Title 48 — Title 48 INSURANCE
101 chapters · 2,134 sections in this title.
RCW 48.39.010 Notice of material amendments to contract—Failure to comply.
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(1) A third-party payor shall provide no less than sixty days' notice to the health care provider of any proposed material amendments to a health care provider's contract with the third-party payor.(2) Any material amendment to a contract must be clearly defined in a notice to th…
RCW 48.39.020 Payor may require provider to extend payor's medicaid rates—Limitations.
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A payor may require a health care provider to extend the payor's medicaid rates, or some percentage above the payor's medicaid rates, that govern a health benefit program administered by a public purchaser to a commercial plan or line of business offered by a payor that is not ad…
RCW 48.39.030 Ambulatory surgical facilities—Payor survey requirements.
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If a payor that contracts with an ambulatory surgical facility licensed under chapter 70.230 RCW requires successful completion of a survey as part of the contract, the ambulatory surgical facility is deemed to have met survey requirements if it has successfully completed a surve…
RCW 48.41.010 Short title.
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This chapter shall be known and may be cited as the "Washington state health insurance coverage access act".[ 1987 c 431 s 1.]
RCW 48.41.020 Intent.
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It is the purpose and intent of the legislature to provide access to health insurance coverage to all residents of Washington who are denied health insurance. It is the intent of the Washington state health insurance coverage access act to provide a mechanism to ensure the availa…
RCW 48.41.030 Definitions.
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The definitions in this section apply throughout this chapter unless the context clearly requires otherwise.(1) "Accounting year" means a twelve-month period determined by the board for purposes of recordkeeping and accounting. The first accounting year may be more or less than t…
RCW 48.41.037 Washington state health insurance pool account.
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The Washington state health insurance pool account is created in the custody of the state treasurer. All receipts from moneys specifically appropriated to the account must be deposited in the account. Expenditures from this account shall be used to cover deficits incurred by the …
RCW 48.41.040 Health insurance pool—Creation, membership, organization, operation, rules.
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(1) There is created a nonprofit entity to be known as the Washington state health insurance pool. All members in this state on or after May 18, 1987, shall be members of the pool. When authorized by federal law, all self-insured employers shall also be members of the pool.(2) Pu…
RCW 48.41.050 Operation plan—Contents.
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The plan of operation submitted by the board to the commissioner shall:(1) Establish procedures for the handling and accounting of assets and moneys of the pool;(2) Establish regular times and places for meetings of the board of directors;(3) Establish procedures for records to b…
RCW 48.41.060 Board powers and duties.
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(1) The board shall have the general powers and authority granted under the laws of this state to insurance companies, health care service contractors, and health maintenance organizations, licensed or registered to offer or provide the kinds of health coverage defined under this…
RCW 48.41.070 Examination and report.
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The pool shall be subject to examination by the commissioner as provided under chapter 48.03 RCW. The board of directors shall submit to the commissioner, not later than one hundred twenty days after the end of each accounting year, a financial report for the year in a form appro…
RCW 48.41.080 Pool administrator—Selection, term, duties, pay.
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The board shall select an administrator through a competitive bidding process to administer the pool.(1) The board shall evaluate bids based upon criteria established by the board, which shall include:(a) The administrator's proven ability to handle health coverage;(b) The effici…
RCW 48.41.090 Financial participation in pool—Computation, deficit assessments.
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(1) Following the close of each accounting year, the pool administrator shall determine the total net cost of pool operation which shall include:(a) Net premium (premiums less administrative expense allowances), the pool expenses of administration, and incurred losses for the yea…
RCW 48.41.100 Eligibility for coverage.
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(1)(a) The following persons who are residents of this state are eligible for pool coverage:(i) Any resident of the state not eligible for medicare coverage or medicaid coverage, and residing in a county where an individual health plan other than a catastrophic health plan as def…
RCW 48.41.110 Policy coverage—Eligible expenses, cost containment, limits—Explanatory brochure.
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(1) The pool shall offer one or more care management plans of coverage. Such plans may, but are not required to, include point of service features that permit participants to receive in-network benefits or out-of-network benefits subject to differential cost shares. The pool may …
RCW 48.41.120 Comprehensive pool policy—Deductibles—Coinsurance—Carryover.
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(1) Subject to the limitation provided in subsection (3) of this section, the comprehensive pool policy offered under RCW 48.41.110(4) shall impose a deductible as provided in this subsection. Deductibles of five hundred dollars and one thousand dollars on a per person per calend…
RCW 48.41.130 Policy forms—Approval required.
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All policy forms issued by the pool shall conform in substance to prototype forms developed by the pool, and shall in all other respects conform to the requirements of this chapter, and shall be filed with and approved by the commissioner before they are issued.[ 2000 c 79 s 15; …
RCW 48.41.140 Coverage for children, dependents.
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(1) Coverage shall provide that health insurance benefits are applicable to children of the person in whose name the policy is issued including adopted and newly born natural children. Coverage shall also include necessary care and treatment of medically diagnosed congenital defe…
RCW 48.41.150 Medical supplement policy.
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(1) The board shall offer a medical supplement policy for persons receiving medicare parts A and B. The supplement policy shall provide benefits of one hundred percent of the deductible and copayment required under medicare and eighty percent of the charges for covered services u…
RCW 48.41.160 Pool policy requirements—Continued coverage—Rate changes—Continuation—Statement of intent to discontinue pool coverage.
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(1) On or before December 31, 2007, the pool shall cancel all existing pool policies and replace them with policies that are identical to the existing policies except for the inclusion of a provision providing for a guarantee of the continuity of coverage consistent with this sec…
RCW 48.41.170 Required rule making.
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The commissioner shall adopt rules pursuant to chapter 34.05 RCW that:(1) Provide for disclosure by the member of the availability of insurance coverage from the pool; and(2) Implement this chapter.[ 1987 c 431 s 17.]
RCW 48.41.190 Civil and criminal immunity.
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The pool, members of the pool, board directors of the pool, officers of the pool, employees of the pool, the commissioner, the commissioner's representatives, and the commissioner's employees shall not be civilly or criminally liable and shall not have any penalty or cause of act…
RCW 48.41.200 Rates—Standard risk and maximum.
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(1) The pool shall determine the standard risk rate by calculating the average individual standard rate charged for coverage comparable to pool coverage by the five largest members, measured in terms of individual market enrollment, offering such coverages in the state. In the ev…
RCW 48.41.210 Last payor of benefits.
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It is the express intent of this chapter that the pool be the last payor of benefits whenever any other benefit is available.(1) Benefits otherwise payable under pool coverage shall be reduced by all amounts paid or payable through any other health insurance, or health benefit pl…
RCW 48.41.220 Mental health services—Definition—Coverage required, when.
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(1) For the purposes of this section, "mental health services" means:(a) For each health insurance policy issued or renewed by the pool before January 1, 2021, medically necessary outpatient and inpatient services provided to treat mental disorders covered by the diagnostic categ…
RCW 48.41.240 Review of populations needing coverage through pool—Analysis and recommendations—Report.
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(1) The board shall review populations that may need ongoing access to coverage through the pool, with specific attention to those persons who may be excluded from or may receive inadequate coverage beginning January 1, 2014, such as persons with end-stage renal disease or HIV/AI…
RCW 48.41.250 Administration of risk management functions—Contract with commissioner authorized—Recommendations—Report to legislature.
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(1) The pool is authorized to contract with the commissioner to administer risk management functions if necessary, consistent with RCW 48.43.720, and consistent with P.L. 111-148 of 2010, as amended. Prior to entering into a contract, the pool may conduct preoperational and plann…
RCW 48.41.900 Federal supremacy.
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If any part of this chapter is found to be in conflict with federal requirements which are a prescribed condition to the allocation of federal funds to the state, the conflicting part of this chapter is hereby declared to be inoperative solely to the extent of the conflict and wi…
RCW 48.41.920 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 …
RCW 48.42.010 Personal coverage, authority of commissioner—Definition.
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(1) Notwithstanding any other provision of law, and except as provided in this chapter, any person or other entity which provides coverage in this state for life insurance, annuities, loss of time, medical, surgical, chiropractic, physical therapy, speech pathology, audiology, pr…
RCW 48.42.020 Showing regulation by other agency, how done—Definition.
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(1) A person or entity may show that it is subject to the jurisdiction and regulation of another agency of this state, any subdivision thereof, or the federal government, by providing to the insurance commissioner the appropriate certificate, license, or other document issued by …
RCW 48.42.030 Examination by commissioner—When required, scope of.
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Any person or entity which is unable to show under RCW 48.42.020 that it is subject to the jurisdiction and regulation of another agency of this state, any subdivision thereof, or the federal government, shall submit to an examination by the insurance commissioner to determine th…
RCW 48.42.040 Application of this title to otherwise unregulated entities.
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Any person or entity unable to show that it is subject to the jurisdiction and regulation of another agency of this state, any subdivision thereof, or the federal government, shall be subject to all appropriate provisions of this title regarding the conduct of its business includ…
RCW 48.42.050 Notice to purchasers by uninsured production agency—Notice to production agency by administrator of coverage.
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Any production agency or administrator which advertises, sells, transacts, or administers the coverage in this state described in RCW 48.42.010 and which is required to submit to an examination by the insurance commissioner under RCW 48.42.030, shall, if the coverage is not fully…
RCW 48.42.090 Prenatal testing—Limitation on changes to coverage.
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The carrier or provider of any group disability contract, health care services contract or health maintenance agreement shall not cancel, reduce, limit or otherwise alter or change the coverage provided solely on the basis of the result of any prenatal test.[ 1988 c 276 s 9.]
RCW 48.42.100 Women's health care services—Duties of health care carriers.
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(1) For purposes of this section, health care carriers includes disability insurers regulated under chapter 48.20 or 48.21 RCW, health care services contractors regulated under chapter 48.44 RCW, health maintenance organizations regulated under chapter 48.46 RCW, plans operating …
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…