Washington Administrative Code

(1) For nongrandfathered individual or small group health plans offered, issued or renewed on or after January 1, 2019, if an issuer elects to adjust its premium rates based on geographic area, the issuer must use the geographic rating areas designated in WAC 284-43-6701.(2)(a) E…

(1) The following geographic rating areas are designated for Washington state for nongrandfathered individual and small group plans offered, issued, or renewed on or after January 1, 2014, and on or before December 31, 2018:Area 1: Index geographic rating area: King County.Area 2…

(1) The following geographic rating areas are designated for Washington state for nongrandfathered individual and small group plans issued or renewed on or after January 1, 2019:Area 1: King County.Area 2/West: Clallam, Cowlitz, Grays Harbor, Jefferson, Kitsap, Lewis, Pacific, an…

For the purpose of WAC 284-43-6810 and 284-43-6820:(1) "Actuarial value metal value" or "AV metal value" means the actuarial value that results from use of the federal Actuarial Value Calculator, or a permissible alternative method prescribed in 45 C.F.R. § 156.135(b).(2) "Actuar…

This section applies to all nongrandfathered individual and small group health plans for plan years beginning on or after January 1, 2027.(1) The allowed underlying rate development components of the "actuarial value and cost-sharing design of the plan" adjustment are:(a) AV pric…

(1) This section applies to all individual silver level plans offered on the health benefit exchange for plan years beginning on or after January 1, 2027.(2) The following assumptions will be used by the commissioner in the cost-sharing reduction (CSR) silver load calculation:(a)…

This subchapter applies to:(1) Health plans;(2) Plans deemed by the commissioner to have a short-term limited purpose or duration;(3) Plans deemed by the commissioner to be student-only health plans that are guaranteed renewable while the covered person is enrolled as a regular, …

Aggregate lifetime limit means a dollar limitation on the total amount of specified benefits that may be paid under a plan (or health insurance coverage offered in connection with a plan) for any coverage unit.Annual dollar limit means a dollar limitation on the total amount of s…

(1) A plan providing mental health or substance use disorder benefits, must provide mental health or substance use disorder benefits in every classification in which medical/surgical benefits are provided.(2) Parity requirements must be applied to the following six classification…

(1) Classification of benefits must be measured as follows:(a) By type and level of financial requirement or treatment limitation.(i) A financial requirement or treatment limitation type includes deductibles, copayments, coinsurance, and out-of-pocket maximums. Types of quantitat…

(1) A plan or issuer may not impose an NQTL with respect to mental health or substance use disorder in any classification unless, under the terms of the plan as written and in operation, any processes, strategies, evidentiary standards or other factors used in applying the NQTL t…

(1) Benefits for actual treatment and services rendered may not be denied solely because a course of treatment was interrupted or was not completed.(2) If a service is prescribed for a mental health condition and is medically necessary, it may not be denied solely on the basis th…

(1) Plans and issuers must provide reasonable access to and copies of all documents, records, and other information relevant to an individual's claim.(a) Plans and issuers must provide disclosures consistent with WAC 284-43-4040, 284-43-3170, 284-43-3110, and 284-43-2000. For any…

(1) Plans and issuers must file a justification demonstrating the analysis of each plan's financial requirements and quantitative treatment limitations as required under WAC 284-43-7040.(2) Filing of this justification is subject to the requirements of chapters 284-44A, 284-46A, …

(1) The purpose of this subchapter is to establish uniform regulatory standards for required coverage of contraceptive services and other reproductive health services and supplies, voluntary sterilization, and abortion under RCW 48.43.072 and 48.43.073.(2) This subchapter applies…

(1) "Contraceptive services" means consultations, examinations, procedures, and other health care services to obtain contraceptive supplies or voluntary sterilization. This includes prescribing, dispensing, inserting, delivering, distributing, administering, or removing contracep…

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 …

(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 plan…

(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 con…

(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 a…

(1) A qualifying health plan and a qualifying student health plan for a health savings account ("HSA-qualifying plan") is subject to all of the requirements under RCW 48.43.072. An HSA-qualifying plan may apply a deductible to coverage of over-the-counter contraceptive supplies o…

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, …

(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 benefi…

(1) All carriers offering or issuing a short-term limited duration medical plan with an effective date on or after January 1, 2019, must issue a standard disclosure form for each short-term limited duration medical plan in the same format and with the same content as the disclosu…

(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 …

(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 "…

(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 consti…

(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. The form filing for an association health plan submitted by a carrier must include documents related to "Evidence as an Employer." The documents mu…

(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)…

(1) Issuers must file a group health plan, other than a small group health plan, rate and form filing as provided in RCW 48.43.733. An issuer offering plans through an association or member-governed group must implement all new applicable federal or state health plan market requi…

(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 he…

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" m…

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 regula…

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 …

(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…

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 …

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…

(1) To be certified as an IRO under this chapter, an organization must make an application to the commissioner upon a form to be furnished by the commissioner as required under RCW 48.43.537 and submitted using the commissioner's online service. The application must include or be…

(1) An IRO shall maintain written policies and procedures covering all aspects of review.(2) An IRO shall ensure the confidentiality of medical records and other personal health information received for use in independent reviews, in accordance with applicable federal and state l…

(1) An IRO:(a) Must not be a subsidiary of, or in any way owned or controlled by, a carrier or an association of health care providers or carriers;(b) Shall provide information to the commissioner on its own organizational affiliations and potential conflicts of interest at the t…

(1) Each IRO shall maintain an adequate number and range of qualified expert reviewers in order to:(a) Make determinations regarding the full range of independent review cases occurring in Washington state under RCW 48.43.535; and(b) Meet timelines specified in WAC 284-43A-070(3)…

(1) Information for review.(a) IROs shall, as necessary, request, accept, and consider the following information as relevant to a case:(i) Information that the carrier is required to submit to the IRO under WAC 284-43A-140, including information identified in that section that is…

(1) General criteria and considerations.(a) The determination must be consistent with the standards in RCW 48.43.537, 48.43.535, and chapter 284-43A WAC.(b) The expert reviewers from a certified IRO will make determinations regarding the medical necessity or appropriateness of, a…

(1) In addition to the qualifications listed in WAC 284-43A-060 (3) and (5), at least part of the clinical reviewers' relevant, recent clinical experience must have been obtained in the past three years.(2) Each clinical reviewer shall consider the following information, if appro…

A certified IRO shall:(1) Comply with the provisions of RCW 48.43.535(5), and this chapter;(2) Cooperate with the commissioner during investigations;(3) Provide the commissioner with information requested in a prompt manner. A lack of response within fifteen business days from re…

(1) The commissioner may deny, suspend, revoke, or modify certification of an IRO if the commissioner has reason to believe the applicant, certified IRO, its agents, officers, directors, or any person with any interest in the IRO has failed or refused to comply with the requireme…

(1) The commissioner may deny an application for certification, or suspend, revoke, or modify certification if the applicant, certified IRO, its agents, officers, directors, or any person with any interest:(a) Makes a misrepresentation of, false statement of, or fails to disclose…

This section sets the maximum fee schedule for independent reviews, and the process of review and determination of a case referred to an independent review organization (IRO).(1) IROs may not charge more than the following amount for each review:CategoryAmountContract review, int…

When the internal review of an adverse benefit determination is final, or is deemed exhausted, the appellant may request an external independent review of the final internal adverse benefit determination. Carriers and health plans must inform appellants of their right to external…

Carriers must use the rotational registry system of certified independent review organizations (IROs) established by the commissioner.(1) Using the commissioner's online service carriers must select reviewing IROs in the rotational manner described in the rotational registry syst…