Title 48 — Title 48 INSURANCE
101 chapters · 2,134 sections in this title.
RCW 48.46.010 Legislative declaration—Purpose.
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In affirmation of the declared principle that health care is a right of every citizen of the state, the legislature expresses its concern that the present high costs of health care in Washington may be preventing or inhibiting a large segment of the people from obtaining access t…
RCW 48.46.012 Filings with secretary of state—Copy for commissioner.
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Health maintenance organizations shall send a copy specifically for the office of the insurance commissioner to the secretary of state of any corporate document required to be filed in the office of the secretary of state, including articles of incorporation and bylaws, and any a…
RCW 48.46.020 Definitions.
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As used in this chapter, the terms defined in this section shall have the meanings indicated unless the context indicates otherwise.(1) "Carrier" means a health maintenance organization, an insurer, a health care services contractor, or other entity responsible for the payment of…
RCW 48.46.023 Insurance producer—Definition—License required—Application, issuance, renewal, fees—Penalties involving license.
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(1) Insurance producer, as used in this chapter, means any person appointed or authorized by a health maintenance organization to solicit applications for health care service agreements on its behalf.(2) No person shall act as or hold himself or herself out to be an appointed ins…
RCW 48.46.027 Registration, required—Issuance of securities—Penalty.
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(1) A person may not in this state, by mail or otherwise, act as or hold himself or herself out to be a health maintenance organization as defined in RCW 48.46.020 without first being registered with the commissioner.(2) The issuance, sale, or offer for sale in this state of secu…
RCW 48.46.030 Eligibility requirements for certificate of registration—Application requirements, information—Provider compensation.
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Any corporation, cooperative group, partnership, individual, association, or groups of health professionals licensed by the state of Washington, public hospital district, or public institutions of higher education shall be entitled to a certificate of registration from the insura…
RCW 48.46.033 Unregistered activities—Acts committed in this state—Sanctions.
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(1) As used in this section, "person" has the same meaning as in RCW 48.01.070.(2) For the purpose of this section, an act is committed in this state if it is committed, in whole or in part, in the state of Washington, or affects persons or property within the state and relates t…
RCW 48.46.040 Certificate of registration—Issuance—Grounds for refusal—Name restrictions—Inspection and review of facilities.
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The commissioner shall issue a certificate of registration to the applicant within sixty days of such filing unless he or she notifies the applicant within such time that such application is not complete and the reasons therefor; or that he or she is not satisfied that:(1) The ba…
RCW 48.46.045 Catastrophic health plans permitted.
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Notwithstanding the provisions of this chapter, a health maintenance organization may offer catastrophic health plans as defined in RCW 48.43.005.[ 2000 c 79 s 27.]Notes:Effective date—Severability—2000 c 79: See notes following RCW 48.04.010.
RCW 48.46.060 Prepayment agreements—Standards for forms and documents—Grounds for disapproval—Cancellation or failure to renew—Filing of agreement forms.
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(1) Any health maintenance organization may enter into agreements with or for the benefit of persons or groups of persons, which require prepayment for health care services by or for such persons in consideration of the health maintenance organization providing health care servic…
RCW 48.46.062 Schedule of rates for individual agreements—Loss ratio—Definitions.
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(1) The definitions in this subsection apply throughout this section unless the context clearly requires otherwise.(a) "Claims" means the cost to the health maintenance organization of health care services, as defined in RCW 48.43.005, provided to an enrollee or paid to or on beh…
RCW 48.46.063 Calculation of premiums—Members of a purchasing pool—Adjusted community rating method—Definitions.
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(1) Premiums for health benefit plans for individuals who purchase the plan as a member of a purchasing pool:(a) Consisting of five hundred or more individuals affiliated with a particular industry;(b) To whom care management services are provided as a benefit of pool membership;…
RCW 48.46.064 Calculation of premiums—Adjusted community rate—Definitions.
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(1) Except for health benefit plans covered under RCW 48.46.063, premium rates for health benefit plans for individuals shall be subject to the following provisions:(a) The health maintenance organization shall develop its rates based on an adjusted community rate and may only va…
RCW 48.46.066 Health plan benefits for small employers—Coverage—Exemption from statutory requirements—Premium rates—Requirements for providing coverage for small employers.
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(1)(a) A health maintenance organization offering any health benefit plan to a small employer, either directly or through an association or member-governed group formed specifically for the purpose of purchasing health care, may offer and actively market to the small employer a h…
RCW 48.46.068 Requirements for plans offered to small employers—Definitions.
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(1) A health maintenance organization may not offer any health benefit plan to any small employer without complying with RCW 48.46.066(3).(2) Employers purchasing health plans provided through associations or through member-governed groups formed specifically for the purpose of p…
RCW 48.46.070 Governing body.
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(1) The members of the governing body of a health maintenance organization shall be nominated by the voting members or by the enrolled participants and providers, and shall be elected by the enrolled participants or voting members pursuant to the provisions of their bylaws, which…
RCW 48.46.080 Annual statement—Filings—Contents—Fee—Penalty for failure to file—Accuracy required.
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(1) Every domestic health maintenance organization shall annually, on or before the first day of March, file with the commissioner a statement verified by at least two of the principal officers of the health maintenance organization showing its financial condition as of the last …
RCW 48.46.090 Standard of services provided.
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A health maintenance organization, and the health care facilities and providers with which such organization has entered into contracts to provide health care services to its enrolled participants, shall provide such services in a manner consistent with the dignity of each enroll…
RCW 48.46.100 Grievance procedure.
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A health maintenance organization shall establish and maintain a grievance procedure, approved by the commissioner, to provide reasonable and effective resolution of complaints initiated by enrolled participants concerning any matter relating to the interpretation of any provisio…
RCW 48.46.110 Name restrictions—Discrimination—Recovery of costs of health care services participant not entitled to.
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(1) No health maintenance organization may refer to itself in its name or advertising with any of the words: "insurance", "casualty", "surety", "mutual", or any other words descriptive of the insurance, casualty, or surety business, or deceptively similar to the name or descripti…
RCW 48.46.120 Examination of health maintenance organizations—Duties of organizations, powers of commissioner—Independent audit reports.
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(1) The commissioner may make an examination of the operations of any health maintenance organization as often as he or she deems necessary in order to carry out the purposes of this chapter.(2) Every health maintenance organization shall submit its books and records relating its…
RCW 48.46.130 Investigation of violations—Hearing—Findings—Penalties—Order requiring compliance, etc.—Suspension or revocation of certificate, effect—Application to courts.
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(1) The commissioner may, consistent with the provisions of the administrative procedure act, chapter 34.05 RCW, initiate proceedings to determine whether a health maintenance organization has:(a) Operated in a manner that materially violates its organizational documents;(b) Mate…
RCW 48.46.135 Fine in addition to or in lieu of suspension, revocation, or refusal.
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After hearing or upon stipulation by the registrant and in addition to or in lieu of the suspension, revocation, or refusal to renew any registration of a health maintenance organization, the commissioner may levy a fine against the party involved for each offense in an amount no…
RCW 48.46.140 Fees.
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Every organization subject to this chapter shall pay to the commissioner the following fees:(1) For filing a copy of its application for a certificate of registration or amendment thereto, one hundred dollars;(2) For filing each annual report pursuant to RCW 48.46.080, ten dollar…
RCW 48.46.170 Effect of chapter as to other laws—Construction.
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(1) Solicitation of enrolled participants by a health maintenance organization granted a certificate of registration, or its appointed insurance producers or representatives, does not violate any provision of law relating to solicitation or advertising by health professionals.(2)…
RCW 48.46.180 Duty of employer to inform and make available to employees option of enrolling in health maintenance organization.
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(1) The state government, or any political subdivision thereof, which offers its employees a health benefits plan shall make available to and inform its employees or members of the option to enroll in at least one health maintenance organization holding a valid certificate of aut…
RCW 48.46.190 Payroll deductions for capitation payments to health maintenance organizations.
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See RCW 41.04.233.
RCW 48.46.200 Rules and regulations.
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The commissioner may, in accordance with the provisions of the administrative procedure act, chapter 34.05 RCW, promulgate rules and regulations as necessary or proper to carry out the provisions of this chapter. Nothing in this chapter shall be construed to prohibit the commissi…
RCW 48.46.210 Compliance with federal funding requirements—Construction.
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Nothing in this chapter shall prohibit any health maintenance organization from meeting the requirements of any federal law which would authorize such health maintenance organization to receive federal financial assistance or enroll beneficiaries assisted by federal funds.[ 1975 …
RCW 48.46.220 Review of administrative action.
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Any party aggrieved by a decision, order, or regulation made under this chapter by the commissioner shall have the right to have such reviewed pursuant to the provisions of the administrative procedure act, chapter 34.05 RCW.[ 1975 1st ex.s. c 290 s 23.]
RCW 48.46.225 Financial failure—Supervision of commissioner—Priority of distribution of assets.
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(1) Any rehabilitation, liquidation, or conservation of a health maintenance organization is the same as the rehabilitation, liquidation, or conservation of an insurance company and must be conducted under the supervision of the commissioner pursuant to the law governing the reha…
RCW 48.46.235 Minimum net worth—Requirement to maintain—Determination of amount.
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(1) Except as provided in subsection (2) of this section, every health maintenance organization must have and maintain a minimum net worth equal to the greater of:(a) Three million dollars; or(b) Two percent of annual premium earned as reported on the most recent annual financial…
RCW 48.46.237 Minimum net worth—Domestic or foreign health maintenance organization.
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(1) For purposes of this section:(a) "Domestic health maintenance organization" means a health maintenance organization formed under the laws of this state; and(b) "Foreign health maintenance organization" means a health maintenance organization formed under the laws of the Unite…
RCW 48.46.240 Funded reserve requirements.
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(1) Each health maintenance organization obtaining a certificate of registration from the commissioner shall provide and maintain a funded reserve of one hundred fifty thousand dollars. The funded reserve shall be deposited with the commissioner or with any organization/trustee a…
RCW 48.46.243 Contract—Participant liability.
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(1) Subject to subsection (2) of this section, every contract between a health maintenance organization and its participating providers of health care services shall be in writing and shall set forth that in the event the health maintenance organization fails to pay for health ca…
RCW 48.46.245 Plan for handling insolvency—Commissioner's review.
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Each health maintenance organization shall have a plan for handling insolvency which allows for continuation of benefits for the duration of the agreement period for which premiums have been paid and continuation of benefits to members who are confined on the date of insolvency i…
RCW 48.46.247 Insolvency—Commissioner's duties—Participants' options—Allocation of coverage.
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(1)(a) In the event of insolvency of a health care service contractor or health maintenance organization and upon order of the commissioner, all other carriers then having active enrolled participants under a group plan with the affected agreement holder that participated in the …
RCW 48.46.250 Coverage of dependent children—Newborn infants, congenital anomalies—Notification period.
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(1) Any health maintenance agreement under this chapter which provides coverage for dependent children of the enrolled participant shall provide the same coverage for newborn infants of the enrolled participant from and after the moment of birth. Coverage provided under this sect…
RCW 48.46.260 Individual health maintenance agreement—Return within ten days of delivery—Refunds—Void from beginning.
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Every subscriber of an individual health maintenance agreement may return the agreement to the health maintenance organization or the insurance producer through whom it was purchased within ten days of its delivery to the subscriber if, after examination of the agreement, the sub…
RCW 48.46.270 Financial interests of health maintenance organization authorities, restricted—Exceptions, regulations.
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(1) No person having any authority in the investment or disposition of the funds of a health maintenance organization and no officer or director of a health maintenance organization shall accept, except for the health maintenance organization, or be the beneficiary of any fee, br…
RCW 48.46.272 Diabetes coverage—Definitions.
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The legislature finds that diabetes imposes a significant health risk and tremendous financial burden on the citizens and government of the state of Washington, and that access to the medically accepted standards of care for diabetes, its treatment and supplies, and self-manageme…
RCW 48.46.274 Prescribed, self-administered anticancer medication.
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(1) Each health plan issued or renewed on or after January 1, 2012, that provides coverage for cancer chemotherapy treatment must provide coverage for prescribed, self-administered anticancer medication that is used to kill or slow the growth of cancerous cells on a basis at leas…
RCW 48.46.275 Mammograms—Insurance coverage.
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Each health maintenance agreement issued or renewed after January 1, 1990, that provides benefits for hospital or medical care shall provide benefits for screening or diagnostic mammography services, provided that such services are delivered upon the recommendation of the patient…
RCW 48.46.277 Prostate cancer screening.
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(1) Each health maintenance agreement issued or renewed after December 31, 2006, that provides coverage for hospital or medical expenses shall provide coverage for prostate cancer screening, provided that the screening is delivered upon the recommendation of the patient's physici…
RCW 48.46.280 Reconstructive breast surgery.
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(1) Any health care service plan issued, amended, or renewed after July 24, 1983, shall provide coverage for reconstructive breast surgery resulting from a mastectomy which resulted from disease, illness, or injury.(2) Any health care service plan issued, amended, or renewed afte…
RCW 48.46.285 Mastectomy, lumpectomy.
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No health maintenance organization under this chapter may refuse coverage or cancel or decline coverage solely because of a mastectomy or lumpectomy performed on the insured or prospective insured more than five years previously. The amount of benefits payable, or any term, rate,…
RCW 48.46.291 Mental health services—Health plans—Definition—Coverage required, when.
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(1) For the purposes of this section, "mental health services" means:(a) For health benefit plans issued or renewed before January 1, 2021, medically necessary outpatient and inpatient services provided to treat mental disorders covered by the diagnostic categories listed in the …
RCW 48.46.292 Mental health treatment—Waiver of preauthorization for persons involuntarily committed.
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A health maintenance organization providing services or benefits for hospital or medical care coverage in this state shall waive a preauthorization from the health maintenance organization before an enrolled participant or the enrolled participant's covered dependents receive men…
RCW 48.46.300 Future dividends or refunds, restricted—Issuance or sale of securities regulated.
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(1) No health maintenance organization nor any individual acting in behalf thereof may guarantee or agree to the payment of future dividends or future refunds of unused charges or savings in any specific or approximate amounts or percentages in respect to any contract being offer…
RCW 48.46.310 Registration not endorsement.
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The granting of a certificate of registration to a health maintenance organization is permissive only, and does not constitute an endorsement by the insurance commissioner of any person or thing related to the health maintenance organization, and no person may advertise or displa…