Washington Administrative Code

The designated responsible licensed person (DRLP) must be given the necessary authority and information by the business entity that reasonably assures that the DRLP can cause or influence the entity's compliance with all applicable insurance laws or rules, or both of this state.[…

(1) The purpose of this section is to set forth standards to protect consumers from misleading and fraudulent marketing practices with respect to the use of senior-specific certifications and professional designations in the solicitation, sale or purchase of, or advice made in co…

(1) An individual insurance producer may claim only one state as the home state at a time.(a) Individual insurance producers that claim multiple states as their home state must choose one state to be their home state for all insurance licensing purposes. This will usually be the …

RCW 48.17.530 (1)(m) permits the commissioner to define certain reasonable arrangements where an insurance producer may obtain a loan from an insurance client. The commissioner finds that a reasonable arrangement exists when an insurance producer and an insurance client enter int…

RCW 48.17.270(5) provides that when insurance is purchased over the telephone or by electronic means for which written consent under RCW 48.17.270(3) cannot be reasonably obtained, consent documented by the insurance producer is acceptable in lieu of the signed written disclosure…

RCW 48.17.460 requires the display of the license or licenses of each insurance producer, title insurance agent, or adjuster in a conspicuous place in that part of the place of the licensee's business which is customarily open to the public. Licensees whose personal residence is …

As used in WAC 284-17-705 through 284-17-730, the terms below have the following meaning unless the context clearly requires otherwise:"Certification program" means any crop adjuster educational and examination program meeting the federal Risk Management Agency requirements."Crop…

(1) An applicant for a crop adjuster's license to adjust crop losses insured through a federal crop insurance program must complete all educational and examination requirements of a certification program. With the application, an applicant for a crop adjuster's license must submi…

(1) Every licensed crop adjuster adjusting crop insurance losses insured through a federal insurance program must:(a) Renew their license on or before the expiration of the license; and(b) On or before February 28th of each year, file with the commissioner a true and accurate cop…

(1) All authorized insurance companies and licensed managing general agents must annually, on or before February 28th of each year, file with the commissioner a list of all salaried employees who act on their behalf as crop adjusters adjusting losses insured through a federal cro…

(1) An insurance producer may pay or assign all or a portion of a commission, fee, or other consideration received in connection with the sale, solicitation, or negotiation of insurance to a bona fide charitable or nonprofit organization as defined in chapter 48.30 RCW if all of …

(1) For the purposes of this section, lead card means communications distributed to the public which, regardless of form, content, or stated purpose, are used to compile a list containing names or other personal information regarding individuals who have expressed an interest in …

(1) An unlicensed individual who receives referral compensation under RCW 48.30.133(1) or a referral fee under RCW 48.30.133(4) is not selling, soliciting, or negotiating insurance if all of the following conditions are met:(a) The referral compensation or fee does not depend upo…

An insurance producer may conduct a promotional game of chance provided that:(1) The promotional game of chance is undertaken solely for the purpose of advertising and promoting the insurance producer;(2) No person eligible to receive the prize is required to apply for insurance,…

The purpose of this chapter is to establish uniform regulatory standards for health carriers and to create minimum standards for health plans that ensure consumer access to the health care services promised in these health plans.[Statutory Authority: RCW 48.02.060. WSR 16-07-144 …

This chapter shall apply to all health plans and all health carriers subject to the jurisdiction of the state of Washington except as otherwise expressly provided in this chapter. Health carriers are responsible for compliance with the provisions of this chapter and are responsib…

Health carriers shall comply with all Washington state and federal laws relating to the acts and practices of carriers and laws relating to health plan benefits.[Statutory Authority: RCW 48.02.060. WSR 16-07-144 (Matter No. R 2016-01), as § 284-170-125, filed 3/23/16, effective 4…

Except as defined in other subchapters and unless the context requires otherwise, the following definitions shall apply throughout this chapter.(1) "Adverse determination" has the same meaning as the definition of adverse benefit determination in RCW 48.43.005, and includes:(a) T…

The following definitions apply only to RCW 48.43.732 and WAC 284-170-441, 284-170-445, and 284-170-447.(1) "Cause to be made" means initiating, arranging, or directing another entity to make a public statement defined in this section.(2) "Control" including the terms "controlled…

(1) An issuer must maintain each provider network for each health plan in a manner that is sufficient in numbers and types of providers and facilities to assure that, to the extent feasible based on the number and type of providers and facilities in the service area, all health p…

(1) Issuers must meet the network access standards of this chapter related to emergency mental health services and substance use disorder services, including services provided by behavioral health emergency services providers. An issuer that is unable to meet these standards must…

(1) Where an issuer's network meets one or more of the criteria in WAC 284-170-200 (15)(a) through (d), the issuer may submit an alternate access delivery request for the commissioner's review and approval. The alternate access delivery request must be made using the Alternate Ac…

An issuer that meets the criteria in RCW 48.49.135 (2)(b) may submit an amended alternate access delivery request to the commissioner for review and approval. The amended alternate access delivery request must be made using the Amended Alternate Access Delivery Request Form E, as…

(1) An issuer must maintain and monitor its provider networks on an ongoing basis for compliance with the network access standards set forth in WAC 284-170-200. This includes an issuer of a stand-alone dental plan offered through the exchange or a stand-alone dental plan offered …

(1) The primary contractor with each provider and facility in an issuer's network must be specifically identified in network report filings with the commissioner. An issuer may use subcontracted networks as part of a provider network for a service area, subject to the following r…

(1) For each carrier that uses a provider network, the carrier must make information about that network available to the general public, prospective enrollees and enrollees, in the form of an easily accessible and searchable online provider directory.Easily accessible for the pur…

(1) Issuers must not exclude any category of providers licensed by the state of Washington who provide health care services or care within the scope of their practice for services covered as essential health benefits, as defined in WAC 284-43-5640 and 284-43-5642 and RCW 48.43.71…

(1) An issuer must submit its provider network materials to the commissioner for approval prior to or at the time it files a newly offered health plan.(a) For individual and small groups, the submission must occur when the issuer submits its plan under WAC 284-43-0200. For groups…

(1) Not later than July 1, 2021, carriers must establish and maintain a web page entitled "Important Mental Health and Substance Use Disorder Treatment Information" that complies with the requirements in this section. By July 1, 2021, carriers must prominently post the informatio…

"Essential community provider" means providers listed on the Centers for Medicare and Medicaid Services Non-Exhaustive List of Essential Community Providers. This list includes providers and facilities that have demonstrated service to medicaid, low-income, and medically underser…

(1) An issuer must include essential community providers in its provider network for qualified health plans and qualified stand-alone dental plans in compliance with this section and as defined in WAC 284-170-300.(2) An issuer must include a sufficient number and type of essentia…

(1) An issuer must make available to the commissioner upon request its records, contracts, and agreements related to its provider networks.(a) Records to support proof of good faith contracting efforts must be retained for seven years.(b) Signed contracts, reimbursement agreement…

(1) "Tiered provider network" means a network that identifies and groups providers and facilities into specific groups to which different provider reimbursement, enrollee cost-sharing, or provider access requirements, or any combination thereof, apply as a means to manage cost, u…

(1) The commissioner will assess whether an issuer's provider network access meets the requirements of WAC 284-170-200, 284-170-210, and 284-170-270 such that all health plan services to enrollees will be accessible in a timely manner appropriate for the enrollee's condition. Fac…

(1)(a) "Women's health care services" means organized services to provide health care to women, inclusive of the women's preventive services required by the Health Resources and Services Administration of the U.S. Department of Health and Human Services. The services include, but…

(1) Each issuer must allow an enrollee to choose a primary care provider who is accepting new patients from a list of participating providers.(a) Enrollees also must be permitted to change primary care providers at any time with the change becoming effective not later than the be…

(1) Each carrier must cover services of a primary care provider whose contract with the plan or whose contract with a subcontractor is being terminated by the plan or subcontractor without cause under the terms of that contract:(a) For at least 60 days following notice of termina…

Enrollees must have access to emergency services twenty-four hours per day, seven days per week. An issuer must make good faith attempts to contract with provider groups offering services within hospital emergency departments, if the hospital is included in its network. Such evid…

It is a longstanding and widespread practice for contracted network providers to retain substitute providers to take over their professional practices when the contracted network providers are absent for reasons such as illness, pregnancy, vacation, or continuing medical educatio…

In lieu of substitution of a provider during a period of active duty military service longer than sixty continuous days, carriers must provide contracted network providers with the opportunity to return to the carrier's network after the provider's active duty military service is…

(1) An issuer contracting with providers or facilities for health care service delivery to enrollees must satisfy all the requirements contained in this subchapter.(2) An issuer must ensure that subcontractors of its contracted providers and facilities comply with the requirement…

(1) An issuer must develop standards for selecting participating providers, for primary care providers, and for each health care provider or facility license and professional specialty. The standards must be used in determining the selection of health care providers and facilitie…

The execution of a contract by an issuer does not relieve the issuer of its obligations to any enrollee for the provision of health care services, nor of its responsibility for compliance with statutes or regulations. In addition to the contract form filing requirements of this s…

(1) Every participating provider and facility contract shall set forth a schedule for the prompt payment of amounts owed by the carrier to the provider or facility and shall include penalties for carrier failure to abide by that schedule. At a minimum, these contract provisions s…

(1)(a) Every participating provider contract must, for health plans issued or renewed on or after January 1, 2017, provide that a health carrier shall reimburse a provider for a health care service provided to a covered person through telemedicine or store and forward technology …

Except as otherwise required by a specific federal or state statute or regulation governing dispute resolution, no process for the resolution of disputes arising out of a participating provider or facility contract shall be considered fair under RCW 48.43.055 unless the process m…

(1) In the case of a provider contract defined in RCW 48.43.732 that is expiring by its own terms or for which one party has given notice to the other party of an intended termination without cause in accordance with the terms of the provider contract, carriers, health care provi…

(1) This section applies to any contract termination other than those under RCW 48.43.732.(2) Each carrier must make a good faith effort to assure that notice of a termination is provided at least 30 days prior to the effective date of the termination to all enrollees who are pat…

(1) This section applies to provider contracts as set forth in RCW 48.43.732 that are expiring by their own terms or for which one party has given notice to the other party of an intended termination without cause in accordance with the terms of the provider contracts.(2) By Dece…

(1) For violations of RCW 48.43.732 and WAC 284-170-421 (4) and (5), 284-170-441, and 284-170-445 committed by carriers on or after January 1, 2026, the commissioner may pursue enforcement actions under RCW 48.02.080 or impose a civil monetary penalty upon carriers of up to $100 …