Washington Administrative Code

A carrier and health plan must cover prescribed, self-administered anticancer medication that is used to kill or slow the growth of cancerous cells on at least a comparable basis to the plan's coverage for the delivery of cancer chemotherapy medications administered in a clinical…

For plan years beginning on or after January 1, 2014, each nongrandfathered health benefit plan offered, issued, or renewed to small employers or individuals, both inside and outside the Washington health benefit exchange, must provide coverage for a package of essential health b…

The following definitions apply to WAC 284-43-5400 through 284-43-5820 unless the context indicates otherwise."Base-benchmark plan" means the small group plan with the largest enrollment, as designated in WAC 284-43-5602(1) until December 31, 2025, or the updated essential health…

A carrier must not restrict coverage of routine patient costs for enrollees who participate in a clinical trial. "Routine costs" means items and services delivered to the enrollee that are consistent with and typically covered by the plan or coverage for an enrollee who is not en…

(1) An issuer's certificate of coverage and the summary of coverage for the health benefit plan must specifically explain any uniformly applied limitation on the scope, visit number or duration of a benefit, and state whether the uniform limitation is subject to adjustment based …

A nongrandfathered individual or small group health benefit plan offered, issued, amended, or renewed on or after January 1, 2017, must, at a minimum, include coverage for essential health benefits. "Essential health benefits" means all of the following:(1) The benefits and servi…

A nongrandfathered individual or small group health benefit plan offered, issued, amended, or renewed on or after January 1, 2026, must, at a minimum, include coverage for essential health benefits. "Essential health benefits" means all of the following:(1) The benefits and servi…

(1) A nongrandfathered individual or small group health benefit plan offered, issued, or renewed, on or after January 1, 2017, must provide coverage that is substantially equal to the EHB-benchmark plan, as described in WAC 284-43-5642, 284-43-5702, and 284-43-5782.(a) For plans …

(1) A nongrandfathered individual or small group health benefit plan offered, issued, or renewed, on or after January 1, 2026, must provide coverage that is substantially equal to the EHB-benchmark plan, as described in WAC 284-43-5644, 284-43-5704, and 284-43-5784.(a) For plans …

(1) A health benefit plan must cover "ambulatory patient services" in a manner substantially equal to the base-benchmark plan. For purposes of determining a plan's actuarial value, an issuer must classify as "ambulatory patient services" those medically necessary services deliver…

(1) A health benefit plan must cover "ambulatory patient services" in a manner substantially equal to the base-benchmark plan. For purposes of determining a plan's actuarial value, an issuer must classify as "ambulatory patient services" those medically necessary services deliver…

A health benefit plan must include "pediatric dental benefits" in its essential health benefits package. Pediatric dental benefits means coverage for the oral services listed in subsection (3) of this section, delivered to those under age 19. Plans must provide this coverage for …

A health benefit plan must include "pediatric dental benefits" in its essential health benefits package. Pediatric dental benefits means coverage for the oral services listed in subsection (3) of this section, delivered to those under age 19. Plans must provide this coverage for …

For plan years beginning on or after January 1, 2015, each nongrandfathered health benefit plan offered, issued or renewed to small employers or individuals, outside the Washington health benefit exchange, must include pediatric dental benefits as an essential health benefit (EHB…

"PPACA" or "ACA" means the federal Patient Protection and Affordable Care Act (Public Law 111-148), as amended by the federal Health Care and Education Reconciliation Act of 2010 (Public Law 111-152), collectively known as the Affordable Care Act, and any rules, regulations, or g…

(1) An issuer of a health benefit plan may satisfy the requirement of WAC 284-43-5720 in any one of the following ways.(a) A health benefit plan includes pediatric dental benefits as an embedded benefit; or(b) A separate health benefit plan is offered without pediatric dental ben…

A health benefit plan must include "pediatric vision services" in its essential health benefits package. The designated base-benchmark plan for pediatric vision benefits consists of the benefits and services covered by health care service contractor Regence BlueShield as the Rege…

A health benefit plan must include "pediatric vision services" in its essential health benefits package. The designated base-benchmark plan for pediatric vision benefits consists of the benefits and services covered within Appendix B - Washington Essential Health Benefits Benchma…

(1) A health benefit plan must not apply cost-sharing requirements to Native Americans purchasing a health benefit plan through the exchange, whose incomes are at or below 300 percent of federal poverty level.(2) A small group health benefit plan that includes the essential healt…

A health benefit plan issuer must not indicate or imply that a health benefit plan covers essential health benefits unless the plan, policy, or contract covers the essential health benefits in compliance with WAC 284-43-5400 through 284-43-5800. This requirement applies to any he…

The effective date of WAC 284-43-0160, 284-170-200, 284-170-360, 284-43-2000, 284-43-4020, 284-43-4040, 284-43-5130, and 284-43A-150 is July 1, 2001.[Statutory Authority: RCW 48.02.060, 48.43.535, and 48.43.537. WSR 16-23-168 (Matter No. R 2016-17), § 284-43-5900, filed 11/23/16,…

An issuer offering an individual, small group or large group health plan may not impose waiting periods for organ transplant services in any health plan.[Statutory Authority: RCW 48.02.060, 48.43.012, 48.43.01211, 48.43.0123, 48.43.0124, 48.43.0126, 48.43.0127, 48.43.0128, and 48…

A health plan cannot be rescinded by an issuer during the coverage period, except for an enrollee who has performed an act or practice that constitutes fraud or makes an intentional misrepresentation of a material fact as prohibited by the terms of the plan or coverage. If the pl…

(1) An issuer offering qualified health plans as defined in 42 U.S.C. 18021, and its officials, employees, agents, and representatives must not employ marketing practices or benefit designs with respect to these plans that the commissioner determines will have the effect of disco…

As used in WAC 284-43-5940 through 284-43-5980, the following terms have the following meaning:(1) Auxiliary aids and services include:(a) Qualified interpreters on-site or through video remote interpreting (VRI) services, as defined in 28 C.F.R. 35.104 and 36.303(b); note takers…

(1) The purpose of this regulation is to effectuate the provisions of chapter 245, Laws of 2023, by requiring health carriers to include coverage for hearing instruments.(2) This section applies to health carriers offering nongrandfathered group health plans, other than small gro…

(1) For purposes of compliance with RCW 48.43.135 and WAC 284-43-5644, which require health plans issued or renewed on or after January 1, 2026, to cover hearing instruments and related services:(a) "Hearing instrument" has the same meaning as defined in RCW 48.43.135;(b) "Initia…

(1) An issuer offering a plan, and the issuer's officials, employees, agents, or representatives may not:(a) Design plan benefits, or implement its plan benefits, in a manner that results in discrimination against individuals because of their age, expected length of life, present…

Each issuer offering a plan, and the issuer's officials, employees, agents or representatives must take fair and reasonable steps to provide meaningful access to each enrollee or individual likely to be encountered who has limited-English proficiency or a disability consistent wi…

(1) General requirement. An issuer offering a plan shall take reasonable steps to provide meaningful access to each enrollee or individual likely to be encountered with limited-English proficiency.(2) Evaluation of compliance. In evaluating whether an issuer has met its obligatio…

An issuer offering a plan shall:(1) Take appropriate steps to ensure that communications with individuals with disabilities are as effective as communications with others with respect to benefits and services, in accordance with the standards found at 28 C.F.R. 35.160 through 35.…

An issuer offering a plan, and the issuer's officials, employees, agents, or representatives shall:(1) Provide individuals equal access with respect to the plan including, but not limited to, plan administration, member communication, medical protocols or criteria for medical nec…

(1) Each issuer shall designate at least one employee to coordinate its efforts to comply with and carry out its responsibilities under RCW 48.43.0128 and WAC 284-43-5935 through 284-43-5980, including the investigation of any grievance communicated to it alleging noncompliance w…

(1) An issuer offering a plan shall take appropriate initial and continuing steps to notify enrollees, applicants, and members of the public of the following:(a) The issuer does not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, …

This subchapter is adopted under the general authority of RCW 48.02.060, 48.44.017, 48.44.020, 48.44.050, 48.46.060, 48.46.062, 48.46.200, and 48.43.733. Its purpose is to provide guidelines for the implementation of RCW 48.44.017(2), 48.44.020(3), 48.44.022, 48.44.023, 48.44.040…

This subchapter applies to grandfathered individual and small group health benefit plans offered by health care service contractors and health maintenance organizations transacting business in this state under chapter 48.44 or 48.46 RCW, stand-alone dental plans and stand-alone v…

For the purpose of this subchapter:(1) "Adjusted earned premium" means the amount of "earned premium" the "carrier" would have earned had the "carrier" charged current "premium rates" for all applicable "plans."(2) "Annualized earned premium" means the "earned premium" that would…

(1) The provisions of this section are in addition to the requirements set forth in RCW 48.44.022, 48.44.023, 48.46.064, and 48.46.066.(2) Benefits will be found not to be unreasonable if the projected earned premium for the rate renewal period is equal to the following:(a) An ac…

Under RCW 48.44.022 and 48.46.064 the experience of all individual plans must be pooled. Under RCW 48.44.023 and 48.46.066 the experience of all small group plans must be pooled. Filings for individual plans must include each individual plan rate schedule. Filings for small group…

This subchapter is adopted under the general authority of RCW 48.02.060. This subchapter 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, stand-alone dental plans and stand-alone vision plans. Thi…

For the purpose of this subchapter:(1) "Contract" means an agreement to provide health care services or pay health care costs for or on behalf of a "subscriber" or group of "subscribers" and such eligible dependents as may be included therein.(2) "Contract form" means the prototy…

Groups Other Than Small Groups Filing SummaryCarrier Name Address Contract Holder/Pool Category and Name (Check One Box)□ Single Employer Group: Employer Name: □ Multiemployer other than Association/Trust Groups Group Pool Name: □ Association/Trust Groups Association/Trust Group …

(1) All rates and forms of group health benefit plans other than small group plans and all stand-alone dental and stand-alone vision plans offered by a health carrier or limited health care service contractor as defined in RCW 48.44.035 and modification of a contract form or rate…

Each filing required by WAC 284-43-6560 must be submitted with the filing transmittal form prescribed by and available from the commissioner. The form must include the name of the filing entity, its address, identification number, the type of filing being submitted, the form name…

For the purposes of mitigating inequity in the health insurance market, unless waived by the commissioner pursuant to RCW 48.43.725 and subsection (3) of this section, the commissioner must assess a fee on any health carrier offering a health plan or student health plan that excl…

Every issuer offering or renewing a health benefit plan on or after January 1, 2016, must attest to the insurance commissioner that the transparency tools available to their members meet the requirements of RCW 48.43.007.(1) Annually, each health plan issuer must file an attestat…

(1) For each plan, carriers must maintain the following records for five years:(a) Incurred claims;(b) Earned premiums; and(c) Expenses.(2) Such records must include data for rider and endorsement forms that are used with the contract forms. Separate data may be maintained for ea…

In determining the credibility and appropriateness of experience data, consideration will be given to all relevant factors, including:(1) Statistical credibility of the amount charged and services and benefits paid, such as low exposure, low loss frequency, and recoupment;(2) Act…

INDIVIDUAL AND SMALL GROUP FILING SUMMARYCarrier Name Address Carrier Identification Number Rate Renewal Period:From To Date Submitted: Proposed Rate SummaryCurrent community rateper monthProposed community rateper monthPercentage change%Portion of carrier's total enrollment affe…

(1) For nongrandfathered individual or small group health plans offered, issued or renewed on or after January 1, 2014, and on or before December 31, 2018, if an issuer elects to adjust its premium rates based on geographic area, the issuer must use the geographic rating areas de…