Title 48 — Title 48 INSURANCE
101 chapters · 2,134 sections in this title.
RCW 48.43.605 Overpayment recovery—Health care provider.
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(1) Except in the case of fraud, or as provided in subsection (2) of this section, a health care provider may not: (a) Request additional payment from a carrier to satisfy a claim unless he or she does so in writing to the carrier within twenty-four months after the date that the…
RCW 48.43.670 Plan or contract renewal—Modification of wellness program.
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Upon the renewal date of an individual or group health benefit plan or contract containing health benefits, the modification of a wellness program, as defined in 45 C.F.R. 146.121(f), included in such a plan or contract shall not be considered a cancellation or nonrenewal of such…
RCW 48.43.680 Lifetime limit on transplants—Definition.
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(1) A health benefit plan that is issued or renewed on or after January 1, 2010, and that provides coverage for organ and tissue transplants, may not permit a separate lifetime limit on transplants of any less than three hundred fifty thousand dollars. The lifetime limit on trans…
RCW 48.43.690 Assessments under RCW 70.290.040 considered medical expenses.
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Assessments paid by carriers under RCW 70.290.040 may be considered medical expenses for purposes of rate setting and regulatory filings.[ 2010 c 174 s 15.]Notes:Effective date—2010 c 174: See RCW 70.290.900.
RCW 48.43.700 Exchange—Plans that a carrier must offer—Review—Rules.
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(1) For plan or policy years beginning January 1, 2014, a carrier offering a health benefit plan that meets the definition of bronze level in section 1302 of P.L. 111-148 of 2010, as amended, in the individual market outside of the exchange must also offer plans that meet the def…
RCW 48.43.705 Plans offered outside of exchange.
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All nongrandfathered individual and small group health plans, other than catastrophic health plans, offered outside of the exchange must conform with the actuarial value tiers specified in section 1302 of P.L. 111-148 of 2010, as amended, as bronze, silver, gold, or platinum.[ 20…
RCW 48.43.710 Certification as qualified health plan not an exemption.
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Certification by the Washington health benefit exchange of a plan as a qualified health plan, or of a carrier as a qualified issuer, does not exempt the plan or carrier from any of the requirements of this title or rules adopted by the commissioner pursuant to chapter 34.05 RCW t…
RCW 48.43.715 Individual and small group market—Selection of benchmark plan—Minimum requirements—Criteria—List of state-mandated health benefits.
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(1) Until the effective date of an updated essential health benefits benchmark plan submitted under section 1, chapter 87, Laws of 2023, the commissioner, in consultation with the board and the health care authority, shall, by rule, select the largest small group plan in the stat…
RCW 48.43.720 Reinsurance and risk adjustment programs—Affordable care act—Rules.
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(1)(a) The commissioner, in consultation with the board, shall adopt rules establishing the reinsurance and risk adjustment programs required by P.L. 111-148 of 2010, as amended.(b) The commissioner must include in deliberations related to reinsurance rule making an analysis of a…
RCW 48.43.725 Exclusion of mandated benefits from health plan—Carrier requirements—Notice—Fees—Commissioner's duties.
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(1) A health carrier that excludes, under state or federal law, any benefit required or mandated by this title or rules adopted by the commissioner from any health plan or student health plan shall:(a) Notify each enrollee in writing of the following:(i) Which benefits the health…
RCW 48.43.730 Carrier must file provider contracts and compensation agreements with commissioner—Approval or disapproval—Confidentiality—Hearings—Rules—Definitions.
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(1) For the purposes of this section:(a) "Carrier" means a:(i) Health carrier as defined in RCW 48.43.005; and(ii) Limited health care service contractor that offers limited health care service as defined in RCW 48.44.035.(b) "Provider" means:(i) A health care provider as defined…
RCW 48.43.731 Health care benefit management contracts—Carrier filing requirements—Notice to enrollees—Confidentiality of filings.
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(1) A carrier must file with the commissioner in the form and manner prescribed by the commissioner every contract and contract amendment between the carrier and any health care benefit manager registered under RCW 48.200.030, within thirty days following the effective date of th…
RCW 48.43.732 Provider contracts—Public statements—Language.
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(1) In the case of a provider contract that is expiring by its own terms or for which one party has given notice to the other party of an intended termination without cause in accordance with the terms of the provider contract, neither the health care provider, the health care fa…
RCW 48.43.733 Rates and forms of group health benefit plans—Timing of filings—Exceptions—Rules.
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(1) All rates and forms of group health benefit plans other than small group plans, and all stand-alone dental and all 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…
RCW 48.43.734 Health carrier rate filings—Review of surplus, capital, and profit levels.
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(1) For individual and small group rate filings with an effective date on or after January 1, 2021, submitted by a health carrier for either the individual or small group markets, the commissioner may review the carrier's surplus, capital, or profit levels as an element in determ…
RCW 48.43.735 Reimbursement of health care services provided through telemedicine or store and forward technology—Audio-only telemedicine.
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(1)(a) For health plans issued or renewed on or after January 1, 2017, a health carrier shall reimburse a provider for a health care service provided to a covered person through telemedicine or store and forward technology if:(i) The plan provides coverage of the health care serv…
RCW 48.43.740 Dental only plan—Emergency dental conditions—Definitions.
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(1) A health carrier offering a dental only plan may not deny coverage for treatment of emergency dental conditions that would otherwise be considered a covered service of an existing benefit contract on the basis that the services were provided on the same day the covered person…
RCW 48.43.743 Dental only plan—Annual data statement—Contents—Public use—Definition.
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(1) Each health carrier offering a dental only plan in Washington shall submit to the commissioner on or before April 1st of each year as part of the additional data statement, or as a supplemental data statement, Washington specific data for the preceding year that is derived fr…
RCW 48.43.745 Dental only plan—Denturist services.
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(1) Every health carrier offering dental only coverage and every health carrier offering dental only coverage in addition to a health plan delivered, issued for delivery, or renewed by a health carrier on and after January 1, 2024, shall permit denturists licensed under chapter 1…
RCW 48.43.747 Dental only plan—Coverage for same day procedures.
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(1) A dental only plan offered by a carrier or limited health care service contractor, as defined in RCW 48.44.035, may not deny coverage for procedures solely on the basis that the procedures were performed on the same day.(2) Nothing in this section shall prevent a dental only …
RCW 48.43.748 Dental only plan—Payments by credit card.
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(1) A dental only plan offered by a carrier or limited health care service contractor, as defined in RCW 48.44.035, may pay a claim for reimbursement made by a dental care provider using a credit card if:(a) The carrier or limited health care service contractor notifies the provi…
RCW 48.43.750 Health care provider credentialing applications—Use of electronic database by health carriers.
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(1)(a) A health carrier must use the database selected pursuant to RCW 48.165.035 to accept and manage credentialing applications from health care providers. A health carrier may not require a health care provider to submit credentialing information in any format other than throu…
RCW 48.43.755 Health care provider credentialing applications—Use of electronic database by providers.
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(1) When submitting a credentialing application to a health carrier, a health care provider shall submit the application to health carriers using the database selected pursuant to RCW 48.165.035.(2) A health care provider shall update credentialing information as necessary to pro…
RCW 48.43.757 Health care provider credentialing applications—Reimbursement requirements.
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(1) If a carrier approves a health care provider's credentialing application, upon completion of the credentialing process, the carrier must reimburse a health care provider under the following circumstances:(a) When credentialing a new health care provider through a new provider…
RCW 48.43.760 Opioid use disorder—Coverage without prior authorization.
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For health plans issued or renewed on or after January 1, 2020, a health carrier shall provide coverage without prior authorization of at least one federal food and drug administration approved product for the treatment of opioid use disorder in the drug classes opioid agonists, …
RCW 48.43.761 Withdrawal management services—Substance use disorder treatment services—Prior authorization—Utilization review—Medical necessity review.
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(1) Except as provided in subsection (2) of this section, a health plan issued or renewed on or after January 1, 2021, may not require an enrollee to obtain prior authorization for withdrawal management services or inpatient or residential substance use disorder treatment service…
RCW 48.43.762 Opioid overdose reversal medication bulk purchasing and distribution program.
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(1) For health plans issued or renewed on or after January 1, 2023, health carriers must participate in the opioid overdose reversal medication bulk purchasing and distribution program established in RCW 70.14.170 once the program is operational. A health plan may not impose enro…
RCW 48.43.764 Standard set of criteria—Authority review.
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When updated versions of the ASAM Criteria, treatment criteria for addictive, substance related, and co-occurring conditions, inclusive of adolescent and transition age youth versions, are published by the American society of addiction medicine, the health care authority and the …
RCW 48.43.765 Health carrier network adequacy—Mental health and substance abuse treatment.
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(1) The commissioner shall amend his or her rules on electronic provider directories to require health carriers to include a notation when any mental health provider or substance abuse provider is closed to new patients.(2) Beginning January 1, 2020, a health carrier shall promin…
RCW 48.43.766 Mental health and substance use disorder services—Coverage—Utilization reviews.
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(1) For the purposes of this section:(a) "Clinical review criteria" means written guidelines, standards, protocols, or decision rules used by a health carrier, or health care benefit manager on behalf of a health carrier, during utilization review to evaluate the medical necessit…
RCW 48.43.767 Behavioral health services—Network access.
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By July 1, 2025, every carrier shall provide access to services provided by behavioral health support specialists in a manner sufficient to meet the network access standards set forth in rules established by the office of the insurance commissioner.[ 2023 c 270 s 12.]
RCW 48.43.770 Individual market health plan availability—Annual report.
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The commissioner shall submit an annual report to the appropriate committees of the legislature on the number of health plans available per county in the individual market.[ 2019 c 364 s 7.]
RCW 48.43.775 Qualified health plan participation—Reimbursement rate for other health plans.
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A carrier may not require a provider or facility participating in a qualified health plan under RCW 41.05.410 to, as a condition of participation in a qualified health plan under RCW 41.05.410, accept a reimbursement rate for other health plans offered by the carrier at the same …
RCW 48.43.780 Cap on enrollee's required payment amount for specific drugs and equipment—Cost-sharing requirements.
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(1)(a) Except as required in (b) of this subsection, a health plan issued or renewed on or after January 1, 2023, that provides coverage for prescription insulin drugs for the treatment of diabetes must cap the total amount that an enrollee is required to pay for a covered insuli…
RCW 48.43.785 COVID-19 personal protective equipment expenses—Health care provider reimbursement.
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(1) For the duration of the federal public health emergency related to COVID-19, a health benefit plan shall reimburse a health care provider who bills for incurred personal protective equipment expenses as a separate expense, using the American medical association's current proc…
RCW 48.43.790 Behavioral services—Next-day appointments.
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Health plans issued or renewed on or after January 1, 2023, must make next-day appointments available to enrollees experiencing urgent, symptomatic behavioral health conditions to receive covered behavioral health services. The appointment may be with a licensed provider other th…
RCW 48.43.795 Qualified health plans—Acceptance of premium and cost-sharing assistance.
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For qualified health plans offered on the exchange, a carrier shall:(1) Accept payments for enrollee premiums or cost-sharing assistance under RCW 43.71.110 or as part of a sponsorship program under RCW 43.71.030(4). Nothing in this subsection expands or restricts the types of sp…
RCW 48.43.800 Primary care expenditures reporting—Review.
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(1) The commissioner may require health carriers to annually report primary care expenditures in previous calendar years or anticipated for upcoming calendar years.(2) The commissioner may determine the form and content of carrier primary care expenditure reporting. In developing…
RCW 48.43.805 Prescription drug upper payment limit—Rules.
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(1) For health plans issued or renewed on or after January 1, 2024, if the prescription drug affordability board, as established in chapter 70.405 RCW, establishes an upper payment limit for a prescription drug pursuant to RCW 70.405.050, a carrier must provide sufficient informa…
RCW 48.43.810 Biomarker testing—Standards—Construction.
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(1) Health plans issued or renewed on or after January 1, 2023, shall exempt an enrollee from prior authorization requirements for coverage of biomarker testing for either of the following:(a) Stage 3 or 4 cancer; or(b) Recurrent, relapsed, refractory, or metastatic cancer.(2) Fo…
RCW 48.43.815 Donor human milk—Standards.
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(1) For group health plans other than small group health plans issued or renewed on or after January 1, 2023, a health carrier shall provide coverage for medically necessary donor human milk for inpatient use when ordered by a licensed health care provider with prescriptive autho…
RCW 48.43.820 Consolidated appropriations act enforcement—Implementation of federal regulations.
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The commissioner is authorized to enforce provisions of P.L. 116-260 (enacted December 27, 2020, as the consolidated appropriations act of 2021) and implementing federal regulations in effect on March 31, 2022, that are applicable to or regulate the conduct of carriers issuing he…
RCW 48.43.825 Certified peer support specialist services—Network access standards.
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By July 1, 2026, each carrier shall provide access to services provided by certified peer support specialists and certified peer support specialist trainees in a manner sufficient to meet the network access standards set forth in rules established by the office of the insurance c…
RCW 48.43.830 Prior authorization.
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*** CHANGE IN 2026 *** (SEE 5395-S2.SL) ***(1) Each carrier offering a health plan issued or renewed on or after January 1, 2024, shall comply with the following standards related to prior authorization for health care services and prescription drugs:(a) The carrier shall meet th…
RCW 48.43.835 Physician assistants—Coverage.
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This chapter authorizes carriers to reimburse employers of physician assistants for covered services rendered by licensed physician assistants. Payment for services within the physician assistant's scope of practice must be made when ordered or performed by a physician assistant …
RCW 48.43.840 Prosthetic limbs and custom orthotic braces—Coverage—Reporting.
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(1) Except as provided in subsection (9) of this section, a health plan offered in the large group or small group market that is issued or renewed on or after January 1, 2026, must include coverage for one or more prostheses per limb and custom orthotic braces per limb when medic…
RCW 48.43.845 Prescription hormone therapy—Coverage.
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(1) A health plan issued or renewed on or after January 1, 2026, that includes coverage for prescription hormone therapy must provide reimbursement for a 12-month refill of covered prescription hormone therapy obtained at one time by the enrollee, unless the enrollee requests a s…
RCW 48.43.902 Effective date—1996 c 312.
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This act shall take effect July 1, 1996.[ 1996 c 312 s 8.]
RCW 48.43.904 Construction—Chapter applicable to state registered domestic partnerships—2009 c 521.
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For the purposes of this chapter, the terms spouse, marriage, marital, husband, wife, widow, widower, next of kin, and family shall be interpreted as applying equally to state registered domestic partnerships or individuals in state registered domestic partnerships as well as to …