Washington Administrative Code

(1) This chapter applies to:(a) Health care benefit managers as defined in RCW 48.200.020, and health carriers who contract with health care benefit managers; and(b) Pharmacy benefit managers who contract with pharmacies on behalf of health carriers, medicaid managed care organiz…

Except as defined in other subchapters and unless the context requires otherwise, the following definitions apply throughout this chapter:(1) "Affiliate" or "affiliated employer" has the same meaning as the definition of affiliate or affiliated employer in RCW 48.200.020.(2) "Ann…

If any provision of this chapter or its application to any person or circumstances is held invalid, the remainder of the chapter or its application of the provision to other persons or circumstances is not affected.[Statutory Authority: RCW 48.02.060, 19.340.010, 19.340.030, 19.3…

(1) The commissioner must establish fees for registration and renewal in an amount that ensures the program for the registration, renewal, and oversight activities of the health care benefit managers is self-supporting. Each health care benefit manager must contribute a sufficien…

(1) Beginning January 1, 2022, and thereafter, to conduct business in this state, health care benefit managers must have an approved registration with the commissioner as required in RCW 48.200.030 and 48.200.300. The registration application is not complete until the commissione…

(1) Health care benefit managers must annually renew their registration and pay their renewal fee as required by RCW 48.200.030. Registration renewal must be submitted through the commissioner's electronic system, which is available at www.insurance.wa.gov.(2) Health care benefit…

(1) When registering, a health care benefit manager must submit with its application an affidavit affirming the application's accuracy. An application for registering as a health care benefit manager must include:(a) The legal name as well as any additional names that it uses to …

(1) Health care benefit managers must maintain all records for a period of seven years from the date of creation and make them available to the commissioner upon request. Records include, but are not limited to:(a) Registration and renewal materials that health care benefit manag…

(1) If the commissioner requests records for inspection for a purpose other than to resolve an appeal under RCW 48.200.280, a health care benefit manager must make the records available to the commissioner within fifteen business days from the date on the written request. If the …

(1) Carriers must post on their website information that identifies each health care benefit manager contracted with the carrier, either directly or indirectly through subcontracting with a health care benefit manager or other entity, and identify the services provided by each he…

The definitions in this section apply throughout this subchapter.(1) "Complete filing" means a package of information containing forms, supporting information, documents and exhibits submitted to the commissioner electronically using the system for electronic rate and form filing…

The purpose of this subchapter is to:(1) Adopt processes and procedures for filers to use when submitting electronic forms and rates to the commissioner by way of SERFF.(2) Designate SERFF as the method by which filers, including carriers and health care benefit managers, must su…

This subchapter applies to all carriers and health care benefit managers that must file forms under chapter 48.200 RCW.[Statutory Authority: RCW 48.02.060 and 48.200.900. WSR 21-02-034, § 284-180-415, filed 12/29/20, effective 1/1/22.]

SERFF is a dynamic application that the NAIC will revise and enhance over time. To be consistent with NAIC filing standards and provide timely instructions to filers, the commissioner will incorporate documents posted on the SERFF website into this chapter. By reference, the comm…

(1) Each health care benefit management contract form and contract amendment form filing must be submitted to the commissioner electronically using SERFF.(a) Every form filed in SERFF must:(i) Be attached to the form schedule; and(ii) Have a unique identifying number and a way to…

(1) The commissioner may reject and close any filing that does not comply with this subchapter. If the commissioner rejects a filing, the filer has not filed forms with the commissioner.(2) If the commissioner rejects a filing and the filer resubmits it as a new filing, the date …

A carrier or health care benefit manager may authorize a third-party filer to file forms or rates on its behalf. For the purposes of this section, a "third-party filer" means a person or entity in the business of providing regulatory compliance services.(1) If a carrier or health…

An objection letter may ask the filer to revise a noncompliant form or provide clarification or additional information. The objection letter will state the reason(s) for the objection, including relevant case law, statutes, and rules. Filers must:(1) Provide a complete response t…

If a carrier or health care benefit manager files a revised or replaced form, the filer must provide the supporting documentation described below:(1) If a form is revised due to an objection(s) from the commissioner, the filer must provide a detailed explanation of all material c…

(1) Filers must include a common implementation date for all forms submitted in a filing.(2) Filers may submit a request to change the implementation date of a filing as a note to reviewer.[Statutory Authority: RCW 48.02.060 and 48.200.900. WSR 21-02-034, § 284-180-450, filed 12/…

(1)(a) A carrier must file all contracts and contract amendments between a health care benefit manager and a carrier within 30 days following the effective date of the contract or contract amendment.(b) To meet its obligations under RCW 48.200.050(5), a carrier must, for any heal…

(1) A health care benefit manager must file all contracts and contract amendments between the health care benefit manager and a health carrier, provider, pharmacy, pharmacy services administration organization, or other health care benefit manager entered into directly or indirec…

(1)(a) A self-funded group health plan governed by the provisions of the federal Employee Retirement Income Security Act of 1974 (29 U.S.C. Sec. 1001 et seq.) that elects under RCW 48.200.330 to participate in RCW 48.200.280, 48.200.310, and 48.200.320 shall provide notice to the…

This subchapter applies to pharmacy benefit managers as defined in RCW 48.200.020.(1) Specifically, this subchapter applies to the actions of pharmacy benefit managers regarding contracts with pharmacies on behalf of a carrier, employee benefits program, or medicaid managed care …

(1) A pharmacy benefit manager may not reimburse a pharmacy in the state an amount less than the amount the pharmacy benefit manager reimburses an affiliate for dispensing the same prescription drug as dispensed by the pharmacy, calculated on a per unit basis.(2) A pharmacy benef…

A network pharmacy may appeal a reimbursement to a health care benefit manager providing pharmacy benefit management services (first tier appeal) if the reimbursement for the drug is less than the net amount the network pharmacy paid to the supplier of the drug and the claim was …

(1)(a) For claims adjudicated on or after January 1, 2026, a network pharmacy, or its representative, may appeal the reimbursement amount for a drug to a health care benefit manager providing pharmacy benefit management services (first tier appeal) if the reimbursement amount for…

In computing any period of time prescribed by this rule, the commissioner:(1) Will not count the first day;(2) Will count the last day, unless the last day is a weekend or a state legal holiday; and(3) Will count the next day that is not a weekend or a state legal holiday as the …

(1) The commissioner has adopted the procedure for brief adjudicative proceedings provided in RCW 34.05.482 through 34.05.494 for actions involving a network pharmacy's appeal of a pharmacy benefit manager's reimbursement for a drug subject to predetermined reimbursement costs fo…

(1) The commissioner has adopted the procedure for brief adjudicative proceedings provided in RCW 34.05.482 through 34.05.494 for actions involving a network pharmacy's appeal of a pharmacy benefit manager's reimbursement for a drug subject to predetermined reimbursement costs fo…

The following procedure applies to brief adjudicative proceedings before the commissioner for actions involving a network pharmacy's appeal of a pharmacy benefit manager's decision in a first tier appeal regarding reimbursement for a drug subject to predetermined reimbursement co…

The following procedure applies to brief adjudicative proceedings before the commissioner for actions involving a network pharmacy's appeal of a pharmacy benefit manager's decision in a first tier appeal regarding reimbursement for a drug, unless the matter is converted to a form…

The following procedure applies to the commissioner's review of a brief adjudicative proceeding conducted pursuant to WAC 284-180-520, unless the matter is converted to a formal proceeding as provided in WAC 284-180-540(4).(1) Request for review of initial order. A party to a bri…

(1) Rules of evidence - Record of the proceeding.(a) Evidence is admissible if in the judgment of the presiding or reviewing officer it is the kind of evidence on which reasonably prudent persons are accustomed to relying on in conducting their affairs. The presiding and reviewin…

(1) For purposes of this section, "issued" means ordered by a prescribing health care provider.(2)(a) For purposes of this section, "new prescription" means:(i) A prescription that is ordered for the first time by a health care provider; or(ii) A prescription that is ordered for …

These rules and regulations are titled the Washington essential property insurance inspection and placement program (referred to as the program).[Statutory Authority: RCW 48.02.060. WSR 98-13-095 (Matter No. R 98-10), § 284-19-010, filed 6/16/98, effective 7/17/98; Order R-69-1, …

The purposes of the program are:(1) To assure stability in the property insurance market of this state.(2) To encourage maximum use, in obtaining essential property insurance, of the available, normal insurance market provided by authorized insurers.(3) To make essential property…

Participation in this program is mandatory for all insurers and fraternal benefit societies authorized to engage in the property insurance business in this state, who have "premiums written," as defined in this chapter.[Statutory Authority: RCW 48.02.060. WSR 98-13-095 (Matter No…

(1) "Insurer" means any insurance company or other organization licensed to write and engage in writing property insurance business, including the property insurance components of multiperil policies, on a direct basis, in this state.(2) "Essential property insurance" means the c…

(1) Any person having an insurable interest in real or tangible personal property at a fixed location is entitled to an inspection of the property by the inspection bureau at no cost, upon application to the facility. The inspection may be requested by the property owner, a repre…

(1) The facility shall not require that the applicant demonstrates that he or she is unable to obtain insurance in the normal market, as a precondition to the placement of business under the FAIR plan. The facility, however, may require an insurance producer to furnish copies of …

(1) Within three business days after receipt of the inspection report, the facility shall notify the insured and the agent that:(a) The risk is acceptable; or(b) The risk will be acceptable if the improvements noted in the action report are made by the applicant and confirmed by …

(1) A joint reinsurance association referred to as the association is created consisting of all insurers.(2) The association is authorized to assume and cede reinsurance on behalf of insurers for eligible risks written by insurers through the FAIR plan. The reinsurance assumed by…

All policies issued shall be for essential property insurance on standard policy forms. The policies shall be separately coded and issued for a term of one year, at rates set by the inspection bureau under filings approved by the commissioner. Individual company deviation filings…

(1) The facility shall not cancel or nonrenew a policy issued under this program except:(a) For cause which would have been grounds for nonacceptance of the risk under the program had the cause been known to the insurer at the time of acceptance; or(b) For nonpayment of premium; …

(1) Any applicant or insurer has a right of appeal to the committee, including the right to appear in person before the committee, if requested by the party seeking appeal.(2) A decision of the committee may be appealed to the commissioner.(3) Each denial of insurance under this …

Commission under this program shall be 10 percent on the policy premium and paid to the licensed producer designated by the applicant.[Statutory Authority: RCW 48.02.060. WSR 98-13-095 (Matter No. R 98-10), § 284-19-130, filed 6/16/98, effective 7/17/98; Order R-69-1, § 284-19-13…

(1) This program shall be administered by a governing committee (referred to as the committee) of the facility, subject to the supervision of the commissioner, and operated by a manager appointed by the committee.(2) The committee consists of nine members, including six insurers,…

(1) There shall be an annual meeting of the insurers on a date fixed by the committee.(2) A special meeting may be called at a time and place designated by the committee or upon the written request to the committee of any ten insurers, not more than one of which may be a group un…

(1) The committee shall meet as often as may be required to perform the general duties of the administration of the program or on the call of the commissioner. Three insurers of the committee shall constitute a quorum.(2) The committee may appoint a manager to budget expenses, le…