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PRIA provides educational policy intelligence and is not a source of investment, legal, or financial advice. Content is for informational purposes only.

Washington Statutes, Title 48

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Washington/Statutes

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Title 48, INSURANCE

102 chapters · 2,150 sections in this title.

All chapters in Title 482,150 Ch 48.43, Insurance reform.150 Ch 48.46, Health maintenance organizations.89 Ch 48.44, Health care services.88 Ch 48.18, The insurance contract.80 Ch 48.20, Disability insurance.72 Ch 48.05, Insurers—General requirements.58 Ch 48.21, Group and blanket disability insurance.58 Ch 48.31, Mergers, rehabilitation, liquidation…56 Ch 48.23, Life insurance and annuities.54 Ch 48.19, Rates.52 Ch 48.36A, Fraternal benefit societies.49 Ch 48.17, Insurance producers, title insurance…46 Ch 48.29, Title insurers.43 Ch 48.30, Unfair practices and frauds.41

2,150 sections·Filtered byTitle 48✕

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 it…

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) Ma…

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 doll…

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 financi…

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 Uni…

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 aft…

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…

RCW 48.46.320 Dependent children, termination of coverage, conditions.

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Any health maintenance agreement which provides that coverage of a dependent child shall terminate upon attainment of the limiting age for dependent children specified in the agreement shall also provide in substance that attainment of such limiting age shall not operate to termi…

RCW 48.46.325 Option to cover child under age twenty-six.

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(1) Each individual health maintenance agreement that is not grandfathered and that provides coverage for a subscriber's child must offer the option of covering any child under the age of twenty-six. (2) Each group health maintenance agreement that is not grandfathered and that p…

RCW 48.46.340 Return of agreement within ten days.

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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 48.46.350 Chemical dependency treatment.

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Each group agreement for health care services that is delivered or issued for delivery or renewed on or after January 1, 1988, must contain provisions providing benefits for the treatment of chemical dependency rendered to covered persons by a provider which is an "approved subst…

RCW 48.46.355 "Chemical dependency" defined.

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For the purposes of RCW 48.46.350, "chemical dependency" means an illness characterized by a physiological of psychological dependency, or both, on a controlled substance regulated under chapter 69.50 RCW and/or alcoholic beverages. It is further characterized by a frequent or in…

RCW 48.46.360 Payment of cost of agreement directly to holder during labor dispute—Changes restricted—Notice to employee.

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Any employee whose compensation includes a health maintenance agreement, the cost of which is paid in full or in part by an employer including the state of Washington, its political subdivisions, or municipal corporations, or paid by payroll deduction, may pay the cost as it beco…

RCW 48.46.370 Coverage not denied for disability.

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No health maintenance organization may deny coverage to a person solely on account of the presence of any disability. Nothing in this section may be construed as limiting a health maintenance organization's authority to deny or otherwise limit coverage to a person when the person…

RCW 48.46.375 Benefits for prenatal diagnosis of congenital disorders—Agreements entered into or renewed on or after January 1, 1990.

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On or after January 1, 1990, every group health maintenance agreement entered into or renewed that covers hospital, medical, or surgical expenses and which provides benefits for pregnancy, childbirth, or related medical conditions to enrollees of such groups, shall offer benefits…

RCW 48.46.380 Notice of reason for cancellation, denial, or refusal to renew agreement.

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Every authorized health maintenance organization, upon canceling, denying, or refusing to renew any individual health maintenance agreement, shall, upon written request, directly notify in writing the applicant or enrolled participant as appropriate, of the reasons for the action…

RCW 48.46.390 Providing information on cancellation or refusal—No liability for insurance commissioner or health maintenance organization.

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With respect to the provisions of health maintenance agreements as set forth in RCW 48.46.380, there shall be no liability on the part of, and no cause of action of any nature shall arise against, the insurance commissioner, the commissioner's agents, or members of the commission…

RCW 48.46.400 False or misleading advertising prohibited.

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No person may knowingly make, publish, or disseminate any false, deceptive, or misleading representation or advertising in the conduct of the business of a health maintenance organization, or relative to the business of a health maintenance organization or to any person engaged t…

RCW 48.46.410 Misrepresentations to induce termination or retention of agreement prohibited.

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No health maintenance organization nor any person representing a health maintenance organization may by misrepresentation or misleading comparisons induce or attempt to induce any member of a health maintenance organization to terminate or retain an agreement or membership in the…

RCW 48.46.420 Penalty for violations.

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(1) Except as otherwise provided in this chapter, any health maintenance organization which, or person who, violates any provision of this chapter is guilty of a gross misdemeanor. (2) A health maintenance organization that fails to comply with the net worth requirements of this …

RCW 48.46.430 Enforcement authority of commissioner.

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For the purposes of this chapter, the insurance commissioner shall have the same powers and duties of enforcement as are provided in RCW 48.02.080. [ 1983 c 106 s 21.]

RCW 48.46.440 Continuation option to be offered.

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Every health maintenance organization that issues agreements providing group coverage for hospital or medical care shall offer the agreement holder an option to include an agreement provision granting a person who becomes ineligible for coverage under the group agreement, the rig…

RCW 48.46.450 Conversion agreement to be offered—Exceptions, conditions.

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(1) Except as otherwise provided by this section, any group health maintenance agreement that provides benefits for hospital or medical care must contain a provision granting a person covered by the group agreement the right to obtain a conversion agreement from the health mainte…

RCW 48.46.460 Conversion agreement—Restrictions and requirements—Rules.

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(1) A health maintenance organization must offer a conversion agreement for comprehensive health care services and shall not require proof of insurability as a condition for issuance of the conversion agreement. (2) A conversion agreement may not contain an exclusion for preexist…