,
				procedures, and medical services that are necessary to prescribe, dispense,
				insert, deliver, distribute, administer, or remove the drugs, devices, and
				other products or services in (a) and (b) of this subsection.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter L - REPRODUCTIVE HEALTH CARE AND CONTRACEPTION › Section 284-43-7230 - Services provided without discrimination, prohibited limitations, and confidentiality

Current through Register Vol. 24-14, July 15, 2024
(1) All
				services and supplies required under
				RCW
				 48.43.072 must be covered without
				discrimination on the basis of race, color, national origin, sex, sexual
				orientation, gender expression or identity, marital status, age, citizenship,
				immigration status, or disability. Health plans and student health plans must
				ensure that all enrollees have access to these services and supplies regardless
				of gender or gender identity. This includes, but is not limited to, coverage of
				any method of over-the-counter contraception without regard to the sex, or
				gender identity or expression, of the covered person.
(2) Reproductive health care, voluntary
				sterilization, abortion or contraceptive services or contraceptive supplies
				provided under a health plan or a student health plan are health care services
				related to reproductive health and protected by the confidentiality
				requirements of
				RCW
				 48.43.505, WAC
				284-04-510,
				and other relevant statutes and regulations providing for enrollee
				confidentiality.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter L - REPRODUCTIVE HEALTH CARE AND CONTRACEPTION › Section 284-43-7240 - Access to contraceptive services and supplies

Current through Register Vol. 24-14, July 15, 2024
(1) Health plans and student health plans
				must provide covered persons access to sufficient numbers and types of
				providers and facilities to assure that covered persons are able to access all
				covered contraceptive services and all Federal Food and Drug Administration
				approved contraceptive supplies without unreasonable delay or burden.
(2) If a health plan or student health plan
				limits coverage of contraceptive services and supplies to in-network providers,
				the carrier must demonstrate that its network for these services and supplies
				meets the access and adequacy standards set forth in chapter 284-170
				WAC.
(3) In any case where the
				health plan's network or student health plan's network has an absence of or an
				insufficient number or type of participating providers or facilities to provide
				a particular covered contraceptive service or supply, including
				over-the-counter contraceptives, in a timely manner appropriate for the
				enrollee's condition, the carrier must ensure that the covered person obtains
				the covered service or supply from a provider or facility within reasonable
				proximity of the enrollee at no greater cost to the enrollee than if the
				service or supply were obtained from network providers and facilities. The
				carrier must satisfy this obligation even if an alternate access delivery
				request under WAC
				284-170-210
				has been submitted and is pending approval by the insurance commissioner.
(4) If a health plan or student
				health plan limits the quantity of covered contraceptive supplies or services,
				the carrier must have a written process for covered persons to request coverage
				of additional services or supplies. The process may not impose any restriction
				or delay on the coverage of contraceptive supplies in violation of
				RCW
				 48.43.072,
				48.43.195,
				or any other state or federal law.
(5) Effective January 1, 2021, contraceptive
				supplies must also be covered when used exclusively for the prevention of
				sexually transmitted infections.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter L - REPRODUCTIVE HEALTH CARE AND CONTRACEPTION › Section 284-43-7250 - Filing requirements

Current through Register Vol. 24-14, July 15, 2024
(1) For
				health plans and student health plans subject to
				RCW
				 48.43.072 and
				48.43.073,
				the carrier must ensure that the health plan and student health plan forms
				clearly inform covered persons of their rights to access contraceptive services
				and supplies, voluntary sterilization and abortion. The health plan and student
				health plan forms must clearly inform covered persons how they access these
				services and supplies.
(2) A health
				plan's forms and student health plan's forms must include a detailed
				description of the plan's benefits provided to covered persons that
				specifically instructs covered persons where and how they access coverage of
				contraceptive supplies, including over-the-counter supplies. This information
				must include:
(a) Whether covered supplies are
				available from in-net-work and out-of-network providers; and
(b) How to submit a claim including, at a
				minimum:
(i) Whether covered persons may
				purchase covered supplies and seek reimbursement from the carrier;
(ii) How to access and submit any necessary
				claim forms; and
(iii) Where to
				send a claim, such as a mailing address or instructions for submitting a claim
				electronically.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter L - REPRODUCTIVE HEALTH CARE AND CONTRACEPTION › Section 284-43-7270 - Access to prenatal vitamins and breast pumps

Current through Register Vol. 24-14, July 15, 2024
Effective January 1, 2021, health plans and student plans are
				  required under
				  RCW
				   48.43.072 to cover prenatal vitamins for
				  covered persons expecting the birth of a child and breast pumps for covered
				  persons expecting the birth or adoption of a child.
(1) Pursuant to
				RCW
				 48.43.072, prenatal vitamins and breast pumps
				can be subject to copayment, deductibles and other forms of cost sharing,
				except:
(a) In accordance with the Affordable
				Care Act and the
Women's Preventative Services Guidelines
,
				folic acid is currently required to be covered as a preventative service
				without copayment, deductibles, or other forms of cost-sharing for covered
				persons. This requirement does not apply to grandfathered plans.
(b) In accordance with the Affordable Care
				Act and the
Women's Preventative Services Guidelines
, breast
				pumps are currently required to be covered as a preventative service without
				copayments, deductibles, or other forms of cost-sharing for covered persons.
				This requirement does not apply to grandfathered plans.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter M - SHORT-TERM LIMITED DURATION MEDICAL PLANS › Section 284-43-8000 - Definition of short-term limited duration medical plan

Current through Register Vol. 24-14, July 15, 2024
(1) "Short-term limited duration medical
				plan" means a policy, contract or agreement offered or issued by a health
				carrier with an effective date on or after January 1, 2019, that:
(a) Provides comprehensive major medical
				coverage, that includes, at a minimum, the following benefits:
(i) Hospital, surgical and medical expense
				coverage, to an aggregate maximum of not less than one million dollars and
				copayment or coinsurance by the covered person not to exceed fifty percent of
				covered charges;
(ii) The coverage
				for hospital services must include:
(A)
				Inpatient services and other miscellaneous services associated with admission
				to a hospital for diagnosis and treatment of a covered condition.
				"Miscellaneous services" includes medically necessary services delivered in a
				hospital setting, including professional services, anesthesia, facility fees,
				supplies, imaging, laboratory, pharmacy services and prescription drugs,
				treatments, therapy, or other services delivered on an inpatient
				basis;
(B) Outpatient services,
				including medically necessary services ordered by the member's attending health
				care practitioner and rendered on an ambulatory basis for diagnosis and
				treatment of a covered condition, including office and clinic visits,
				diagnostic imaging, laboratory services, radiation therapy,
				physical/speech/occupational therapy, and hemodialysis; and
(C) An extension of the medical plan term
				while hospitalized. If a member is hospitalized as an inpatient on the
				expiration date of the medical plan, the member's coverage under the medical
				plan will continue for purposes of that covered medical condition without
				payment of additional premium. The coverage will continue until the date the
				member is discharged from the hospital or until the date on which the
				applicable benefit maximums are reached, whichever occurs first.
(iii) The coverage for surgical
				services for diagnosis and treatment of a covered condition must include
				inpatient and outpatient surgical services at a hospital, ambulatory surgical
				facility, surgical suite or provider's office. "Surgical services" includes
				medically necessary services delivered in a hospital, ambulatory surgical
				facility, surgical suite or provider's office related to provision of a
				surgical service, including professional services, anesthesiology, facility
				fees, supplies, laboratory, pharmacy services and prescription drugs related
				to, or required as a result of, the surgical procedure; and
(iv) The coverage for medical services for
				diagnosis and treatment of a covered condition must include office
				visits.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter M - SHORT-TERM LIMITED DURATION MEDICAL PLANS › Section 284-43-8020 - Commissioner's approval required

Current through Register Vol. 24-14, July 15, 2024
(1) A
				short-term limited duration medical plan form, application form, or disclosure
				form must not be issued, delivered, or used unless it has been filed with and
				approved in writing by the commissioner.
(2) Rates, or modification of rates, for
				short-term limited duration medical plans must not be used until filed with and
				approved in writing by the commissioner.
(3) The commissioner may disapprove any forms
				or rates if the benefit provided therein is unreasonable in relation to the
				premium charged. The commissioner's order disapproving any form or rate shall
				state the grounds therefor.
(4) A
				form or rate must not knowingly be issued, delivered, or used if the
				commissioner's approval does not then exist.
(5) The commissioner may withdraw any
				approval at any time for cause. The commissioner's withdrawal of a previous
				approval shall state the grounds therefor.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter M - SHORT-TERM LIMITED DURATION MEDICAL PLANS › Section 284-43-8030 - Short-term limited duration medical plan cancellation and rescission

Current through Register Vol. 24-14, July 15, 2024
(1) As used in this
				section:
(a) "Rescission" or "rescind" means
				the undoing or retroactive cancellation of a short-term limited duration
				medical plan. Rescission returns the carrier and member to the same positions
				as if the medical plan had never existed.
(b) "Cancellation" or "cancel" means
				termination of a short-term limited duration medical plan before the end of the
				coverage period under the plan.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter M - SHORT-TERM LIMITED DURATION MEDICAL PLANS › Section 284-43-8100 - Definitions

Current through Register Vol. 24-14, July 15, 2024
(1) "Department"
				means the United States (U.S.) Department of Labor.
(2) "Employer member" means an employer that
				participates in the health plan.
(3) "Pathway 1 Association Health Plan" means
				a bona fide group or association of employers to whom a health plan is issued
				that constitutes an employer under section 3(5) of the Employee Retirement
				Income Security Act of 1974 (ERISA) (29 U.S.C. Sec. 1002(5)), and U.S.
				Department of Labor guidance related to Pathway 1 Association Health
				Plans.
(4) "Member-governed group"
				means a group consisting of multiple employers, organized as an entity other
				than an association, that constitutes an employer under section 3(5) of the
				Employee Retirement Income Security Act of 1974 (ERISA) (29 U.S.C. Sec. 1002(5)), and U.S. Department of Labor guidance.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter M - SHORT-TERM LIMITED DURATION MEDICAL PLANS › Section 284-43-8120 - Requirements for governmental plans

Current through Register Vol. 24-14, July 15, 2024
(1) Carriers must file a group health plan,
				other than a small group health plan, rate and form filing as provided in
				RCW
				 48.43.733.
(2) Carriers issuing a governmental plan
				under section 3 (32) of the Employee Retirement Income Security Act of 1974
				(ERISA) (29 U.S.C. Sec. 1002(32)) must submit with their form filing either an
				opinion letter from the Department demonstrating that the plan is a
				governmental plan under section 3(32), or an opinion from an attorney attesting
				to the fact that the entity establishing or maintaining the plan is a
				governmental entity as provided in section 3(32), citing the applicable law
				authorizing establishment of the entity.
(3) An attorney attestation submitted in
				compliance with subsection (2) of this section is not required to comply with
				WAC 284-43-8110(1)(e)(ii) regarding the contents of the attorney attestation,
				and needs only identify the legal and statutory authority for establishment of
				the entity.
(4) This section
				applies to plans issued or renewed on or after January 1, 2020.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter M - SHORT-TERM LIMITED DURATION MEDICAL PLANS › Section 284-43-8140 - Transition of plans purchased by association members

Current through Register Vol. 24-14, July 15, 2024
(1) An issuer must not offer or issue a
				health plan to small groups through an association or member-governed group as
				a large group plan unless the collective number of eligible employees of all
				member employers is more than fifty, and the member-governed group or
				association health plan meets the requirements of WAC 284-43-8110 for a Pathway
				1 Association Health Plan, or WAC 284-43-8120 for a governmental plan.
(2) For plans offered to
				association or member-governed groups that do not meet the requirements of
				subsection (1) of this section, the following specific requirements apply:
(a) An issuer must treat grandfathered plans
				issued under those purchasing arrangements as a closed pool, and file a single
				case closed pool rate filing. For purposes of this section, a single case
				closed pool rate filing means a rate filing which includes the rates and the
				rate filing information only for the issuer's closed pool enrollees.
(b) For each single case closed pool rate
				filing, an issuer must file a certification from an officer of the issuer
				attesting that:
(i) The employer members
				covered by the filing joined the association prior to or on March 23,
				2010;
(ii) The issuer can establish
				with documentation in its files that none of the conditions triggering
				termination of grandfathered status set forth in WAC
				284-43-0250
				or in  45 C.F.R. 2590.715-1251(g)  have occurred for any plan members.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter N - HEALTH CARE SHARING MINISTRIES › Section 284-43-8210 - Definitions

Current through Register Vol. 24-14, July 15, 2024
For the purposes of this subchapter:
(1) "Annual audit" means an audit occurring once a year at approximately the same time each year for the preceding calendar or fiscal year.
(2) "Continuously" means without a break or interruption.
(3) "Generally accepted accounting principles" means the compulsory accrual method of accounting for a public company.
(4) "Health care sharing ministry" means an organization:
(a) That is described in Section  501 (c)(3) of the Internal Revenue Code and is exempt from taxation under Section  501(a) of the Internal Revenue Code;
(b) That has members who share a common set of ethical or religious beliefs and share medical expenses among members in accordance with those beliefs and without regard to the state in which a member resides or is employed;
(c) Whose members retain membership in the health care sharing ministry even after the member develops a medical condition;
(d) Which, or a predecessor of which, has been in existence at all times since December 31, 1999, and medical expenses of its members have been shared continuously and without interruption since at least December 31, 1999; and
(e) That conducts an annual audit, which is performed by an independent certified public accounting firm in accordance with generally accepted accounting principles and which is made available to the public upon request.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter N - HEALTH CARE SHARING MINISTRIES › Section 284-43-8220 - Prompt reply to the commissioner required

Current through Register Vol. 24-14, July 15, 2024
Any entity claiming to be a health care sharing ministry
				  shall timely reply in writing to an inquiry of the commissioner regarding their
				  compliance with
				  RCW
				   48.43.009, and any potential violations of
				  RCW
				   48.05.030(1) and
				  48.15.020(1)
				 and related regulations, including this regulation. A timely response is one
				  that is received by the commissioner within 20 business days from receipt of
				  the inquiry. A response may be provided via electronic mail.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter N - HEALTH CARE SHARING MINISTRIES › Section 284-43-8230 - Continuously sharing medical expenses

Current through Register Vol. 24-14, July 15, 2024
A health care sharing ministry must share medical expenses
				  among its members, and this sharing must be continuous and without
				  interruption. In order for sharing between a predecessor organization and its
				  successor organization to be continuous and without interruption, remaining
				  predecessor organization members must share medical expenses with successor
				  organization members, if any, at the time the successor organization acquires,
				  merges with, or otherwise replaces the predecessor's medical expense sharing
				  activities.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter Y - HEALTH CARE NETWORKS › Section 284-43-9970 - Network access-General standards (Recodified)

Current through Register Vol. 24-14, July 15, 2024
Statutory Authority: RCW  48.02.060, 48.18.120, 48.20.460,
					 48.43.505, 48.43.510, 48.43.515, 48.43.530, 48.43.535, 48.44.050, 48.46.200,
					 48.20.450, 48.44.020, 48.44.080, 48.46.030,  45 C.F.R. §§
												156.230, 156.235, and 156.245. WSR 14-10-017 (Matter No. R 2013-22), § 284-43-200,
					 filed 4/25/14, effective 5/26/14. Statutory Authority: RCW  48.02.060,
					 48.18.120, 48.20.450, 48.20.460, 48.30.010, 48.44.050, 48.46.100, 48.46.200,
					 48.43.505, 48.43.510, 48.43.515, 48.43.520, 48.43.525, 48.43.530, 48.43.535.
					 WSR 01-03-033 (Matter No. R 2000-02), § 284-43-200, filed 1/9/01,
					 effective 7/1/01. Statutory Authority: RCW  48.02.060, 48.18.120, 48.20.450,
					 48.20.460, 48.30.010, 48.44.050, 48.46.030, 48.46.200. WSR 00-04-034 (Matter
					 No. R 99-2), § 284-43-200, filed 1/24/00, effective 3/1/00. Statutory
					 Authority: RCW  48.02.060, 48.20.450, 48.20.460, 48.30.010, 48.44.020,
					 48.44.050, 48.44.080, 48.46.030, 48.46.060(2), 48.46.200 and 48.46.243. WSR
					 98-04-005 (Matter No. R 97-3), § 284-43-200, filed 1/22/98, effective
					 2/22/98.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter Y - HEALTH CARE NETWORKS › Section 284-43-9971 - Alternate access delivery request (Recodified)

Current through Register Vol. 24-14, July 15, 2024
Statutory Authority: RCW  48.02.060, 48.18.120, 48.20.460,
					 48.43.505, 48.43.510, 48.43.515, 48.43.530, 48.43.535, 48.44.050, 48.46.200,
					 48.20.450, 48.44.020, 48.44.080, 48.46.030,  45 C.F.R. §§
												156.230, 156.235, and 156.245. WSR 14-10-017 (Matter No. R 2013-22), § 284-43-201,
					 filed 4/25/14, effective 5/26/14.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter Y - HEALTH CARE NETWORKS › Section 284-43-9972 - Maintenance of sufficient provider networks (Recodified)

Current through Register Vol. 24-14, July 15, 2024
Statutory Authority: RCW  48.02.060, 48.18.120, 48.20.450,
					 48.20.460, 48.43.055, 48.43.505, 48.43.510, 48.43.515, 48.43.530, 48.43.535,
					 48.43.730, 48.44.020, 48.44.050, 48.44.080, 48.46.030, 48.46.200. WSR 16-01-074
					 (Matter No. R 2014-08), § 284-43-202, filed 12/14/15, effective
					 1/14/16.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter Y - HEALTH CARE NETWORKS › Section 284-43-9973 - Use of subcontracted networks (Recodified)

Current through Register Vol. 24-14, July 15, 2024
Statutory Authority: RCW  48.02.060, 48.18.120, 48.20.460,
					 48.43.505, 48.43.510, 48.43.515, 48.43.530, 48.43.535, 48.44.050, 48.46.200,
					 48.20.450, 48.44.020, 48.44.080, 48.46.030,  45 C.F.R. §§
												156.230, 156.235, and 156.245. WSR 14-10-017 (Matter No. R 2013-22), § 284-43-203,
					 filed 4/25/14, effective 5/26/14.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter Y - HEALTH CARE NETWORKS › Section 284-43-9974 - Provider directories (Recodified)

Current through Register Vol. 24-14, July 15, 2024
Statutory Authority: RCW  48.02.060, 48.18.120, 48.20.460,
					 48.43.505, 48.43.510, 48.43.515, 48.43.530, 48.43.535, 48.44.050, 48.46.200,
					 48.20.450, 48.44.020, 48.44.080, 48.46.030,  45 C.F.R. §§
												156.230, 156.235, and 156.245. WSR 14-10-017 (Matter No. R 2013-22), § 284-43-204,
					 filed 4/25/14, effective 5/26/14.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter Y - HEALTH CARE NETWORKS › Section 284-43-9975 - Every category of health care providers (Recodified)

Current through Register Vol. 24-14, July 15, 2024
Statutory Authority: RCW  48.02.060, 48.18.120, 48.20.460,
					 48.43.505, 48.43.510, 48.43.515, 48.43.530, 48.43.535, 48.44.050, 48.46.200,
					 48.20.450, 48.44.020, 48.44.080, 48.46.030,  45 C.F.R. §§
												156.230, 156.235, and 156.245. WSR 14-10-017 (Matter No. R 2013-22), § 284-43-205,
					 filed 4/25/14, effective 5/26/14. Statutory Authority: RCW  48.02.060,
					 48.18.120, 48.20.450, 48.20.460, 48.30.010, 48.44.050 and 48.46.200. WSR
					 99-16-036 (Matter No. R 98-20), § 284-43-205, filed 7/28/99, effective
					 8/28/99.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter Y - HEALTH CARE NETWORKS › Section 284-43-9976 - Network reports-Format (Recodified)

Current through Register Vol. 24-14, July 15, 2024
Statutory Authority: RCW  48.02.060, 48.18.120, 48.20.460,
					 48.43.505, 48.43.510, 48.43.515, 48.43.530, 48.43.535, 48.44.050, 48.46.200,
					 48.20.450, 48.44.020, 48.44.080, 48.46.030,  45 C.F.R. §§
												156.230, 156.235, and 156.245. WSR 14-10-017 (Matter No. R 2013-22), § 284-43-220,
					 filed 4/25/14, effective 5/26/14. Statutory Authority: RCW  48.02.060, 48.43.510 and 48.43.515. WSR 11-07-015 (Matter No. R 2011-01), § 284-43-220, filed
					 3/8/11, effective 4/8/11. Statutory Authority: RCW  48.02.060. WSR 08-17-037
					 (Matter No. R 2008-17), § 284-43-220, filed 8/13/08, effective 9/13/08.
					 Statutory Authority: RCW  48.02.060, 48.18.120, 48.20.450, 48.20.460, 48.43.515,
					 48.44.050, 48.46.030, 48.46.200, 48.42.100, 48.43.515, 48.46.030. WSR 03-09-142
					 (Matter No. R 2003-01), § 284-43-220, filed 4/23/03, effective 5/24/03.
					 Statutory Authority: RCW  48.02.060, 48.18.120, 48.20.450, 48.20.460, 48.30.010,
					 48.44.050, 48.46.030, 48.46.200. WSR 00-04-034 (Matter No. R 99-2), §
					 284-43-220, filed 1/24/00, effective 1/1/01. Statutory Authority: RCW
					  48.02.060, 48.20.450, 48.20.460, 48.30.010, 48.44.020, 48.44.050, 48.44.080,
					 48.46.030, 48.46.060(2), 48.46.200 and 48.46.243. WSR 98-04-005 (Matter No. R
					 97-3), § 284-43-220, filed 1/22/98, effective
					 2/22/98.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter Y - HEALTH CARE NETWORKS › Section 284-43-9977 - Essential community providers for exchange plans-Definition (Recodified)

Current through Register Vol. 24-14, July 15, 2024
Statutory Authority: RCW  48.02.060, 48.44.050, 48.46.200,
					 48.20.450, 48.43.515, 48.44.020, 48.44.080, 48.46.030,  45 C.F.R. 156.230, 156.235, and 156.245. WSR 14-22-007, § 284-43-221, filed 10/23/14,
					 effective 11/23/14. Statutory Authority: RCW  48.02.060, 48.18.120, 48.20.460,
					 48.43.505, 48.43.510, 48.43.515, 48.43.530, 48.43.535, 48.44.050, 48.46.200,
					 48.20.450, 48.44.020, 48.44.080, 48.46.030,  45 C.F.R. §§
												156.230, 156.235, and 156.245. WSR 14-10-017 (Matter No. R 2013-22), § 284-43-221,
					 filed 4/25/14, effective 5/26/14.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter Y - HEALTH CARE NETWORKS › Section 284-43-9978 - Essential community providers for exchange plans-Network access (Recodified)

Current through Register Vol. 24-14, July 15, 2024
Statutory Authority: RCW  48.02.060, 48.44.050, 48.46.200,
					 48.20.450, 48.43.515, 48.44.020, 48.44.080, 48.46.030,  45 C.F.R. 156.230, 156.235, and 156.245. WSR 14-22-007, § 284-43-222, filed 10/23/14,
					 effective 11/23/14. Statutory Authority: RCW  48.02.060, 48.18.120, 48.20.460,
					 48.43.505, 48.43.510, 48.43.515, 48.43.530, 48.43.535, 48.44.050, 48.46.200,
					 48.20.450, 48.44.020, 48.44.080, 48.46.030,  45 C.F.R. §§
												156.230, 156.235, and 156.245. WSR 14-10-017 (Matter No. R 2013-22), § 284-43-222,
					 filed 4/25/14, effective 5/26/14.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter Y - HEALTH CARE NETWORKS › Section 284-43-9979 - Issuer recordkeeping-Provider networks (Recodified)

Current through Register Vol. 24-14, July 15, 2024
Statutory Authority: RCW  48.02.060, 48.18.120, 48.20.450,
					 48.20.460, 48.43.055, 48.43.505, 48.43.510, 48.43.515, 48.43.530, 48.43.535,
					 48.43.730, 48.44.020, 48.44.050, 48.44.080, 48.46.030, 48.46.200. WSR 16-01-074
					 (Matter No. R 2014-08), § 284-43-225, filed 12/14/15, effective
					 1/14/16.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter Y - HEALTH CARE NETWORKS › Section 284-43-9980 - Tiered provider networks (Recodified)

Current through Register Vol. 24-14, July 15, 2024
Statutory Authority: RCW  48.02.060, 48.18.120, 48.20.460,
					 48.43.505, 48.43.510, 48.43.515, 48.43.530, 48.43.535, 48.44.050, 48.46.200,
					 48.20.450, 48.44.020, 48.44.080, 48.46.030,  45 C.F.R. §§
												156.230, 156.235, and 156.245. WSR 14-10-017 (Matter No. R 2013-22), § 284-43-229,
					 filed 4/25/14, effective 5/26/14.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter Y - HEALTH CARE NETWORKS › Section 284-43-9981 - Assessment of access (Recodified)

Current through Register Vol. 24-14, July 15, 2024
Statutory Authority: RCW  48.02.060, 48.18.120, 48.20.460,
					 48.43.505, 48.43.510, 48.43.515, 48.43.530, 48.43.535, 48.44.050, 48.46.200,
					 48.20.450, 48.44.020, 48.44.080, 48.46.030,  45 C.F.R. §§
												156.230, 156.235, and 156.245. WSR 14-10-017 (Matter No. R 2013-22), § 284-43-230,
					 filed 4/25/14, effective 5/26/14.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter Y - HEALTH CARE NETWORKS › Section 284-43-9982 - Issuer standards for women's right to directly access certain health care practitioners for women's health care services (Recodified)

Current through Register Vol. 24-14, July 15, 2024
Statutory Authority: RCW  48.02.060, 48.18.120, 48.20.460,
					 48.43.505, 48.43.510, 48.43.515, 48.43.530, 48.43.535, 48.44.050, 48.46.200,
					 48.20.450, 48.44.020, 48.44.080, 48.46.030,  45 C.F.R. §§
												156.230, 156.235, and 156.245. WSR 14-10-017 (Matter No. R 2013-22), § 284-43-250,
					 filed 4/25/14, effective 5/26/14. Statutory Authority: RCW  48.02.060,
					 48.18.120, 48.20.450, 48.20.460, 48.30.010, 48.44.050, 48.46.030, 48.46.200.
					 WSR 00-04-034 (Matter No. R 99-2), § 284-43-250, filed 1/24/00, effective
					 2/24/00. Statutory Authority: RCW  48.02.060, 48.20.450, 48.20.460, 48.30.010,
					 48.44.020, 48.44.050, 48.44.080, 48.46.030, 48.46.060(2), 48.46.200 and
					 48.46.243. WSR 98-04-005 (Matter No. R 97-3), § 284-43-250, filed 1/22/98,
					 effective 2/22/98.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter Y - HEALTH CARE NETWORKS › Section 284-43-9983 - Enrollee's access to providers (Recodified)

Current through Register Vol. 24-14, July 15, 2024
Statutory Authority: RCW  48.02.060, 48.18.120, 48.20.450,
					 48.20.460, 48.43.055, 48.43.505, 48.43.510, 48.43.515, 48.43.530, 48.43.535,
					 48.43.730, 48.44.020, 48.44.050, 48.44.080, 48.46.030, 48.46.200. WSR 16-01-074
					 (Matter No. R 2014-08), § 284-43-251, filed 12/14/15, effective 1/14/16.
					 Statutory Authority: RCW  48.02.060, 48.18.120, 48.20.450, 48.20.460, 48.30.010,
					 48.44.050, 48.46.100, 48.46.200, 48.43.505, 48.43.510, 48.43.515, 48.43.520,
					 48.43.525, 48.43.530, 48.43.535. WSR 01-03-033 (Matter No. R 2000-02), §
					 284-43-251, filed 1/9/01, effective
					 7/1/01.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter Y - HEALTH CARE NETWORKS › Section 284-43-9984 - Hospital emergency service departments and practice groups (Recodified)

Current through Register Vol. 24-14, July 15, 2024
Statutory Authority: RCW  48.02.060, 48.18.120, 48.20.460,
					 48.43.505, 48.43.510, 48.43.515, 48.43.530, 48.43.535, 48.44.050, 48.46.200,
					 48.20.450, 48.44.020, 48.44.080, 48.46.030,  45 C.F.R. §§
												156.230, 156.235, and 156.245. WSR 14-10-017 (Matter No. R 2013-22), § 284-43-252,
					 filed 4/25/14, effective 5/26/14.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter Y - HEALTH CARE NETWORKS › Section 284-43-9985 - Standards for temporary substitution of contracted network providers-"Locum tenens" providers (Recodified)

Current through Register Vol. 24-14, July 15, 2024
Statutory Authority: RCW  48.02.060 and 48.43.515. WSR
					 08-01-025 (Matter No. R 2005-04), § 284-43-260, filed 12/10/07, effective
					 1/10/08.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter Y - HEALTH CARE NETWORKS › Section 284-43-9986 - Rule concerning contracted network providers called to active duty military service (Recodified)

Current through Register Vol. 24-14, July 15, 2024
Statutory Authority: RCW  48.02.060 and 48.43.515. WSR
					 08-01-025 (Matter No. R 2005-04), § 284-43-262, filed 12/10/07, effective
					 1/10/08.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter Z - PROVIDER CONTRACTS AND PAYMENT › Section 284-43-9990 - Provider and facility contracts with issuers-Generally (Recodified)

Current through Register Vol. 24-14, July 15, 2024
Statutory Authority: RCW  48.02.060, 48.18.120, 48.20.450,
					 48.20.460, 48.43.055, 48.43.505, 48.43.510, 48.43.515, 48.43.530, 48.43.535,
					 48.43.730, 48.44.020, 48.44.050, 48.44.080, 48.46.030, 48.46.200. WSR 16-01-074
					 (Matter No. R 2014-08), § 284-43-300, filed 12/14/15, effective 1/14/16.
					 Statutory Authority: RCW  48.02.060, 48.20.450, 48.20.460, 48.30.010, 48.44.020,
					 48.44.050, 48.44.080, 48.46.030, 48.46.060(2), 48.46.200 and 48.46.243. WSR
					 98-04-005 (Matter No. R 97-3), § 284-43-300, filed 1/22/98, effective
					 2/22/98.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter Z - PROVIDER CONTRACTS AND PAYMENT › Section 284-43-9991 - Selection of participating providers-Credentialing and unfair discrimination (Recodified)

Current through Register Vol. 24-14, July 15, 2024
Statutory Authority: RCW  48.02.060, 48.18.120, 48.20.450,
					 48.20.460, 48.43.055, 48.43.505, 48.43.510, 48.43.515, 48.43.530, 48.43.535,
					 48.43.730, 48.44.020, 48.44.050, 48.44.080, 48.46.030, 48.46.200. WSR 16-01-074
					 (Matter No. R 2014-08), § 284-43-310, filed 12/14/15, effective 1/14/16.
					 Statutory Authority: RCW  48.02.060, 48.20.450, 48.20.460, 48.30.010, 48.44.020,
					 48.44.050, 48.44.080, 48.46.030, 48.46.060(2), 48.46.200 and 48.46.243. WSR
					 98-04-005 (Matter No. R 97-3), § 284-43-310, filed 1/22/98, effective
					 2/22/98.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter Z - PROVIDER CONTRACTS AND PAYMENT › Section 284-43-9992 - Provider contracts-Standards-Hold harmless provisions (Recodified)

Current through Register Vol. 24-14, July 15, 2024
Statutory Authority: RCW  48.02.060, 48.18.120, 48.20.450,
					 48.20.460, 48.43.055, 48.43.505, 48.43.510, 48.43.515, 48.43.530, 48.43.535,
					 48.43.730, 48.44.020, 48.44.050, 48.44.080, 48.46.030, 48.46.200. WSR 16-01-074
					 (Matter No. R 2014-08), § 284-43-320, filed 12/14/15, effective 1/14/16.
					 Statutory Authority: RCW  48.02.060, 48.30.010, 48.43.055, 48.44.050, 48.44.070,
					 48.46.030, 48.46.200 and 48.46.243. WSR 99-21-016 (Matter No. R 98-21), §
					 284-43-320, filed 10/11/99, effective 11/11/99. Statutory Authority: RCW
					  48.02.060, 48.20.450, 48.20.460, 48.30.010, 48.44.020, 48.44.050, 48.44.080,
					 48.46.030, 48.46.060(2), 48.46.200 and 48.46.243. WSR 98-04-005 (Matter No. R
					 97-3), § 284-43-320, filed 1/22/98, effective
					 2/22/98.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter Z - PROVIDER CONTRACTS AND PAYMENT › Section 284-43-9993 - Provider contracts-Terms and conditions of payment (Recodified)

Current through Register Vol. 24-14, July 15, 2024
Statutory Authority: RCW  48.02.060, 48.30.010, 48.43.055,
					 48.44.050, 48.44.070, 48.46.030, 48.46.200 and 48.46.243. WSR 99-21-016 (Matter
					 No. R 98-21), § 284-43-321, filed 10/11/99, effective
					 11/11/99.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter Z - PROVIDER CONTRACTS AND PAYMENT › Section 284-43-9994 - Provider contracts-Dispute resolution process (Recodified)

Current through Register Vol. 24-14, July 15, 2024
Statutory Authority: RCW  48.02.060, 48.30.010, 48.43.055,
					 48.44.050, 48.44.070, 48.46.030, 48.46.200 and 48.46.243. WSR 99-21-016 (Matter
					 No. R 98-21), § 284-43-322, filed 10/11/99, effective
					 11/11/99.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter Z - PROVIDER CONTRACTS AND PAYMENT › Section 284-43-9995 - Pharmacy identification cards (Recodified)

Current through Register Vol. 24-14, July 15, 2024
Statutory Authority: RCW  48.02.060, 48.43.023, 48.44.050,
					 48.46.200. WSR 03-07-006 (Matter No. R 2002-04), § 284-43-323, filed
					 3/6/03, effective 4/6/03.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter Z - PROVIDER CONTRACTS AND PAYMENT › Section 284-43-9996 - Provider contracts-Audit guidelines (Recodified)

Current through Register Vol. 24-14, July 15, 2024
Statutory Authority: RCW  48.02.060, 48.30.010, 48.43.055,
					 48.44.050, 48.44.070, 48.46.030, 48.46.200 and 48.46.243. WSR 99-21-016 (Matter
					 No. R 98-21), § 284-43-324, filed 10/11/99, effective
					 11/11/99.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter Z - PROVIDER CONTRACTS AND PAYMENT › Section 284-43-9997 - Pharmacy claims-Rejections, notifications and disclosures (Recodified)

Current through Register Vol. 24-14, July 15, 2024
Statutory Authority: RCW  48.02.060, 48.20.450, 48.20.460,
					 48.165.0301, 48.43.525, 48.43.530, 48.44.020, 48.44.050, 48.46.060(2), and
					 48.46.200. WSR 15-24-074 (Matter No. R 2014-13), § 284-43-325, filed
					 11/25/15, effective 7/1/16.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter Z - PROVIDER CONTRACTS AND PAYMENT › Section 284-43-9998 - Participating provider-Filing and approval (Recodified)

Current through Register Vol. 24-14, July 15, 2024
Statutory Authority: RCW  48.02.060, 48.18.120, 48.20.450,
					 48.20.460, 48.43.055, 48.43.505, 48.43.510, 48.43.515, 48.43.530, 48.43.535,
					 48.43.730, 48.44.020, 48.44.050, 48.44.080, 48.46.030, 48.46.200. WSR 16-01-074
					 (Matter No. R 2014-08), § 284-43-330, filed 12/14/15, effective 1/14/16.
					 Statutory Authority: RCW  48.02.060, 48.44.050, 48.46.030, 48.46.200, and   2013 c
					  277
											§
												1. WSR 13-16-045 (Matter No. R 2012-24), § 284-43-330, filed
					 7/31/13, effective 8/31/13. Statutory Authority: RCW  48.02.060, 48.30.010,
					 48.43.055, 48.44.050, 48.44.070, 48.46.030, 48.46.200 and 48.46.243. WSR
					 99-21-016 (Matter No. R 98-21), § 284-43-330, filed 10/11/99, effective
					 11/11/99. Statutory Authority: RCW  48.02.060, 48.20.450, 48.20.460, 48.30.010,
					 48.44.020, 48.44.050, 48.44.080, 48.46.030, 48.46.060(2), 48.46.200 and
					 48.46.243. WSR 98-04-005 (Matter No. R 97-3), § 284-43-330, filed 1/22/98,
					 effective 2/22/98.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter Z - PROVIDER CONTRACTS AND PAYMENT › Section 284-43-9999 - Effective date (Recodified)

Current through Register Vol. 24-14, July 15, 2024
Statutory Authority: RCW  48.02.060, 48.18.120, 48.20.460,
					 48.43.505, 48.43.510, 48.43.515, 48.43.530, 48.43.535, 48.44.050, 48.46.200,
					 48.20.450, 48.44.020, 48.44.080, 48.46.030,  45 C.F.R. §§
												156.230, 156.235, and 156.245. WSR 14-10-017 (Matter No. R 2013-22), § 284-43-331,
					 filed 4/25/14, effective 5/26/14. Statutory Authority: RCW  48.02.060,
					 48.30.010, 48.43.055, 48.44.050, 48.44.070, 48.46.030, 48.46.200 and 48.46.243.
					 WSR 99-21-016 (Matter No. R 98-21), § 284-43-331, filed 10/11/99,
					 effective 11/11/99.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43A - INDEPENDENT REVIEW ORGANIZATIONS (IROs) › Subchapter A - GENERAL PROVISIONS › Section 284-43A-001 - Purpose and scope

Current through Register Vol. 24-14, July 15, 2024
(1) Purpose. These
				rules are adopted by the Washington state office of the insurance commissioner
				to implement the provisions of
				RCW
				 48.43.535 regarding the certification and
				requirements of independent review organizations (IROs) and requirements for
				carriers referring review of adverse benefit determinations to IROs. Certified
				IROs are qualified to receive referrals from the commissioner or designee under
				RCW
				 48.43.535 to make binding determinations
				related to health care coverage and payment disputes between health insurance
				carriers and their enrollees.
(2)
				Other applicable rules. Independent review is also subject to rules of the
				commissioner implementing
				RCW
				 48.43.535.
(3) Applicability. These rules apply to
				independent review cases originating in Washington state under
				RCW
				 48.43.535, and to independent review
				organizations conducting these reviews.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43A - INDEPENDENT REVIEW ORGANIZATIONS (IROs) › Subchapter A - GENERAL PROVISIONS › Section 284-43A-010 - Definitions

Current through Register Vol. 24-14, July 15, 2024
The definitions in this section apply throughout the chapter
				  unless the context clearly requires otherwise.
(1) "Adverse benefit determination" has the
				same meaning as defined in
				RCW
				 48.43.005 and includes:
(a) The determination includes any decision
				by a health carrier's designee utilization review organization that a request
				for a benefit under the health carrier's health benefit plan does not meet the
				health carrier's requirements for medical necessity, appropriateness, health
				denied, reduced, or terminated or payment is not provided or made, in whole or
				in part for the benefit;
(b) The
				denial, reduction, termination, or failure to provide or make payment, in whole
				or in part, for a benefit based on a determination by a health carrier or its
				designee utilization review organization of a covered person's eligibility to
				participate in the health carrier's health benefit plan;
(c) Any prospective review or retrospective
				review determination that denies, reduces, or terminates or fails to provide or
				make payment in whole or in part for a benefit;
(d) A rescission of coverage
				determination;
(e) A carrier's
				denial of an application for coverage; or
(f) Any adverse determination made by a
				carrier under
				RCW
				 48.49.020,
				48.49.030, or sections 2799A-1 or
				2799A-2 of the Public Health Service Act (42 U.S.C. Sec. 300gg-111 or 300gg-112) and federal regulations implementing those provisions of
				P.L.
				116-260. Examples of such determinations include,
				but are not limited to:
(i) Calculation of
				enrollee cost-sharing;
(ii)
				Application of consumer cost-sharing to an enrollee's deductible and maximum
				out-of-pocket; and
(iii)
				Determination of whether a claim is subject to the Balance Billing Protection
				Act.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43A - INDEPENDENT REVIEW ORGANIZATIONS (IROs) › Subchapter B - CERTIFICATION AND REQUIREMENTS FOR INDEPENDENT REVIEW ORGANIZATIONS (IROs) › Section 284-43A-020 - General requirements for certification

Current through Register Vol. 24-14, July 15, 2024
In order to qualify for certification, an IRO shall:
(1) Submit an application for certification
				to the commissioner as described in
				RCW
				 48.43.537.
(2) Hold a current accreditation from a
				nationally recognized private accrediting organization acceptable to the
				federal Department of Health and Human Services or Department of Labor for the
				federal external review process.
(3) Demonstrate expertise and a history of
				reviewing health care in terms of medical necessity, appropriateness, and
				application of other health plan coverage and contract provisions.
(4) Demonstrate the ability to handle a full
				range of review cases, including contract provisions, occurring in Washington
				state. Certified IROs may contract with more specialized review organizations;
				however, the certified IRO shall ensure that each review conducted meets all
				the requirements of this chapter.
(5) Demonstrate capability to review
				administrative and contractual coverage issues, as well as medical necessity
				and effectiveness, and the appropriateness of experimental and investigational
				treatments.
(6) Comply with all
				conflict of interest provisions in WAC 284-43A-050.
(7) Maintain and assign qualified expert
				reviewers in compliance with WAC 284-43A-060.
(8) Conduct reviews, reach determinations and
				document determinations consistent with WAC 284-43A-040 through
				284-43A-090.
(9) Maintain
				administrative processes and capabilities in compliance with WAC
				284-43A-040.