Title 48 — Title 48 INSURANCE
101 chapters · 2,134 sections in this title.
RCW 48.43.001 Intent.
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It is the intent of the legislature to ensure that all enrollees in managed care settings have access to adequate information regarding health care services covered by health carriers' health plans, and provided by health care providers and health care facilities. It is only thro…
RCW 48.43.005 Definitions.
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*** CHANGE IN 2026 *** (SEE 6248-S.SL) ***Unless otherwise specifically provided, the definitions in this section apply throughout this chapter.(1) "Adjusted community rate" means the rating method used to establish the premium for health plans adjusted to reflect actuarially dem…
RCW 48.43.007 Availability of price and quality information—Transparency tools for members—Requirements.
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(1) Each carrier offering or renewing a health benefit plan on or after January 1, 2016, must offer member transparency tools with certain price and quality information to enable the member to make treatment decisions based on cost, quality, and patient experience. The transparen…
RCW 48.43.008 Enrollment in employer-sponsored health plan—Person eligible for medical assistance.
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When the health care authority determines that it is cost-effective to enroll a person eligible for medical assistance under chapter 74.09 RCW in an employer-sponsored health plan, a carrier shall permit the enrollment of the person in the health plan for which he or she is other…
RCW 48.43.009 Health care sharing ministries.
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Health care sharing ministries are not health carriers as defined in RCW 48.43.005 or insurers as defined in RCW 48.01.050. For purposes of this section, "health care sharing ministry" has the same meaning as in 26 U.S.C. Sec. 5000A.[ 2011 c 314 s 18.]
RCW 48.43.012 Health plans—Preexisting conditions—Rules.
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(1) No carrier may reject an individual for an individual or group health benefit plan based upon preexisting conditions of the individual.(2) No carrier may deny, exclude, or otherwise limit coverage for an individual's preexisting health conditions including, but not limited to…
RCW 48.43.01211 Health plans—Eligibility—Health status-related factors—Rules.
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(1) A health carrier or health plan may not establish rules for eligibility, including continued eligibility, of any individual to enroll under the terms of the plan or coverage based on any of the following health status-related factors in relation to the individual or a depende…
RCW 48.43.0122 Individual health benefit plans—Open enrollment and special enrollment periods—Rules—Enforcement.
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(1) The commissioner shall adopt rules establishing and implementing requirements for the open enrollment periods and special enrollment periods that carriers must follow for individual health benefit plans.(2) The commissioner shall monitor the sale of individual health benefit …
RCW 48.43.0123 Health plans—Rescission of coverage—Rules.
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(1) A health plan or health carrier offering group or individual coverage may not rescind such coverage with respect to an enrollee once the enrollee is covered under the plan or coverage involved, except that this section does not apply to a covered person who has performed an a…
RCW 48.43.0124 Health plans—Cost sharing for essential health benefits—Rules.
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(1) For plan years beginning in 2020, the cost sharing incurred under a health plan for the essential health benefits may not exceed the following amounts:(a) For self-only coverage:(i) The amount required under federal law for the calendar year; or(ii) If there are no cost-shari…
RCW 48.43.0125 Essential health benefits—Annual or lifetime dollar limits.
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A health carrier may not impose annual or lifetime dollar limits on an essential health benefit, other than those permitted as reference-based limitations under rules adopted by the commissioner.[ 2019 c 33 s 12.]Notes:Effective date—2019 c 33: See note following RCW 48.43.005.
RCW 48.43.0126 Summary of benefits and explanation of coverage—Standards and requirements—Notice of modification—Fines—Standards for definitions of health insurance terms—Rules.
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(1) The commissioner shall develop standards for use by a health carrier offering individual or group coverage, in compiling and providing to applicants and enrollees a summary of benefits and coverage explanation that accurately describes the benefits and coverage under the appl…
RCW 48.43.0127 Group health plans—Waiting period—Rules.
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(1) A group health plan and a health carrier offering group health coverage may not apply any waiting period that exceeds ninety days.(2) Unless preempted by federal law, the commissioner shall adopt any rules necessary to implement this section, consistent with federal rules and…
RCW 48.43.0128 Nongrandfathered health plans and plans issued or renewed on or after January 1, 2022—Prohibited discrimination—Rules.
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(1) A health carrier offering a nongrandfathered health plan or a plan deemed by the commissioner to have a short-term limited purpose or duration, or to be a student-only plan that is guaranteed renewable while the covered person is enrolled as a regular, full-time undergraduate…
RCW 48.43.016 Utilization management standards and criteria—Health carrier requirements—Definitions.
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(1) A health carrier or its contracted entity that imposes different prior authorization standards and criteria for a covered service among tiers of contracting providers of the same licensed profession in the same health plan shall inform an enrollee which tier an individual pro…
RCW 48.43.0161 Prior authorization practices—Carrier annual reporting requirements—Commissioner's standardized report.
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*** CHANGE IN 2026 *** (SEE 5395-S2.SL) ***(1) By October 1, 2020, and annually thereafter, for individual and group health plans issued by a carrier that has written at least one percent of the total accident and health insurance premiums written by all companies authorized to o…
RCW 48.43.021 Personally identifiable health information—Restrictions on release.
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Except as otherwise required by statute or rule, a carrier and the Washington state health insurance pool, and persons acting at the direction of or on behalf of a carrier or the pool, who are in receipt of an enrollee's or applicant's personally identifiable health information i…
RCW 48.43.022 Enrollee identification card—Social security number restriction.
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After December 31, 2005, a health carrier that issues a card identifying a person as an enrollee, and requires the person to present the card to providers for purposes of claims processing, may not display on the card an identification number that includes more than a four-digit …
RCW 48.43.023 Pharmacy identification cards—Rules.
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(1) A health carrier that provides coverage for prescription drugs provided on an outpatient basis and issues a card or other technology for claims processing, or an administrator of a health benefit plan including, but not limited to, third-party administrators for self-insured …
RCW 48.43.028 Eligibility to purchase certain health benefit plans—Small employers and small groups.
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To the extent required of the federal health insurance portability and accountability act of 1996, the eligibility of an employer or group to purchase a health benefit plan set forth in RCW 48.21.045(1)(b), 48.44.023(1)(b), and 48.46.066(1)(b) must be extended to all small employ…
RCW 48.43.035 Group health benefit plans—Guaranteed issue and continuity of coverage—Exceptions.
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For group health benefit plans, the following shall apply:(1) All health carriers shall accept for enrollment any state resident within the group to whom the plan is offered and within the carrier's service area and provide or assure the provision of all covered services regardle…
RCW 48.43.038 Individual health plans—Guarantee of continuity of coverage—Exceptions.
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(1) Except as provided in subsection (4) of this section, all individual health plans shall contain or incorporate by endorsement a guarantee of the continuity of coverage of the plan. For the purposes of this section, a plan is "renewed" when it is continued beyond the earliest …
RCW 48.43.039 Grace period—Notification or information—Information concerning delinquencies or nonpayment of premiums—Defined.
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(1) For an enrollee who is in the second or third month of the grace period, an issuer of a qualified health plan shall:(a) Upon request by a health care provider or health care facility, provide information regarding the enrollee's eligibility status in real time;(b) Notify a he…
RCW 48.43.041 Individual health benefit plans—Mandatory benefits.
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(1) All individual health benefit plans, other than catastrophic health plans, offered or renewed on or after October 1, 2000, shall include benefits described in this section. Nothing in this section shall be construed to require a carrier to offer an individual health benefit p…
RCW 48.43.043 Colorectal cancer examinations and laboratory tests—Required benefits or coverage.
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(1) Health plans issued or renewed on or after July 1, 2008, must provide benefits or coverage for colorectal cancer examinations and laboratory tests consistent with the guidelines or recommendations of the United States preventive services task force or the federal centers for …
RCW 48.43.045 Health plan requirements—Annual reports—Exemptions.
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(1) Every health plan delivered, issued for delivery, or renewed by a health carrier on and after January 1, 1996, shall:(a) Permit every category of health care provider to provide health services or care included in the basic essential health benefits benchmark plan established…
RCW 48.43.047 Health plans—Minimum coverage for preventive services—No cost-sharing requirements.
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*** CHANGE IN 2026 *** (SEE 2242-S.SL) ***(1) A nongrandfathered health plan issued on or after June 6, 2024, must, at a minimum, provide coverage for the following preventive services as the recommendations or guidelines existed on January 8, 2024:(a) Evidence-based items or ser…
RCW 48.43.055 Procedures for review and adjudication of health care provider complaints—Requirements.
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(1) Except as provided by subsection (2) of this section, each health carrier as defined under RCW 48.43.005 shall file with the commissioner its procedures for review and adjudication of complaints initiated by health care providers. Procedures filed under this section shall pro…
RCW 48.43.059 Payments made by a second-party payment process—Definition.
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(1) For the purposes of this section, "second-party payment process" means a process in which: (a) An individual has an account under his or her name maintained with a financial institution and is either managed by the financial institution or an entity that, with the express agr…
RCW 48.43.065 Right of individuals to receive services—Right of providers, carriers, and facilities to refuse to participate in or pay for services for reason of conscience or religion—Requirements.
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(1) The legislature recognizes that every individual possesses a fundamental right to exercise their religious beliefs and conscience. The legislature further recognizes that in developing public policy, conflicting religious and moral beliefs must be respected. Therefore, while …
RCW 48.43.071 Health care information—Requirement to provide free copy to covered person appealing denial of social security benefits—Exceptions.
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Upon request of a covered person or a covered person's personal representative, an issuer shall provide the covered person or representative with one copy of the covered person's health care information free of charge if the covered person is appealing the denial of federal suppl…
RCW 48.43.072 Required reproductive health care coverage—Restrictions on copayments, deductibles, and other form of cost sharing.
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(1) A health plan or student health plan, including student health plans deemed by the insurance commissioner to have a short-term limited purpose or duration or to be guaranteed renewable while the covered person is enrolled as a regular full-time undergraduate or graduate stude…
RCW 48.43.0725 Reproductive health plan coverage—Immediate postpartum contraception devices.
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(1) For births taking place in a licensed hospital or birthing center, a health plan must allow a provider to separately bill for devices, implants, professional services, or a combination thereof, associated with immediate postpartum contraception and may not consider such devic…
RCW 48.43.073 Required abortion coverage—Limitations.
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(1)(a) Except as provided in subsection (5) of this section, if a health plan issued or renewed on or after January 1, 2019, provides coverage for maternity care or services, the health plan must also provide a covered person with substantially equivalent coverage to permit the a…
RCW 48.43.074 Qualified health plans—Single invoice billing—Certification of compliance required in the segregation plan for premium amounts attributable to coverage of abortion services.
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(1) The legislature intends to codify the state's current practice of requiring health carriers to bill enrollees with a single invoice and to segregate into a separate account the premium attributable to abortion services for which federal funding is prohibited. Washington has a…
RCW 48.43.076 Digital breast examinations—Cost sharing.
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(1) Except as provided in subsection (2) of this section, for nongrandfathered health plans issued or renewed on or after January 1, 2024, that include coverage of supplemental breast examinations and diagnostic breast examinations, health carriers may not impose cost sharing for…
RCW 48.43.078 Digital breast tomosynthesis—Intent to ensure women with access—Commissioner's and health care authority's duty to clarify mandates.
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(1) Digital breast tomosynthesis, also called three-dimensional mammography, is the latest advancement in breast imaging. Studies indicate that digital breast tomosynthesis can result in a forty-one percent increase in invasive cancer detection, a fifteen percent decrease in the …
RCW 48.43.081 Anatomic pathology services—Payment for services—Definitions.
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(1) A clinical laboratory or physician, located in this state, or in another state, providing anatomic pathology services for patients in this state, shall present or cause to be presented a claim, bill, or demand for payment for these services only to the following:(a) The patie…
RCW 48.43.083 Chiropractor services—Participating provider agreement—Health carrier reimbursement.
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(1) A health carrier must reimburse a chiropractor who has signed a participating provider agreement for services determined by the carrier to be medically necessary if:(a) The service is:(i) Covered chiropractic health care, as defined in RCW 48.43.515, by the health plan under …
RCW 48.43.085 Health carrier may not prohibit its enrollees from contracting for services outside the health care plan.
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Notwithstanding any other provision of law, no health carrier subject to the jurisdiction of the state of Washington may prohibit directly or indirectly its enrollees from freely contracting at any time to obtain any health care services outside the health care plan on any terms …
RCW 48.43.087 Contracting for services at enrollee's expense—Mental health care practitioner—Conditions—Exception.
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(1) For purposes of this section:(a) "Health carrier" includes disability insurers regulated under chapter 48.20 or 48.21 RCW, health care services contractors regulated under chapter 48.44 RCW, plans operating under the health care authority under chapter 41.05 RCW, the basic he…
RCW 48.43.091 Health carrier coverage of outpatient mental health services—Requirements.
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Every health carrier that provides coverage for any outpatient mental health service shall comply with the following requirements:(1) In performing a utilization review of mental health services for a specific enrollee, the utilization review is limited to accessing only the spec…
RCW 48.43.093 Health carrier coverage of emergency medical services—Requirements—Conditions.
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(1)(a) A health carrier shall cover emergency services provided to a covered person if a prudent layperson acting reasonably would have believed that an emergency medical condition existed. In addition, a health carrier shall not require prior authorization of emergency services …
RCW 48.43.094 Pharmacist provided services—Health plan requirements.
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(1) For health plans issued or renewed on or after January 1, 2017:(a) Benefits shall not be denied for any health care service performed by a pharmacist licensed under chapter 18.64 RCW if:(i) The service performed was within the lawful scope of such person's license;(ii) The pl…
RCW 48.43.096 Medication synchronization policy required for health plans covering prescription drugs—Requirements—Definitions.
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(1) A health benefit plan issued or renewed after December 31, 2015, that provides coverage for prescription drugs must implement a medication synchronization policy for the dispensing of prescription drugs to the plan's enrollees.(a) If an enrollee requests medication synchroniz…
RCW 48.43.0961 Continuity of coverage for health plans covering prescription drugs for behavioral health.
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(1) Except as provided in subsection (2) of this section, for health plans that include prescription drug coverage issued or renewed on or after January 1, 2025, a health carrier or its health care benefit manager may not require the substitution of a nonpreferred drug with a pre…
RCW 48.43.097 Filing of financial statements—Every health carrier.
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Every health carrier holding a registration from the commissioner shall file its financial statements as required by this code and by the commissioner in accordance with the accounting practices and procedures manuals as adopted by the national association of insurance commission…
RCW 48.43.105 Preparation of documents that compare health carriers—Immunity—Due diligence.
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(1) A public or private entity who exercises due diligence in preparing a document of any kind that compares health carriers of any kind is immune from civil liability from claims based on the document and the contents of the document.(2)(a) There is absolute immunity to civil li…
RCW 48.43.115 Maternity services—Intent—Definitions—Patient preference—Clinical sovereignty of provider—Notice to policyholders—Application.
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(1) The legislature recognizes the role of health care providers as the appropriate authority to determine and establish the delivery of quality health care services to maternity patients and their newly born children. It is the intent of the legislature to recognize patient pref…
RCW 48.43.121 Ground ambulance services organizations—Coverage.
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(1) For health plans issued or renewed on or after January 1, 2025, a health carrier shall provide coverage for ground ambulance transports to behavioral health emergency services providers for enrollees who are experiencing an emergency medical condition as defined in RCW 48.43.…