Title 48 — Title 48 INSURANCE
101 chapters · 2,134 sections in this title.
RCW 48.43.734 Health carrier rate filings—Review of surplus, capital, and profit levels.
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(1) For individual and small group rate filings with an effective date on or after January 1, 2021, submitted by a health carrier for either the individual or small group markets, the commissioner may review the carrier's surplus, capital, or profit levels as an element in determ…
RCW 48.43.735 Reimbursement of health care services provided through telemedicine or store and forward technology—Audio-only telemedicine.
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(1)(a) For health plans issued or renewed on or after January 1, 2017, a health carrier shall reimburse a provider for a health care service provided to a covered person through telemedicine or store and forward technology if:(i) The plan provides coverage of the health care serv…
RCW 48.43.740 Dental only plan—Emergency dental conditions—Definitions.
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(1) A health carrier offering a dental only plan may not deny coverage for treatment of emergency dental conditions that would otherwise be considered a covered service of an existing benefit contract on the basis that the services were provided on the same day the covered person…
RCW 48.43.743 Dental only plan—Annual data statement—Contents—Public use—Definition.
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(1) Each health carrier offering a dental only plan in Washington shall submit to the commissioner on or before April 1st of each year as part of the additional data statement, or as a supplemental data statement, Washington specific data for the preceding year that is derived fr…
RCW 48.43.745 Dental only plan—Denturist services.
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(1) Every health carrier offering dental only coverage and every health carrier offering dental only coverage in addition to a health plan delivered, issued for delivery, or renewed by a health carrier on and after January 1, 2024, shall permit denturists licensed under chapter 1…
RCW 48.43.747 Dental only plan—Coverage for same day procedures.
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(1) A dental only plan offered by a carrier or limited health care service contractor, as defined in RCW 48.44.035, may not deny coverage for procedures solely on the basis that the procedures were performed on the same day.(2) Nothing in this section shall prevent a dental only …
RCW 48.43.748 Dental only plan—Payments by credit card.
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(1) A dental only plan offered by a carrier or limited health care service contractor, as defined in RCW 48.44.035, may pay a claim for reimbursement made by a dental care provider using a credit card if:(a) The carrier or limited health care service contractor notifies the provi…
RCW 48.43.750 Health care provider credentialing applications—Use of electronic database by health carriers.
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(1)(a) A health carrier must use the database selected pursuant to RCW 48.165.035 to accept and manage credentialing applications from health care providers. A health carrier may not require a health care provider to submit credentialing information in any format other than throu…
RCW 48.43.755 Health care provider credentialing applications—Use of electronic database by providers.
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(1) When submitting a credentialing application to a health carrier, a health care provider shall submit the application to health carriers using the database selected pursuant to RCW 48.165.035.(2) A health care provider shall update credentialing information as necessary to pro…
RCW 48.43.757 Health care provider credentialing applications—Reimbursement requirements.
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(1) If a carrier approves a health care provider's credentialing application, upon completion of the credentialing process, the carrier must reimburse a health care provider under the following circumstances:(a) When credentialing a new health care provider through a new provider…
RCW 48.43.760 Opioid use disorder—Coverage without prior authorization.
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For health plans issued or renewed on or after January 1, 2020, a health carrier shall provide coverage without prior authorization of at least one federal food and drug administration approved product for the treatment of opioid use disorder in the drug classes opioid agonists, …
RCW 48.43.761 Withdrawal management services—Substance use disorder treatment services—Prior authorization—Utilization review—Medical necessity review.
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(1) Except as provided in subsection (2) of this section, a health plan issued or renewed on or after January 1, 2021, may not require an enrollee to obtain prior authorization for withdrawal management services or inpatient or residential substance use disorder treatment service…
RCW 48.43.762 Opioid overdose reversal medication bulk purchasing and distribution program.
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(1) For health plans issued or renewed on or after January 1, 2023, health carriers must participate in the opioid overdose reversal medication bulk purchasing and distribution program established in RCW 70.14.170 once the program is operational. A health plan may not impose enro…
RCW 48.43.764 Standard set of criteria—Authority review.
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When updated versions of the ASAM Criteria, treatment criteria for addictive, substance related, and co-occurring conditions, inclusive of adolescent and transition age youth versions, are published by the American society of addiction medicine, the health care authority and the …
RCW 48.43.765 Health carrier network adequacy—Mental health and substance abuse treatment.
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(1) The commissioner shall amend his or her rules on electronic provider directories to require health carriers to include a notation when any mental health provider or substance abuse provider is closed to new patients.(2) Beginning January 1, 2020, a health carrier shall promin…
RCW 48.43.766 Mental health and substance use disorder services—Coverage—Utilization reviews.
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(1) For the purposes of this section:(a) "Clinical review criteria" means written guidelines, standards, protocols, or decision rules used by a health carrier, or health care benefit manager on behalf of a health carrier, during utilization review to evaluate the medical necessit…
RCW 48.43.767 Behavioral health services—Network access.
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By July 1, 2025, every carrier shall provide access to services provided by behavioral health support specialists in a manner sufficient to meet the network access standards set forth in rules established by the office of the insurance commissioner.[ 2023 c 270 s 12.]
RCW 48.43.770 Individual market health plan availability—Annual report.
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The commissioner shall submit an annual report to the appropriate committees of the legislature on the number of health plans available per county in the individual market.[ 2019 c 364 s 7.]
RCW 48.43.775 Qualified health plan participation—Reimbursement rate for other health plans.
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A carrier may not require a provider or facility participating in a qualified health plan under RCW 41.05.410 to, as a condition of participation in a qualified health plan under RCW 41.05.410, accept a reimbursement rate for other health plans offered by the carrier at the same …
RCW 48.43.780 Cap on enrollee's required payment amount for specific drugs and equipment—Cost-sharing requirements.
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(1)(a) Except as required in (b) of this subsection, a health plan issued or renewed on or after January 1, 2023, that provides coverage for prescription insulin drugs for the treatment of diabetes must cap the total amount that an enrollee is required to pay for a covered insuli…
RCW 48.43.785 COVID-19 personal protective equipment expenses—Health care provider reimbursement.
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(1) For the duration of the federal public health emergency related to COVID-19, a health benefit plan shall reimburse a health care provider who bills for incurred personal protective equipment expenses as a separate expense, using the American medical association's current proc…
RCW 48.43.790 Behavioral services—Next-day appointments.
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Health plans issued or renewed on or after January 1, 2023, must make next-day appointments available to enrollees experiencing urgent, symptomatic behavioral health conditions to receive covered behavioral health services. The appointment may be with a licensed provider other th…
RCW 48.43.795 Qualified health plans—Acceptance of premium and cost-sharing assistance.
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For qualified health plans offered on the exchange, a carrier shall:(1) Accept payments for enrollee premiums or cost-sharing assistance under RCW 43.71.110 or as part of a sponsorship program under RCW 43.71.030(4). Nothing in this subsection expands or restricts the types of sp…
RCW 48.43.800 Primary care expenditures reporting—Review.
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(1) The commissioner may require health carriers to annually report primary care expenditures in previous calendar years or anticipated for upcoming calendar years.(2) The commissioner may determine the form and content of carrier primary care expenditure reporting. In developing…
RCW 48.43.805 Prescription drug upper payment limit—Rules.
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(1) For health plans issued or renewed on or after January 1, 2024, if the prescription drug affordability board, as established in chapter 70.405 RCW, establishes an upper payment limit for a prescription drug pursuant to RCW 70.405.050, a carrier must provide sufficient informa…
RCW 48.43.810 Biomarker testing—Standards—Construction.
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(1) Health plans issued or renewed on or after January 1, 2023, shall exempt an enrollee from prior authorization requirements for coverage of biomarker testing for either of the following:(a) Stage 3 or 4 cancer; or(b) Recurrent, relapsed, refractory, or metastatic cancer.(2) Fo…
RCW 48.43.815 Donor human milk—Standards.
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(1) For group health plans other than small group health plans issued or renewed on or after January 1, 2023, a health carrier shall provide coverage for medically necessary donor human milk for inpatient use when ordered by a licensed health care provider with prescriptive autho…
RCW 48.43.820 Consolidated appropriations act enforcement—Implementation of federal regulations.
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The commissioner is authorized to enforce provisions of P.L. 116-260 (enacted December 27, 2020, as the consolidated appropriations act of 2021) and implementing federal regulations in effect on March 31, 2022, that are applicable to or regulate the conduct of carriers issuing he…
RCW 48.43.825 Certified peer support specialist services—Network access standards.
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By July 1, 2026, each carrier shall provide access to services provided by certified peer support specialists and certified peer support specialist trainees in a manner sufficient to meet the network access standards set forth in rules established by the office of the insurance c…
RCW 48.43.830 Prior authorization.
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*** CHANGE IN 2026 *** (SEE 5395-S2.SL) ***(1) Each carrier offering a health plan issued or renewed on or after January 1, 2024, shall comply with the following standards related to prior authorization for health care services and prescription drugs:(a) The carrier shall meet th…
RCW 48.43.835 Physician assistants—Coverage.
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This chapter authorizes carriers to reimburse employers of physician assistants for covered services rendered by licensed physician assistants. Payment for services within the physician assistant's scope of practice must be made when ordered or performed by a physician assistant …
RCW 48.43.840 Prosthetic limbs and custom orthotic braces—Coverage—Reporting.
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(1) Except as provided in subsection (9) of this section, a health plan offered in the large group or small group market that is issued or renewed on or after January 1, 2026, must include coverage for one or more prostheses per limb and custom orthotic braces per limb when medic…
RCW 48.43.845 Prescription hormone therapy—Coverage.
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(1) A health plan issued or renewed on or after January 1, 2026, that includes coverage for prescription hormone therapy must provide reimbursement for a 12-month refill of covered prescription hormone therapy obtained at one time by the enrollee, unless the enrollee requests a s…
RCW 48.43.902 Effective date—1996 c 312.
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This act shall take effect July 1, 1996.[ 1996 c 312 s 8.]
RCW 48.43.904 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 48.44.010 Definitions.
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For the purposes of this chapter:(1) "Carrier" means a health maintenance organization, an insurer, a health care service contractor, or other entity responsible for the payment of benefits or provision of services under a group or individual contract.(2) "Census date" means the …
RCW 48.44.011 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 care service contractor to solicit applications for health care service contracts on its behalf.(2) No person shall act as or hold himself or herself out to be an appointed insur…
RCW 48.44.013 Filings with secretary of state—Copy for commissioner.
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Health care service contractors and limited health care service contractors 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 arti…
RCW 48.44.015 Registration by health care service contractors required—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 care service contractor, as defined in RCW 48.44.010 without first being registered with the commissioner.(2) The issuance, sale, or offer for sale in this state of secu…
RCW 48.44.016 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 48.44.017 Schedule of rates for individual contracts—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 care service contractor of health care services, as defined in RCW 48.43.005, provided to a contract holder or paid to or o…
RCW 48.44.020 Contracts for services—Examination of contract forms by commissioner—Grounds for disapproval—Liability of participant.
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(1) Any health care service contractor may enter into contracts 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 such health care service contractor providing one or more health ca…
RCW 48.44.021 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 48.44.022 Calculation of premiums—Adjusted community rate—Definitions.
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(1) Except for health benefit plans covered under RCW 48.44.021, premium rates for health benefit plans for individuals shall be subject to the following provisions:(a) The health care service contractor shall develop its rates based on an adjusted community rate and may only var…
RCW 48.44.023 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 care services contractor 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 48.44.024 Requirements for plans offered to small employers—Definitions.
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(1) A health care service contractor may not offer any health benefit plan to any small employer without complying with RCW 48.44.023(3).(2) Employers purchasing health plans provided through associations or through member-governed groups formed specifically for the purpose of pu…
RCW 48.44.026 Payment for certain health care services.
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Checks in payment for claims pursuant to any health care service contract for health care services provided by persons licensed or regulated under chapters 18.25, 18.29, 18.30, 18.32, 18.53, 18.57, 18.64, 18.71, 18.73, 18.74, 18.83, or 18.79 RCW, as it applies to registered nurse…
RCW 48.44.030 Underwriting of indemnity by insurance policy, bond, securities, or cash deposit.
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If any of the health care services which are promised in any such agreement are not to be performed by the health care service contractor, or by a participating provider, such activity shall not be subject to the laws relating to insurance, provided provision is made for reimburs…
RCW 48.44.033 Financial failure—Supervision of commissioner—Priority of distribution of assets.
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(1) Any rehabilitation, liquidation, or conservation of a health care service contractor shall be deemed to be the rehabilitation, liquidation, or conservation of an insurance company and shall be conducted under the supervision of the commissioner pursuant to the law governing t…
RCW 48.44.035 Limited health care service—Uncovered expenditures—Minimum net worth requirements.
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(1) For purposes of this section only, "limited health care service" means dental care services, vision care services, mental health services, chemical dependency services, pharmaceutical services, podiatric care services, and such other services as may be determined by the commi…