Title 48, INSURANCE

(1) The legislature finds that: (a) Phenylketonuria is a rare inherited genetic disorder. (b) Children with phenylketonuria are unable to metabolize an essential amino acid, phenylalanine, which is found in the proteins of most food. (c) To remain healthy, children with phenylket…

(1) Each employer-sponsored group contract for comprehensive health care service which is entered into, or renewed, on or after twelve months after July 23, 1989, shall include coverage for neurodevelopmental therapies for covered individuals age six and under. (2) Benefits provi…

(1) Except as provided in this section, a health maintenance agreement entered into or renewed after December 31, 1989, shall offer optional coverage for the treatment of temporomandibular joint disorders. (a) Health maintenance organizations offering medical coverage only may li…

Health maintenance organizations who through an authorized representative have first approved, by any means, an individual prescription claim as eligible may not reject that claim at some later date. Pharmacists or drug dispensing outlets who obtain preapproval of claims shall ke…

For the purposes of this chapter, a nonresident pharmacy is defined as any pharmacy located outside this state that ships, mails, or delivers, in any manner, except when delivered in person to an enrolled participant or his/her representative, controlled substances, legend drugs,…

Except to the extent that a health maintenance organization contracts with a group medical practice which only treats that organization's patients, a health maintenance organization may not discriminate in the terms and conditions, including reimbursement, for the provision of fo…

Notwithstanding any provision of any health maintenance organization agreement 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)…

A health maintenance organization that provides health care services to the general public may not discriminate against a qualified doctor of osteopathic medicine and surgery licensed under chapter 18.57 RCW, who has applied to practice with the health maintenance organization, s…

A health maintenance organization may not deny coverage for the treatment of an injury solely because the injury was sustained as a consequence of the enrolled participant's being intoxicated or under the influence of a narcotic. [ 2004 c 112 s 5.] Notes: Finding—Application—2004…

(1) Every health maintenance organization 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 a…

No acquisitions or dispositions of assets need be reported pursuant to RCW 48.46.600 if the acquisitions or dispositions are not material. For purposes of RCW 48.46.600 through 48.46.625, a material acquisition, or the aggregate of any series of related acquisitions during any th…

(1) Asset acquisitions subject to RCW 48.46.600 through 48.46.625 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 health maintenance organization o…

The following information is required to be disclosed in any report of a material acquisition or disposition of assets: (1) Date of the transaction; (2) Manner of acquisition or disposition; (3) Description of the assets involved; (4) Nature and amount of the consideration given …

(1) No nonrenewals, cancellations, or revisions of ceded reinsurance agreements need be reported under RCW 48.46.600 if the nonrenewals, cancellations, or revisions are not material. For purposes of RCW 48.46.600 through 48.46.625, a material nonrenewal, cancellation, or revision…

The following is required to be disclosed in any report of a material nonrenewal, cancellation, or revision of ceded reinsurance agreements: (1) The effective date of the nonrenewal, cancellation or revision; (2) The description of the transaction with an identification of the in…

It is intended that the provisions of this chapter shall be liberally construed to accomplish the purposes provided for and authorized herein. [ 1975 1st ex.s. c 290 s 24.]

This 1975 amendatory act may be known and cited as "The Washington Health Maintenance Organization Act of 1975". [ 1975 1st ex.s. c 290 s 27.]

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 …

The legislature finds that there is a continued interest in mandating certain health coverages or offering of health coverages by health carriers; and that improved access to these health care services to segments of the population which desire them can provide beneficial social …

Unless otherwise specifically provided, the definitions in this section apply throughout this chapter. (1) "Appropriate committees of the legislature" or "committees" means nonfiscal standing committees of the Washington state senate and house of representatives that have jurisdi…

Mandated health benefits shall be established as follows: (1) Every person who, or organization that, seeks to establish a mandated benefit shall, at least ninety days prior to a regular legislative session, submit a mandated benefit proposal to the appropriate committees of the …

(1) Based on the availability of relevant information, the following criteria shall be used to assess the impact of proposed mandated benefits: (a) The social impact: (i) To what extent is the benefit generally utilized by a significant portion of the population? (ii) To what ext…

(1) The legislature finds that: (a) Consumers receive surprise bills or balance bills for services provided at nonparticipating facilities, by nonparticipating health care providers at in-network facilities, and by ground ambulance services organizations; (b) Consumers must not b…

This chapter may be known and cited as the balance billing protection act. [ 2019 c 427 s 4.]

The definitions in RCW 48.43.005 apply throughout this chapter unless the context clearly requires otherwise. [ 2019 c 427 s 5.]

(1) A nonparticipating provider or facility may not balance bill an enrollee for the following health care services as provided in section 2799A-1(b) of the public health service act (42 U.S.C. Sec. 300gg-111(b)) and implementing federal regulations in effect on March 31, 2022: (…

(1) If an enrollee receives emergency services from a behavioral health emergency services provider under the circumstances described in RCW 48.49.020(3): (a) The enrollee satisfies his or her obligation to pay for the health care services if he or she pays the in-network cost-sh…

(1) Effective July 1, 2023, or a later date determined by the commissioner, services described in RCW 48.49.020(1) other than air ambulance services are subject to the independent dispute resolution process established in sections 2799A-1 and 2799A-2 of the public health service …

(1) The commissioner, in consultation with health carriers, health care providers, health care facilities, behavioral health emergency services providers, ground ambulance services organizations, and consumers, must develop standard template language for a notice of consumer righ…

(1)(a) A hospital, ambulatory surgical facility, behavioral health emergency services provider, or ground ambulance services organization must post the following information on its website, if one is available: (i) The listing of the carrier health plan provider networks with whi…

(1)(a) A health care provider must provide the following information on its website, if one is available: (i) The listing of the carrier health plan provider networks with which the provider contracts, based upon the information provided by the carrier pursuant to RCW 48.43.730(7…

(1) A carrier must update its website and provider directory no later than thirty days after the addition or termination of a facility or provider. (2) A carrier must provide an enrollee with: (a) A clear description of the health plan's out-of-network health benefits; (b) The no…

(1) If the commissioner has cause to believe that any health care provider, hospital, ambulatory surgical facility, or behavioral health emergency services provider, has engaged in a pattern of unresolved violations of RCW 48.49.020 or 48.49.030, the commissioner may submit infor…

(1) The commissioner may adopt rules to implement and administer this chapter, including rules governing the dispute resolution process established in RCW 48.49.040. (2) The commissioner may adopt rules to adopt or incorporate by reference without material change federal regulati…

This chapter does not apply to health plans that provide benefits under chapter 74.09 RCW. [ 2019 c 427 s 22.]

As authorized in 45 C.F.R. Sec. 149.30 as in effect on March 31, 2022, the provisions of this chapter apply to a self-funded group health plan whether governed by or exempt from the provisions of the federal employee retirement income security act of 1974 (29 U.S.C. Sec. 1001 et …

(1) When determining the adequacy of a proposed provider network or the ongoing adequacy of an in-force provider network, the commissioner must review the carrier's proposed provider network or in-force provider network to determine whether the network includes a sufficient numbe…

This chapter must be liberally construed to promote the public interest by ensuring that consumers are not billed out-of-network charges and do not receive additional bills from providers under the circumstances described in RCW 48.49.020. [ 2019 c 427 s 24.]

(1)(a) Until July 1, 2023, or a later date determined by the commissioner under RCW 48.49.040, the allowed amount paid to a nonparticipating provider for health care services described under RCW 48.49.020(1) other than air ambulance services shall be a commercially reasonable amo…

(1) Carriers must make available through electronic and other methods of communication generally used by a provider or facility to verify enrollee eligibility and benefits information regarding whether an enrollee's health plan is subject to the requirements of this chapter or se…

The commissioner is authorized to enforce provisions of P.L. 116-260 (enacted December 27, 2020, as the consolidated appropriations act of 2021) that are applicable to or regulate the conduct of carriers issuing health plans or grandfathered health plans to residents of Washingto…

(1) For health plans issued or renewed on or after January 1, 2025, a nonparticipating ground ambulance services organization may not balance bill an enrollee for covered ground ambulance services. (2) If an enrollee receives covered ground ambulance services: (a) The enrollee sa…

(1) Each local governmental entity that has established or contracted for rates for ground ambulance services provided in their geographic service area must submit the rates to the office of the insurance commissioner, in the form and manner prescribed by the commissioner for pur…

(1) The commissioner must undertake a process to review the reasonableness of the percentage of the medicare rate established in RCW 48.49.200 and any trends in changes to ground ambulance services rates set by local governmental entities and ground ambulance services organizatio…

Except for section 26 of this act, this act takes effect January 1, 2020. [ 2019 c 427 s 31.]

This chapter shall be known and may be cited as the Insurance Fraud Reporting Immunity Act. [ 1995 c 285 s 20; 1979 ex.s. c 80 s 1.] Notes: Effective date—1995 c 285: See RCW 48.30A.900.