Washington Administrative Code

(1) The definitions in RCW 48.43.005 apply throughout this chapter unless the context clearly requires otherwise, or the term is defined otherwise in subsection (2) of this section.(2) The following definitions shall apply throughout this chapter:(a) "Air ambulance service" has t…

(1) Coverage of emergency services is governed by RCW 48.43.093. Emergency services, as defined in RCW 48.43.005, include services provided after an enrollee is stabilized and as part of outpatient observation or an inpatient or outpatient stay with respect to the visit during wh…

(1) If an enrollee receives any emergency services from a nonparticipating facility, provider, or behavioral health emergency services provider, any nonemergency health care services performed by a nonparticipating provider at certain participating facilities, or any air ambulanc…

If an enrollee receives covered ground ambulance services:(1) The enrollee satisfies their obligation to pay for the ground ambulance services if they pay the in-network cost-sharing amount specified in the enrollee's applicable health plan contract. The enrollee's obligation mus…

(1) Except for mutual aid transports as provided in subsection (2) of this section, until December 31, 2027, the allowed amount paid to a nonparticipating ground ambulance services organization for covered ground ambulance services under a health plan issued by a carrier must be …

(1) Each local governmental entity that has established rates for ground ambulance services provided in their geographic area must submit the rates to the office of the insurance commissioner in the form and manner prescribed by the commissioner. Rates established for ground ambu…

For services described in RCW 48.49.020(1) (other than air ambulance services) provided prior to July 1, 2023, or a later date determined by the commissioner, and for services provided by a nonparticipating emergency behavioral health services provider if the federal government d…

(1) Effective for services provided on or after July 1, 2023, or a later date determined by the commissioner, services described in RCW 48.49.020(1) other than air ambulance services are subject to the independent dispute resolution process established in sections 2799A-1 and 279…

(1)(a) To initiate arbitration, the carrier, provider, or facility must provide written notification to the commissioner and the noninitiating party no later than 10 calendar days following completion of the period of good faith negotiation under WAC 284-43B-030(3) using the arbi…

(1) For purposes of calculating the date that written submissions to the arbitrator under RCW 48.49.040 are due, final selection of the arbitrator occurs on the date that the commissioner sends by electronic transmittal the notice of selection to the arbitrator. The parties must …

(1) To implement RCW 48.49.170, carriers must make information regarding whether an enrollee's health plan is subject to the requirements of chapter 48.49 RCW or section 2799A-1 et seq. of the Public Health Service Act (42 U.S.C. Sec. 300gg-111 et seq.) and federal regulations im…

(1) The commissioner shall develop a standard template for a notice of consumer protections from balance billing under the Balance Billing Protection Act and the federal No Surprises Act (P.L. 116-260). The notice may be modified periodically, as determined necessary by the commi…

(1)(a) If the commissioner has cause to believe that any health facility, behavioral health emergency services provider, provider, or ground ambulance services organization has engaged in a pattern of unresolved violations of RCW 48.49.020, 48.49.030, or 48.49.200 the commissione…

(1) A self-funded group health plan that elects to participate in RCW 48.49.020 through 48.49.040, 48.49.160, and 48.49.200, shall provide notice to the commissioner of their election decision on a form prescribed by the commissioner. The completed form must include an attestatio…

If any provision of this chapter or its application to any person or circumstance is for any reason held to be invalid by a court, the remainder of this chapter and the application of the provisions to other persons or circumstances shall not be affected.[Statutory Authority: RCW…

All required forms referenced in this chapter, shall be on forms designated by the commissioner for that purpose. The forms will be available on the commissioner's website. Any new or updated forms will be posted on the commissioner's website at least 30 days before their effecti…

(1) This regulation, WAC 284-44-010 through 284-44-070, is promulgated pursuant to RCW 48.44.050 and 48.44.020, and may be cited as the "Washington state health care service contractor regulation."(2) This regulation, chapter 284-44 WAC, shall apply to every health care service c…

(1) No contract may contain a discretionary clause. "Discretionary clause" means a provision that purports to reserve discretion to a carrier, its agents, officers, employees, or designees in interpreting the terms of a contract or deciding eligibility for benefits, or requires d…

Every health care service contract issued or renewed after December 31, 1974 shall conform to the following format standards:(1) The style, arrangement and over-all appearance of the contract shall give no undue prominence to any portion of the text, and every printed portion of …

Every health care service contract issued or renewed after December 31, 1974, shall conform to the following standards:(1) A contract shall not unreasonably limit benefits to a specified period of time. For example, a provision that services for a particular condition will be cov…

(1) Pursuant to RCW 48.44.460, each offer of new or renewal group coverage made on or after January 1, 1993, must include one or more offers of optional coverage for the treatment of temporomandibular joint disorders. Health care service contractors are encouraged to exercise bro…

(1) Every health care service contract which excludes or limits, or reserves the right to exclude or limit, benefits for any treatment, procedure, facility, equipment, drug, drug usage, medical device, or supply (hereinafter individually and collectively referred to as services) …

(1) Every health care service contractor agreement which is entered into initially or renewed after the effective date of this rule, and which provides benefits for any health care service to be performed by doctors of medicine, and every certificate issued thereunder, shall cont…

(1) The purpose of this regulation is to effectuate the provisions of RCW 48.44.325 by establishing definitions for the exceptions to coverage for mammograms. This regulation shall apply to every group and individual health care service contract which is delivered or issued for d…

Every contractor shall issue to the employer, a contract holder, or other person or association in whose name a contract is issued, for delivery to each person covered by a group contract, a certificate setting forth in summary form a statement of the essential features of the co…

The effective date of this regulation shall be August 1, 1974.[Order R-74-1, § 284-44-070, filed 6/4/74, effective 8/1/74.]

Beginning January 1, 1983, to aid in the administration of chapter 48.44 RCW, every health care service contractor shall account for its business on the accrual basis, and any annual financial statement filed after December 31, 1983, pursuant to RCW 48.44.095, shall be reported o…

(1) The purpose of this regulation, WAC 284-44-300 through 284-44-360, is to establish indemnity requirement rules and procedures for the effectuation of RCW 48.44.030 and to aid in the administration thereof.(2) This regulation applies to every health care service contractor reg…

(1) If, pursuant to RCW 48.44.030, the agreement is underwritten by a contract or policy of insurance, such contract or policy shall:(a) Have a continuous term;(b) Fully insure the benefits of the persons who have paid for or contracted for covered health care services, which per…

(1) If, pursuant to RCW 48.44.030, the agreement is guaranteed by a surety company, such agreement shall:(a) Be in an amount equal to the greater of (i) one hundred fifty thousand dollars, or (ii) one-twelfth of the total sum of money received during the preceding calendar year a…

(1) If, pursuant to RCW 48.44.030, the agreement is guaranteed by a deposit of cash or securities, the deposit must be in an amount equal to the greater of (i) one hundred fifty thousand dollars, or (ii) one-twelfth of the total sum of money received during the preceding calendar…

(1) Reduced deposit requirements may be permitted when data satisfactory to the commissioner are provided which indicate an amount less than that set forth in WAC 284-44-320 and 284-44-330 is adequate to cover incurred but unpaid reimbursement or indemnity benefits. In determinin…

(1) Each health care service contractor shall maintain records which separately reflect the amount of service benefits and the amount of reimbursement or indemnity benefits. Reasonable approximation based on paid claims data may be used to project incurred indemnity benefits. Suc…

(1) The purpose of this section is to effectuate the provisions of section 3, chapter 173, Laws of 1988, by establishing the requirements and exceptions with respect to coverage for the formulas necessary for the treatment of phenylketonuria (PKU), applicable to health care servi…

(1) As an alternative to hospitalization or institutionalization of an insured and with the intent to cover placement of the insured patient in the most appropriate and cost-effective setting, every individual or group contract of a health care service contractor issued, amended,…

The definitions in this section apply throughout this chapter.(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 (S…

The purpose of this chapter is to:(1) Adopt processes and procedures for filers and HCSCs to use when submitting electronic forms and rates to the commissioner by way of SERFF.(2) Effective July 1, 2010, designate SERFF as the method by which filers and HCSCs must submit all form…

This chapter applies to all HCSCs that must file forms and rates under RCW 48.44.040, 48.44.070, and 48.66.035.[Statutory Authority: RCW 48.02.060, 48.44.050, and 48.46.200. WSR 10-01-118 (Matter No. R 2009-04), § 284-44A-030, filed 12/17/09, effective 1/17/10.]

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 form or rate 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 distinguish it from other versions of the same form.(b) Fil…

(1) If a rate filing is required under RCW 48.44.040 or 48.66.035, the filer must submit it:(a) Separate from any corresponding form filing; and(b) Concurrently with the corresponding form filing if new forms are being introduced.(2) Each rate filing must include, if appropriate:…

(1) The commissioner may reject and close any filing that does not comply with WAC 284-44A-040, 284-44A-050, or 284-44A-060. If the commissioner rejects a filing, the filer has not filed forms or rates with the commissioner.(2) If the commissioner rejects a filing and the filer r…

A HCSC 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 an HCSC delegates filing authority to a third-party f…

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

If an HCSC 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 changes to the disapproved form.(2…

(1) Filers must include a common implementation date for all forms or rates 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, 48.44.050, and 48.46.200. WSR 10-01-118 (Matt…

HCSCs may issue forms written in languages other than English.(1) If the HCSC translates the form from English to another language, the HCSC must:(a) File the translated version of the form.(b) Include written disclosure statements on the translated contract indicating that it is…

(1) No contract may contain a discretionary clause. "Discretionary clause" means a provision that purports to reserve discretion to a health maintenance organization, its agents, officers, employees, or designees in interpreting the terms of a contract or deciding eligibility for…

Each filing made of a rate or contract form shall be submitted with the filing transmittal form prescribed by and available from the commissioner. Use of a standardized transmittal form makes it easier for the commissioner to identify filings, issuers, and other important identif…

(1) The purpose of this section is to effectuate the provisions of section 4, chapter 173, Laws of 1988, by establishing the requirements with respect to coverage for the formulas necessary for the treatment of phenylketonuria (PKU), applicable to health maintenance organizations…