Title 48 — Title 48 INSURANCE
101 chapters · 2,134 sections in this title.
RCW 48.43.300 Definitions.
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The definitions in this section apply throughout RCW 48.43.300 through 48.43.370 unless the context clearly requires otherwise.(1) "Adjusted RBC report" means an RBC report that has been adjusted by the commissioner in accordance with RCW 48.43.305(4).(2) "Corrective order" means…
RCW 48.43.305 Report of RBC levels—Distribution of report—Formula for determination—Commissioner may make adjustments.
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(1) Every domestic carrier shall, on or prior to the filing date of March 1st, prepare and submit to the commissioner a report of its RBC levels as of the end of the calendar year just ended, in a form and containing such information as is required by the RBC instructions. In add…
RCW 48.43.310 Company action level event—Required RBC plan—Commissioner's review—Notification—Challenge by carrier.
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(1) "Company action level event" means any of the following events:(a) The filing of an RBC report by a carrier which indicates that:(i) The carrier's total adjusted capital is greater than or equal to its regulatory action level RBC but less than its company action level RBC; or…
RCW 48.43.315 Regulatory action level event—Required RBC plan—Commissioner's review—Notification—Challenge by carrier.
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(1) "Regulatory action level event" means, with respect to any carrier, any of the following events:(a) The filing of an RBC report by the carrier which indicates that the carrier's total adjusted capital is greater than or equal to its authorized control level RBC but less than …
RCW 48.43.320 Authorized control level event—Commissioner's options.
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(1) "Authorized control level event" means any of the following events:(a) The filing of an RBC report by the carrier which indicates that the carrier's total adjusted capital is greater than or equal to its mandatory control level RBC but less than its authorized control level R…
RCW 48.43.325 Mandatory control level event—Commissioner's duty—Regulatory control.
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(1) "Mandatory control level event" means any of the following events:(a) The filing of an RBC report which indicates that the carrier's total adjusted capital is less than its mandatory control level RBC;(b) Notification by the commissioner to the carrier of an adjusted RBC repo…
RCW 48.43.330 Carrier's right to hearing—Request by carrier—Date set by commissioner.
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(1) Upon notification to a carrier by the commissioner of any of the following, the carrier shall have the right to a hearing, in accordance with chapters 48.04 and 34.05 RCW, at which the carrier may challenge any determination or action by the commissioner:(a) Of an adjusted RB…
RCW 48.43.335 Confidentiality of RBC reports and plans—Use of certain comparisons prohibited—Certain information intended solely for use by commissioner.
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(1) All RBC reports, to the extent the information therein is not required to be set forth in a publicly available annual statement schedule, and RBC plans, including the results or report of any examination or analysis of a carrier and any corrective order issued by the commissi…
RCW 48.43.340 Powers or duties of commissioner not limited—Rules.
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(1) The provisions of RCW 48.43.300 through 48.43.370 are supplemental to any other provisions of the laws and rules of this state, and shall not preclude or limit any other powers or duties of the commissioner under such laws and rules, including, but not limited to, chapter 48.…
RCW 48.43.345 Foreign or alien carriers—Required RBC report—Commissioner may require RBC plan—Mandatory control level event.
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(1) Any foreign or alien carrier shall, upon the written request of the commissioner, submit to the commissioner an RBC report as of the end of the calendar year just ended by the later of:(a) The date an RBC report would be required to be filed by a domestic carrier under RCW 48…
RCW 48.43.350 No liability or cause of action against commissioner or department.
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There is no liability on the part of, and no cause of action shall arise against, the commissioner or insurance department or its employees or agents for any action taken by them in the performance of their powers and duties under RCW 48.43.300 through 48.43.370.[ 1998 c 241 s 11…
RCW 48.43.355 Notice by commissioner to carrier—When effective.
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All notices by the commissioner to a carrier that may result in regulatory action are effective upon dispatch if transmitted by registered or certified mail, or in the case of any other transmission, are effective upon the carrier's receipt of such notice.[ 1998 c 241 s 12.]
RCW 48.43.360 Initial RBC reports—Calculation of initial RBC levels—Subsequent reports.
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For RBC reports to be filed by carriers commencing operations after June 11, 1998, those carriers shall calculate the initial RBC levels using financial projections, considering managed care arrangements, for its first full year in operation. Such projections, including the risk-…
RCW 48.43.366 Self-funded multiple employer welfare arrangements.
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A self-funded multiple employer welfare arrangement, as defined in RCW 48.125.010, is subject to the same RBC reporting requirements as a domestic carrier under RCW 48.43.300 through 48.43.370.[ 2004 c 260 s 19.]Notes:Effective date—2004 c 260: See RCW 48.125.901.
RCW 48.43.370 RBC standards not applicable to certain carriers.
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RCW 48.43.300 through 48.43.370 shall not apply to a carrier which is subject to the provisions of RCW 48.05.430 through * 48.05.490.[ 1998 c 241 s 15.]Notes:*Reviser's note: RCW 48.05.490 was repealed by 2006 c 25 s 11.
RCW 48.43.400 Prescription drug utilization management—Definitions.
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The definitions in this section apply throughout this section and RCW 48.43.410 and 48.43.420 unless the context clearly requires otherwise.(1) "Clinical practice guidelines" means a systemically developed statement to assist decision making by health care providers and patients …
RCW 48.43.410 Prescription drug utilization management—Clinical review criteria—Requirement to be evidence-based and updated regularly.
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For health plans delivered, issued for delivery, or renewed on or after January 1, 2021, clinical review criteria used to establish a prescription drug utilization management protocol must be evidence-based and updated on a regular basis through review of new evidence, research, …
RCW 48.43.420 Prescription drug utilization management—Exception request process—Conditions, requirements, and time frames for approval or denial of requests—Emergency fill coverage—Notice of new policies and procedures.
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For health plans delivered, issued for delivery, or renewed on or after January 1, 2021:(1) When coverage of a prescription drug for the treatment of any medical condition is subject to prescription drug utilization management, the patient and prescribing practitioner must have a…
RCW 48.43.430 Prescription medication—Maximum charge at point of sale—Requirements.
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(1) Beginning January 1, 2021, the maximum amount a health carrier or pharmacy benefit manager may require a person to pay at the point of sale for a covered prescription medication is the lesser of:(a) The applicable cost sharing for the prescription medication; or(b) The amount…
RCW 48.43.435 Prescription medication—Cost-sharing calculation—Application—Rules.
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(1)(a) Except as provided in (b) of this subsection, when calculating an enrollee's contribution to any applicable cost-sharing or out-of-pocket maximum, a health carrier offering a nongrandfathered health plan with a pharmacy benefit, or a health care benefit manager administeri…
RCW 48.43.440 Human immunodeficiency virus postexposure prophylaxis drugs—Cost sharing and prior authorization.
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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, 2025, a health carrier may not impose cost sharing or require prior authorization for the drugs that comprise at least one regimen recommended by t…
RCW 48.43.500 Intent—Purpose—2000 c 5.
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It is the intent of the legislature that enrollees covered by health plans receive quality health care designed to maintain and improve their health. The purpose of chapter 5, Laws of 2000 is to ensure that health plan enrollees:(1) Have improved access to information regarding t…
RCW 48.43.505 Enrollee's and protected individual's right to privacy and confidential services—Health carrier or insurer duties—Requests for confidential communications—Rules.
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(1) Health carriers and insurers shall adopt policies and procedures that conform administrative, business, and operational practices to protect an enrollee's and protected individual's right to privacy or right to confidential health care services granted under state or federal …
RCW 48.43.5051 Requests for confidential communications—Monitoring and ensuring compliance—Standardized form for submission of requests—Rules.
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(1) The commissioner shall:(a) Develop a process for the regular collection of information from carriers on requests for confidential communications pursuant to RCW 48.43.505 for the purposes of monitoring compliance, including monitoring:(i) The effectiveness of the process desc…
RCW 48.43.510 Carrier required to disclose health plan information—Marketing and advertising restrictions—Rules.
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(1) A carrier that offers a health plan may not offer to sell a health plan to an enrollee or to any group representative, agent, employer, or enrollee representative without first offering to provide, and providing upon request, the following information before purchase or selec…
RCW 48.43.515 Access to appropriate health services—Enrollee options—Rules.
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(1) Each enrollee in a health plan must have adequate choice among health care providers.(2) Each carrier must allow an enrollee to choose a primary care provider who is accepting new enrollees from a list of participating providers. Enrollees also must be permitted to change pri…
RCW 48.43.517 Enrollment of child participating in medical assistance program—Employer-sponsored health plan.
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When the health care authority has determined that it is cost-effective to enroll a child participating in a medical assistance program under chapter 74.09 RCW in an employer-sponsored health plan, the carrier shall permit the enrollment of the participant who is otherwise eligib…
RCW 48.43.520 Requirement to maintain a documented utilization review program description and written utilization review criteria—Rules.
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(1) Carriers that offer a health plan shall maintain a documented utilization review program description and written utilization review criteria based on reasonable medical evidence. The program must include a method for reviewing and updating criteria. Carriers shall make clinic…
RCW 48.43.525 Prohibition against retrospective denial of health plan coverage—Rules.
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*** CHANGE IN 2026 *** (SEE 5395-S2.SL) ***(1) A health carrier that offers a health plan shall not retrospectively deny coverage for emergency and nonemergency care that had prior authorization under the plan's written policies at the time the care was rendered.(2) The commissio…
RCW 48.43.530 Requirement for carriers to have comprehensive grievance and appeal processes—Carrier's duties—Procedures—Appeals—Rules.
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(1) Each carrier and health plan must have fully operational, comprehensive grievance and appeal processes, and for plans that are not grandfathered, fully operational, comprehensive, and effective grievance and review of adverse benefit determination processes that comply with t…
RCW 48.43.535 Independent review of health care disputes—System for using certified independent review organizations—Rules.
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*** CHANGE IN 2026 *** (SEE 5395-S2.SL) ***(1) There is a need for a process for the fair consideration of disputes relating to decisions by carriers that offer a health plan to deny, modify, reduce, or terminate coverage of or payment for health care services for an enrollee. Fo…
RCW 48.43.537 Health care disputes—Certifying independent review organizations—Application—Restrictions—Maximum fee schedule for conducting reviews—Rules.
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(1) No later than January 1, 2017, the insurance commissioner shall adopt rules providing a procedure and criteria for certifying one or more organizations to perform independent review of health care disputes described in RCW 48.43.535.(2) The rules must require that the organiz…
RCW 48.43.540 Requirement to designate a licensed medical director—Exemption.
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Any carrier that offers a health plan and any self-insured health plan subject to the jurisdiction of Washington state shall designate a medical director who is licensed under chapter 18.57 or 18.71 RCW. However, a naturopathic or complementary alternative health plan, which prov…
RCW 48.43.545 Standard of care—Liability—Causes of action—Defense—Exception.
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(1)(a) A health carrier shall adhere to the accepted standard of care for health care providers under chapter 7.70 RCW when arranging for the provision of medically necessary health care services to its enrollees. A health carrier shall be liable for any and all harm proximately …
RCW 48.43.550 Delegation of duties—Carrier accountability.
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Each carrier is accountable for and must oversee any activities required by chapter 5, Laws of 2000 that it delegates to any subcontractor. No contract with a subcontractor executed by the health carrier or the subcontractor may relieve the health carrier of its obligations to an…
RCW 48.43.600 Overpayment recovery—Carrier.
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*** CHANGE IN 2026 *** (SEE 5845-S.SL) ***(1) Except in the case of fraud, or as provided in subsections (2) and (3) of this section, a carrier may not: (a) Request a refund from a health care provider of a payment previously made to satisfy a claim unless it does so in writing t…
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…