Title 48 — Title 48 INSURANCE
101 chapters · 2,134 sections in this title.
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.…
RCW 48.43.125 Coverage at a long-term care facility following hospitalization—Definition.
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(1) A carrier that provides coverage for a person at a long-term care facility following the person's hospitalization shall, upon the request of the person or his or her legal representative as authorized in RCW 7.70.065, provide such coverage at the facility in which the person …
RCW 48.43.135 Hearing instruments—Coverage.
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(1) For nongrandfathered group health plans other than small group health plans issued or renewed on or after January 1, 2024, and for health plans issued or renewed on or after January 1, 2026, a health carrier shall include coverage for hearing instruments, including bone condu…
RCW 48.43.176 Eosinophilic gastrointestinal associated disorder—Elemental formula.
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(1) Each health benefit plan issued or renewed after December 31, 2015, must offer benefits or coverage for medically necessary elemental formula, regardless of delivery method, when a licensed physician or other health care provider with prescriptive authority:(a) Diagnoses a pa…
RCW 48.43.180 Denturist services.
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Notwithstanding any provision of any certified health plan covering dental care as provided for in this chapter, effective January 1, 1995, benefits shall not be denied thereunder for any service performed by a denturist licensed under chapter 18.30 RCW if (1) the service perform…
RCW 48.43.185 General anesthesia services for dental procedures.
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(1) Each group health benefit plan that provides coverage for hospital, medical, or ambulatory surgery center services must cover general anesthesia services and related facility charges in conjunction with any dental procedure performed in a hospital or ambulatory surgical cente…
RCW 48.43.190 Payment of chiropractic services—Parity.
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(1)(a) A health carrier may not pay a chiropractor less for a service or procedure identified under a particular physical medicine and rehabilitation code, evaluation and management code, or spinal manipulation code, as listed in a nationally recognized services and procedures co…
RCW 48.43.195 Contraceptive drugs—Twelve-month refill coverage.
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(1) A health benefit plan issued or renewed on or after January 1, 2018, that includes coverage for contraceptive drugs must provide reimbursement for a twelve-month refill of contraceptive drugs obtained at one time by the enrollee, unless the enrollee requests a smaller supply …
RCW 48.43.200 Disclosure of certain material transactions—Report—Information is confidential.
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(1) Every certified health plan domiciled in this state shall file a report with the commissioner disclosing material acquisitions and dispositions of assets or material nonrenewals, cancellations, or revisions of ceded reinsurance agreements unless these acquisitions and disposi…
RCW 48.43.205 Material acquisitions or dispositions.
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No acquisitions or dispositions of assets need be reported pursuant to RCW 48.43.200 if the acquisitions or dispositions are not material. For purposes of RCW 48.43.200 through 48.43.225, a material acquisition, or the aggregate of any series of related acquisitions during any th…
RCW 48.43.210 Asset acquisitions—Asset dispositions.
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(1) Asset acquisitions subject to RCW 48.43.200 through 48.43.225 include every purchase, lease, exchange, merger, consolidation, succession, or other acquisition other than the construction or development of real property by or for the reporting certified health plan or the acqu…
RCW 48.43.215 Report of a material acquisition or disposition of assets—Information required.
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(1) The following information is required to be disclosed in any report of a material acquisition or disposition of assets:(a) Date of the transaction;(b) Manner of acquisition or disposition;(c) Description of the assets involved;(d) Nature and amount of the consideration given …
RCW 48.43.220 Material nonrenewals, cancellations, or revisions of ceded reinsurance agreements.
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(1) No nonrenewals, cancellations, or revisions of ceded reinsurance agreements need be reported under RCW 48.43.200 if the nonrenewals, cancellations, or revisions are not material. For purposes of RCW 48.43.200 through 48.43.225, a material nonrenewal, cancellation, or revision…
RCW 48.43.225 Report of a material nonrenewal, cancellation, or revision of ceded reinsurance agreements—Information required.
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(1) The following is required to be disclosed in any report of a material nonrenewal, cancellation, or revision of ceded reinsurance agreements:(a) The effective date of the nonrenewal, cancellation, or revision;(b) The description of the transaction with an identification of the…
RCW 48.43.290 Coverage for prescribed durable medical equipment and mobility enhancing equipment—Sales and use taxes—Definitions.
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(1) Health plans issued or renewed on or after January 1, 2011, that include coverage for prescribed durable medical equipment and mobility enhancing equipment must include the sales tax or use tax calculation in plan payment, consistent with the application of sales tax in chapt…