Washington Administrative Code

(1) Issuers of health benefit plans in Washington state, and third party administrators of health benefit coverage offered in Washington, must participate as contributing entities in the transitional reinsurance program established pursuant to RCW 48.43.720.(2) The U.S. Departmen…

(1) An issuer of a nongrandfathered individual or small group health plan in Washington state must participate in the permanent risk adjustment program, established pursuant to RCW 48.43.720. (2) U.S. Department of Health and Human Services (HHS) will administer the risk adjustme…

(1) An issuer must retain in its files all necessary documentation to support its determination that a purchaser's plan is grandfathered. The information must be sufficient to demonstrate that the issuer's determination of grandfathered status is credible. For purposes of this se…

(1) An issuer may allow a group covered by grandfathered health insurance coverage to add new employees to its health benefit plan, and move employees between benefit options at open enrollment without affecting grandfathered status, as long as the group's plan does not change in…

(1) For all nongrandfathered small group plans issued and in effect prior to January 1, 2014, in 2014 issuers must replace issued nongrandfathered small group health benefit plans with health benefit plans approved by the commissioner as follows:(a) An issuer may elect to withdra…

(1) For all nongrandfathered individual health benefit plans issued and in effect prior to January 1, 2014, during 2014 issuers must replace the plans with health benefit plans approved by the commissioner as follows:(a) An issuer may elect to withdraw a product, pursuant to RCW …

(1) The purpose of this subchapter is to establish uniform regulatory standards for health carriers and to create minimum standards for carriers to adopt policies and procedures that conform administrative, business, and operational practices to protect an enrollee's right to pri…

(1) "Communications subject to confidentiality" means written, verbal, or electronic communication regarding sensitive health care services, and all health care services if a protected individual has requested to limited disclosure including:(a) Bills and attempts to collect paym…

(1) A health carrier must direct all communication regarding sensitive health care services, including communications subject to confidentiality, directly to the protected individual. To facilitate communication of these services, a carrier must allow the protected individual to …

(1) When requested by an enrollee, a health carrier must limit disclosure of that enrollee's information, including personal health information and communications subjected to confidentiality. Once limited, a health carrier must communicate directly with the enrollee through the …

(1) A "special enrollment period" means a period of time outside the initial or annual group renewal period during which an individual applicant may enroll if the individual has experienced a qualifying event. An issuer must make periods for special enrollment in its small group …

(1) Issuers of small group qualified health plans must comply with the additional special enrollment period requirements set forth in 45 C.F.R. 155.420 (b)(2) and 45 C.F.R. 155.725.(2) In addition to meeting the requirements set forth in WAC 284-43-1020, issuers must include in q…

(1) This section applies to nongrandfathered small group plans offered on or off the health benefit exchange.(2) Special enrollment periods must not be shorter than sixty days from the date of the qualifying event.(3) The effective date of coverage for those enrolling in a small …

(1) For purposes of this section, "open enrollment" means a specific period of time each year during which enrollment in a health benefit plan is permitted. This section applies to plans offered in the individual market.(2) An issuer must limit the dates for enrollment in plans o…

(1) For a nongrandfathered individual health plan offered on or off the health benefit exchange, an issuer must make a special enrollment period of not less than sixty days available to any person who experiences a qualifying event, permitting enrollment in an individual health b…

(1) An issuer offering individual qualified health plans on the health benefit exchange must make special enrollment opportunities, subject to the same terms and conditions specified in WAC 284-43-1100, available to applicants who experience a qualifying event.(2) In addition to …

(1) Special enrollment periods must not be shorter than sixty days from the date of the qualifying event.(2) The effective date of coverage for those enrolling in an individual health plan through a special enrollment period is the first date of the next month after the premium i…

(1) Unless provided otherwise in this chapter or chapter 284-170 WAC with respect to utilization review of prescription drug services, this section governs issuer utilization review programs.(2) These definitions apply to this section:(a) "Concurrent care review request" means:(i…

(1) These definitions apply to the prescription drug utilization management timelines covered in this section only, excluding prescription drug prior authorization timelines, which are covered in WAC 284-43-2050:(a) "Nonurgent review request" means any request for approval of car…

(1) For purposes of this section and WAC 284-43-2022:(a) "Emergency fill" means a limited dispensed amount of medication that allows time for the processing of prescription drug utilization management.(b) "Medically appropriate" means prescription drugs that under the applicable …

(1) A carrier must make an exception request determination in a timely manner as defined in this section. A carrier may not deny the exception request if the enrollee or provider does not receive a response to an exception request within the time frames in this section.(2) A carr…

(1) This section applies to health benefit plans as defined in RCW 48.43.005, contracts for limited health care services as defined in RCW 48.44.035, and stand-alone dental and stand-alone vision plans. This section applies to plans issued or renewed on or after January 1, 2018. …

(1) This section applies to health benefit plans as defined in RCW 48.43.005, contracts for limited health care services as defined in RCW 48.44.035, and stand-alone dental and stand-alone vision plans. This section applies to plans issued or renewed on or after January 1, 2018.(…

A carrier must accept the universal format for authorization and reauthorization of inpatient or residential substance use disorder treatment services developed pursuant to section 9, chapter 366, Laws of 2024. The form will be posted on the insurance commissioner's website. Any …

Carriers and not grandfathered plans must follow the rules in this subchapter in order to comply with the adverse benefit determination process required by RCW 48.43.530 and 48.43.535. These rules apply to any request for a review of an adverse benefit determination made by a car…

These definitions apply to the sections in this subchapter, WAC 284-43-3030 through 284-43-3190 and 284-43A-140:"Adverse benefit determination" has the same meaning as defined in RCW 48.43.005 and WAC 284-43-0160."Appellant" means an applicant or a person covered as an enrollee, …

(1) Each carrier must establish and implement a comprehensive process for the review of adverse benefit determinations. The process must offer an appellant the opportunity for both internal review and external review of an adverse benefit determination. The process must meet acce…

A carrier must clearly communicate in writing the right to request a review of an adverse benefit determination.(1) At a minimum, the notice must be sent at the following times:(a) Upon request;(b) As part of the notice of adverse benefit determination;(c) To new enrollees at the…

(1) A carrier must notify enrollees of an adverse benefit determination either electronically or by U.S. mail. The notification must be provided:(a) To an appellant or their authorized representative;(b) To the provider if the adverse benefit determination involves the preservice…

(1) Except as otherwise provided by applicable law, rule, or regulation, a carrier furnishing documents through electronic media is deemed to satisfy the notice and disclosure requirements regarding adverse benefit determinations with respect to applicants, covered persons, and a…

An appellant seeking review of an adverse benefit determination must use the carrier's review process. Each carrier must include the opportunity for internal review of an adverse benefit determination in its review process. Treating providers may seek expedited review on a patien…

(1) If a carrier fails to strictly adhere to its requirements with respect to the internal review, the internal review process is deemed exhausted, and the appellant may request external review without receiving an internal review determination from the carrier or the health plan…

Each carrier's review process must require delivery of written notification of the internal review determination to the appellant. In addition to the requirements of WAC 284-43-3070, the written determination must include:(1) The actual reasons for the determination;(2) If applic…

(1) A carrier's internal and external review processes must permit an expedited review of an adverse benefit determination at any time in the review process, if:(a) The appellant is currently receiving or is prescribed treatment or benefits that would end because of the adverse b…

(1) "Concurrent expedited review" means initiation of both the internal and external expedited review simultaneously to:(a) Review of a decision made under WAC 284-43-2000; or(b) Review conducted during a patient's stay or course of treatment in a facility, the office of a health…

Subchapter F applies to grandfathered health plans. For any grandfathered health plan as defined in RCW 48.43.005, a carrier may comply with RCW 48.43.530 and 48.43.535 by using an appeal process that conforms to the procedures and standards set forth in WAC 284-43-4020 through 2…

(1) Each carrier must adopt and implement a comprehensive process for the resolution of appeals of adverse determinations. This process shall meet accepted national certification standards such as those used by the National Committee for Quality Assurance except as otherwise requ…

(1) An enrollee or the enrollee's representative, including the treating provider (regardless of whether the provider is affiliated with the carrier) acting on behalf of the enrollee may appeal an adverse determination in writing. The carrier must reconsider the adverse determina…

This definition applies to subchapter G. "Grievant" means a person filing a grievance as defined in WAC 284-43-0160, and who is not an appellant under either subchapter E or F of this chapter.[Statutory Authority: RCW 48.02.060. WSR 16-14-106 (Matter No. R 2016-11), § 284-43-4500…

This section applies to a health benefit plan regardless of its status as grandfathered or nongrandfathered.(1) Each carrier and health plan must offer applicants, covered persons, and providers a way to resolve grievances.(2) Each carrier must maintain a log or otherwise registe…

For health plans offered, issued or renewed on or after January 1, 2014, issuers must not condition or otherwise limit enrollment based on preexisting health conditions.[WSR 16-01-081, recodified as § 284-43-5000, filed 12/14/15, effective 12/14/15. Statutory Authority: RCW 48.02…

(1) All carriers required pursuant to law to offer and file with the commissioner a plan providing benefits identical to the basic health plan services (the model plan) shall file for such plan a full description of the process it will use to recognize an organization or individu…

A health carrier must not offer, renew, or issue a health benefit plan providing a prescription drug benefit, which the commissioner determines results or can reasonably be expected to result in an unreasonable restriction on the treatment of patients. A carrier may restrict pres…

(1) Except as provided in subsection (2) of this section, a carrier may design its prescription drug benefit to include cost control measures, including requiring preferred drug substitution in a given therapeutic class, if the restriction is for a less expensive, equally therape…

An issuer is not required to use a formulary as part of its prescription drug benefit design. If a formulary is used, an issuer must, at a minimum, comply with these requirements when a formulary change occurs. (1) In addition to the requirements set forth in WAC 284-30-450, an i…

(1) A carrier and health plan unreasonably restrict the treatment of patients if an ancillary charge, in addition to the plan's normal copayment or coinsurance requirements, is imposed for a drug that is covered because of one of the circumstances set forth in either WAC 284-43-5…

(1) Health plan disclosure information must comply with and include each requirement listed in RCW 48.43.510.(2) Health plan disclosures must be current and:(a) Provided by paper copy upon request;(b) Provided by electronic communication upon request;(c) Clearly identified as hea…

(1) It is an unfair practice for any health carrier to restrict, exclude, or reduce coverage or benefits under any health plan on the basis of sex. By way of example, a health plan providing generally comprehensive coverage of prescription drugs and prescription devices restricts…

When a treatment or service is gender affirming treatment, as defined in RCW 48.43.0128, it is an unfair practice for any health carrier to:(1) Deny or limit coverage, issue automatic denials of coverage, impose additional cost sharing or other limitations or restrictions on cove…

(1) A carrier must include the following information in the certificate of coverage issued for a health benefit plan, policy or agreement that includes a prescription drug benefit in addition to those required elsewhere in Titles 48 RCW and 284 WAC. The commissioner may disapprov…