RCW ch. 41.05 — Revised Code of Washington Chapter 41.05 RCW — State Health Care Authority

RCW 41.05.004 Intent—Use of word "board." It is the intent of the legislature that the word "board" be read to mean both the school employees' benefits board and the public employees' benefits board throughout this chapter. The use of "board" should be liberally construed to mean both boards, to the extent not in conflict with state or federal law. In no case shall either board be limited from exercising its individual authority as authorized within this chapter. [ 2018 c 260 s 5.] RCW 41.05.006 Purpose. (1) The legislature recognizes that (a) the state is a major purchaser of health care services, (b) the increasing costs of such health care services are posing and will continue to pose a great financial burden on the state, (c) it is the state's policy, consistent with the best interests of the state, to provide comprehensive health care as an employer, to public employees, officials, their dependents, and to those who are dependent on the state for necessary medical care, and (d) it is imperative that the state begin to develop effective and efficient health care delivery systems and strategies for procuring health care services in order for the state to continue to purchase the most comprehensive health care possible. (2) It is therefore the purpose of this chapter to establish the Washington state health care authority whose purpose shall be to (a) develop health care benefit programs that provide access to at least one comprehensive benefit plan funded to the fullest extent possible by the employer, and a health savings account/high deductible health plan option as defined in section 1201 of the medicare prescription drug improvement and modernization act of 2003, as amended, for eligible public employees, officials, and their dependents, and (b) study all state purchased health care, alternative health care delivery systems, and strategies for the procurement of health care services and make recommendations aimed at minimizing the financial burden which health care poses on the state, public employees, and its charges, while at the same time allowing the state to provide the most comprehensive health care options possible. [ 2023 c 51 s 1; 2018 c 260 s 2; 2006 c 299 s 1; 1988 c 107 s 2.] RCW 41.05.008 Duties of employing agencies. (1) Every employing agency shall carry out all actions required by the authority under this chapter including, but not limited to, those necessary for the operation of benefit plans, education of employees, claims administration, and appeals process. (2) Employing agencies shall report all data relating to employees eligible to participate in benefits or plans administered by the authority in a format designed and communicated by the authority. [ 2009 c 537 s 1; 2005 c 143 s 4.] NOTES: Effective date— RCW 41.05.009 Determination of public employee eligibility for benefits. (1) The authority, or an employing agency at the authority's direction, shall initially determine and periodically review whether a public employee is eligible for benefits pursuant to the criteria established under this chapter. (2) An employing agency shall inform a public employee in writing whether or not he or she is eligible for benefits when initially determined and upon any subsequent change, including notice of the public employee's right to an appeal. [ 2023 c 51 s 2; 2018 c 260 s 3; 2015 c 116 s 1; 2009 c 537 s 2.] NOTES: Effective date— RCW 41.05.0091 Eligibility exists prior to January 1, 2010. An employee determined eligible for benefits prior to January 1, 2010, shall not have his or her eligibility terminated pursuant to the criteria established under chapter 537, Laws of 2009 unless the termination is the result of: (1) A voluntary reduction in work hours; or (2) the employee's employment with an agency other than the agency by which he or she was determined eligible prior to January 1, 2010. [ 2009 c 537 s 10.] NOTES: Effective date— RCW 41.05.011 Definitions. (Effective until June 30, 2029.) The definitions in this section apply throughout this chapter unless the context clearly requires otherwise. (1) "Authority" means the Washington state health care authority. (2) "Board" means the public employees' benefits board established under RCW 41.05.055 and the school employees' benefits board established under RCW 41.05.740. (3) "Dependent care assistance program" means a benefit plan whereby employees and school employees may pay for certain employment related dependent care with pretax dollars as provided in the salary reduction plan under this chapter pursuant to 26 U.S.C. Sec. 129 or other sections of the internal revenue code. (4) "Director" means the director of the authority. (5) "Emergency service personnel killed in the line of duty" means law enforcement officers and firefighters as defined in RCW 41.26.030, members of the Washington state patrol retirement fund as defined in RCW 43.43.120, and reserve officers and firefighters as defined in RCW 41.24.010 who die as a result of injuries sustained in the course of employment as determined consistent with Title 51 RCW by the department of labor and industries. (6)(a) "Employee" for the public employees' benefits board program includes all employees of the state, whether or not covered by civil service; elected and appointed officials of the executive branch of government, including full-time members of boards, commissions, or committees; justices of the supreme court and judges of the court of appeals and the superior courts; and members of the state legislature. Pursuant to contractual agreement with the authority, "employee" may also include: (i) Employees of a county, municipality, or other political subdivision of the state and members of the legislative authority of any county, city, or town who are elected to office after February 20, 1970, if the legislative authority of the county, municipality, or other political subdivision of the state submits application materials to the authority to provide any of its insurance programs by contract with the authority, as provided in RCW 41.04.205 and 41.05.021(1)(g); (ii) employees of employee organizations representing state civil service employees, at the option of each such employee organization; (iii) through December 31, 2019, employees of a school district if the authority agrees to provide any of the school districts' insurance programs by contract with the authority as provided in RCW 28A.400.350; (iv) employees of a tribal government, if the governing body of the tribal government seeks and receives the approval of the authority to provide any of its insurance programs by contract with the authority, as provided in RCW 41.05.021(1) (f) and (g); (v) employees of the Washington health benefit exchange if the governing board of the exchange established in RCW 43.71.020 seeks and receives approval of the authority to provide any of its insurance programs by contract with the authority, as provided in RCW 41.05.021(1) (g) and (n); and (vi) through December 31, 2019, employees of a charter school established under chapter 28A.710 RCW. "Employee" does not include: Adult family home providers; unpaid volunteers; patients of state hospitals; inmates; students of institutions of higher education as determined by their institution; and any others not expressly defined as employees under this chapter or by the authority under this chapter. (b) Effective January 1, 2020, "school employee" for the school employees' benefits board program includes: (i) All employees of school districts and charter schools established under chapter 28A.710 RCW; (ii) Represented employees of educational service districts; (iii) Effective January 1, 2024, all employees of educational service districts; and (iv) Effective January 1, 2024, pursuant to contractual agreement with the authority, "school employee" may also include: (A) Employees of employee organizations representing school employees, at the option of each such employee organization; and (B) employees of a tribal school as defined in RCW 28A.715.010, if the governing body of the tribal school seeks and receives the approval of the authority to provide any of its insurance programs by contract with the authority, as provided in RCW 41.05.021(1) (f) and (g). (7) "Employee group" means employees of a similar employment type, such as administrative, represented classified, nonrepresented classified excluding such employees in educational service districts until December 31, 2023, confidential, represented certificated, or nonrepresented certificated excluding such employees in educational service districts until December 31, 2023, within a school employees' benefits board organization. (8)(a) "Employer" for the public employees' benefits board program means the state of Washington. (b) "Employer" for the school employees' benefits board program means school districts and educational service districts and charter schools established under chapter 28A.710 RCW. (9)(a) "Employer group" for the public employees' benefits board program means those counties, municipalities, political subdivisions, the Washington health benefit exchange, tribal governments, and employee organizations representing state civil service employees obtaining employee benefits through a contractual agreement with the authority to participate in benefit plans developed by the public employees' benefits board. (b) "Employer group" for the school employees' benefits board program means an employee organization representing school employees and a tribal school as defined in RCW 28A.715.010, obtaining employee benefits through a contractual agreement with the authority to participate in benefit plans developed by the school employees' benefits board. (10)(a) "Employing agency" for the public employees' benefits board program means a division, department, or separate agency of state government, including an institution of higher education; a county, municipality, or other political subdivision; and a tribal government covered by this chapter. (b) "Employing agency" for the school employees' benefits board program means school districts, educational service districts, and charter schools. (11) "Faculty" means an academic employee of an institution of higher education whose workload is not defined by work hours but whose appointment, workload, and duties directly serve the institution's academic mission, as determined under the authority of its enabling statutes, its governing body, and any applicable collective bargaining agreement. (12) "Flexible benefit plan" means a benefit plan that allows public employees to choose the level of health care coverage provided and the amount of employee or school employee contributions from among a range of choices offered by the authority. (13) "Flexible spending arrangement" means a benefit plan whereby public employees may reduce their salary before taxes to pay for medical expenses not reimbursed by insurance as provided in the salary reduction plan under this chapter pursuant to 26 U.S.C. Sec. 125 or other sections of the internal revenue code. (14) "Insuring entity" means an insurer as defined in chapter 48.01 RCW, a health care service contractor as defined in chapter 48.44 RCW, or a health maintenance organization as defined in chapter 48.46 RCW. (15) "Participant" means an individual who fulfills the eligibility and enrollment requirements under the salary reduction plan. (16) "Plan year" means the time period established by the authority. (17) "Premium payment plan" means a benefit plan whereby public employees may pay their share of group health plan premiums with pretax dollars as provided in the salary reduction plan under this chapter pursuant to 26 U.S.C. Sec. 125 or other sections of the internal revenue code. (18) "Public employee" has the same meaning as employee and school employee. (19) "Retired or disabled school employee" means: (a) Persons who separated from employment with a school district or educational service district and are receiving a retirement allowance under chapter 41.32 or 41.40 RCW as of September 30, 1993; (b) Persons who separate from employment with a school district, educational service district, or charter school on or after October 1, 1993, and immediately upon separation receive a retirement allowance under chapter 41.32, 41.35, or 41.40 RCW; (c) Persons who separate from employment with a school district, educational service district, or charter school due to a total and permanent disability, and are eligible to receive a deferred retirement allowance under chapter 41.32, 41.35, or 41.40 RCW. (20) "Salary" means a public employee's monthly salary or wages. (21) "Salary reduction plan" means a benefit plan whereby public employees may agree to a reduction of salary on a pretax basis to participate in the dependent care assistance program, flexible spending arrangement, or premium payment plan offered pursuant to 26 U.S.C. Sec. 125 or other sections of the internal revenue code. (22) "School employees' benefits board organization" means a public school district or educational service district or charter school established under chapter 28A.710 RCW that is required to participate in benefit plans provided by the school employees' benefits board. (23) "School year" means school year as defined in RCW 28A.150.203(11). (24) "Seasonal employee" means a state employee hired to work during a recurring, annual season with a duration of three months or more, and anticipated to return each season to perform similar work. (25) "Separated employees" means persons who separate from employment with an employer as defined in: (a)(i) RCW 41.32.010(17) on or after July 1, 1996; or (ii) RCW 41.35.010 on or after September 1, 2000; or (iii) RCW 41.40.010 on or after March 1, 2002; and who are at least age fifty-five and have at least ten years of service under the teachers' retirement system plan 3 as defined in RCW 41.32.010(33), the Washington school employees' retirement system plan 3 as defined in RCW 41.35.010, or the public employees' retirement system plan 3 as defined in RCW 41.40.010; or (b) For the purposes of RCW 41.05.080: (i) RCW 41.32.010 on or after January 1, 2024; or (ii) RCW 41.35.010 on or after January 1, 2024; or (iii) RCW 41.40.010 on or after January 1, 2024; and who are at least age 55 and have at least 20 years of service under the teachers' retirement system plan 2 as defined in RCW 41.32.010, the Washington school employees' retirement system plan 2 as defined in RCW 41.35.010, or the public employees' retirement system plan 2 as defined in RCW 41.40.010. (26) "State purchased health care" or "health care" means medical and behavioral health care, pharmaceuticals, and medical equipment purchased with state and federal funds by the department of social and health services, the department of health, the basic health plan, the state health care authority, the department of labor and industries, the department of corrections, the department of veterans affairs, and local school districts. (27) "Tribal government" means an Indian tribal government as defined in section 3(32) of the employee retirement income security act of 1974, as amended, or an agency or instrumentality of the tribal government, that has government offices principally located in this state. [ 2023 c 164 s 1; 2023 c 51 s 3; 2023 c 13 s 2; 2019 c 411 s 4; 2018 c 260 s 4; 2017 3rd sp.s. c 13 s 802. Prior: 2016 c 241 s 136; 2016 c 67 s 2; prior: 2015 c 116 s 2; 2013 c 2 s 306 (Initiative Measure No. 1240, approved November 6, 2012); 2012 c 87 s 22; prior: 2011 1st sp.s. c 15 s 54; 2009 c 537 s 3; 2008 c 229 s 2; prior: 2007 c 488 s 2; 2007 c 114 s 2; 2005 c 143 s 1; 2001 c 165 s 2; prior: 2000 c 247 s 604; 2000 c 230 s 3; 1998 c 341 s 706; 1996 c 39 s 21; 1995 1st sp.s. c 6 s 2; 1994 c 153 s 2; prior: 1993 c 492 s 214; 1993 c 386 s 5; 1990 c 222 s 2; 1988 c 107 s 3.] NOTES: Reviser's note: RCW 41.05.013 State purchased health care programs—Uniform policies. (1) The authority shall coordinate state agency efforts to develop and implement uniform policies across state purchased health care programs that will ensure prudent, cost-effective health services purchasing, maximize efficiencies in administration of state purchased health care programs, improve the quality of care provided through state purchased health care programs, and reduce administrative burdens on health care providers participating in state purchased health care programs. The policies adopted should be based, to the extent possible, upon the best available scientific and medical evidence and shall endeavor to address: (a) Methods of formal assessment, such as a health technology assessment under RCW 70.14.080 through 70.14.130. Consideration of the best available scientific evidence does not preclude consideration of experimental or investigational treatment or services under a clinical investigation approved by an institutional review board; (b) Monitoring of health outcomes, adverse events, quality, and cost-effectiveness of health services; (c) Development of a common definition of medical necessity; and (d) Exploration of common strategies for disease management and demand management programs, including asthma, diabetes, heart disease, and similar common chronic diseases. Strategies to be explored include individual asthma management plans. (2) The director may invite health care provider organizations, carriers, other health care purchasers, and consumers to participate in efforts undertaken under this section. (3) For the purposes of this section "best available scientific and medical evidence" means the best available clinical evidence derived from systematic research. [ 2023 c 51 s 4; 2006 c 307 s 8; 2005 c 462 s 3; 2003 c 276 s 1.] NOTES: Captions not law— RCW 41.05.014 Applications, enrollment forms, and eligibility certification documents—Signatures. (1) The director may require applications, enrollment forms, and eligibility certification documents for benefits that are administered by the authority under this chapter and chapter 70.47 RCW to be signed by the person submitting them. The director may accept electronic signatures. (2) For the purpose of this section, "electronic signature" means an electronic sound, symbol, or process attached to or logically associated with a record and executed or adopted by a person with the intent to sign the record. [ 2020 c 57 s 84; 2009 c 201 s 2.] RCW 41.05.015 Medical director—Appointment of personnel. The director shall designate a medical director who is licensed under chapter 18.57 or 18.71 RCW. The director shall also appoint such professional personnel and other assistants and employees, including professional medical screeners, as may be reasonably necessary to carry out the provisions of this chapter and chapters 74.09, 71.05, 71.24, and 71.34 RCW and other applicable law. The medical screeners must be supervised by one or more physicians whom the director or the director's designee shall appoint. [ 2023 c 51 s 5; 2018 c 201 s 7001; 2011 1st sp.s. c 15 s 55; 2000 c 5 s 16.] NOTES: Findings— RCW 41.05.017 Provisions applicable to health plans offered under this chapter. Each health plan that provides medical insurance offered under this chapter, including plans created by insuring entities, plans not subject to the provisions of Title 48 RCW, and plans created under RCW 41.05.140, are subject to the provisions of RCW 48.43.500, 70.02.045, 48.43.505 through 48.43.535, 48.43.537, 48.43.545, 48.43.550, 70.02.110, 70.02.900, 48.43.190, 48.43.083, 48.43.0128, 48.43.780, 48.43.435, 48.43.815, 48.200.020 through 48.200.280, 48.200.300 through 48.200.320, 48.43.440, 48.43.845, 48.43.732, 48.43.850, 48.43.013, and chapter 48.49 RCW. [ 2026 c 158 s 3; 2026 c 48 s 2. Prior: 2025 c 389 s 3; 2025 c 171 s 2; prior: 2024 c 251 s 5; 2024 c 242 s 10; prior: 2022 c 236 s 3; 2022 c 228 s 2; 2022 c 10 s 2; 2021 c 280 s 2; 2019 c 427 s 21; 2016 c 139 s 4; 2008 c 304 s 2; 2007 c 502 s 2; 2000 c 5 s 20.] NOTES: Reviser's note: RCW 41.05.018 Transfer of certain behavioral health-related powers, duties, and functions from the department of social and health services. (1) The powers, duties, and functions of the department of social and health services pertaining to the behavioral health system and purchasing function of the behavioral health administration, except for oversight and management of state-run mental health institutions and licensing and certification activities, are hereby transferred to the Washington state health care authority to the extent necessary to carry out the purposes of chapter 201, Laws of 2018. All references to the secretary or the department of social and health services in the Revised Code of Washington shall be construed to mean the director of the health care authority or the health care authority when referring to the functions transferred in this section. (2)(a) All reports, documents, surveys, books, records, files, papers, or written material in the possession of the department of social and health services pertaining to the powers, duties, and functions transferred shall be delivered to the custody of the health care authority. All cabinets, furniture, office equipment, motor vehicles, and other tangible property employed by the department of social and health services in carrying out the powers, duties, and functions transferred shall be made available to the health care authority. All funds, credits, or other assets held by the department of social and health services in connection with the powers, duties, and functions transferred shall be assigned to the health care authority. (b) Any appropriations made to the department of social and health services for carrying out the powers, functions, and duties transferred shall, on July 1, 2018, be transferred and credited to the health care authority. (c) Whenever any question arises as to the transfer of any personnel, funds, books, documents, records, papers, files, equipment, or other tangible property used or held in the exercise of the powers and the performance of the duties and functions transferred, the director of financial management shall make a determination as to the proper allocation and certify the same to the state agencies concerned. (3) All rules and all pending business before the department of social and health services pertaining to the powers, duties, and functions transferred shall be continued and acted upon by the health care authority. All existing contracts and obligations shall remain in full force and shall be performed by the health care authority. (4) The transfer of the powers, duties, functions, and personnel of the department of social and health services shall not affect the validity of any act performed before July 1, 2018. (5) If apportionments of budgeted funds are required because of the transfers directed by this section, the director of financial management shall certify the apportionments to the agencies affected, the state auditor, and the state treasurer. Each of these shall make the appropriate transfer and adjustments in funds and appropriation accounts and equipment records in accordance with the certification. (6) On July 1, 2018, all employees of the department of social and health services engaged in performing the powers, functions, and duties transferred to the health care authority are transferred to the health care authority. All employees classified under chapter 41.06 RCW, the state civil service law, are assigned to the health care authority to perform their usual duties upon the same terms as formerly, without any loss of rights, subject to any action that may be appropriate thereafter in accordance with the laws and rules governing state civil service law. (7) Positions in any bargaining unit within the health care authority existing on July 1, 2018, will not be removed from an existing bargaining unit as a result of this section unless and until the existing bargaining unit is modified by the public employment relations commission pursuant to Title 391 WAC. The portions of any bargaining units of employees at the department of social and health services existing on July 1, 2018, that are transferred to the health care authority shall be considered separate appropriate units within the health care authority unless and until modified by the public employment relations commission pursuant to Title 391 WAC. The exclusive bargaining representatives recognized as representing the portions of the bargaining units of employees at the department of social and health services existing on July 1, 2018, shall continue as the exclusive bargaining representatives of the transferred bargaining units without the necessity of an election. (8) The public employment relations commission may review the appropriateness of the collective bargaining units that are a result of the transfer from the department of social and health services to the health care authority under chapter 201, Laws of 2018. The employer or the exclusive bargaining representative may petition the public employment relations commission to review the bargaining units in accordance with this section. (9) On July 1, 2018, the health care authority must enter into an agreement with the department of health to ensure coordination of preventative behavioral health services or other necessary agreements to carry out the intent of chapter 201, Laws of 2018. (10) The health care authority may enter into agreements as necessary with the department of social and health services to carry out the transfer of duties as set forth in chapter 201, Laws of 2018. [ 2018 c 201 s 10001.] NOTES: Findings— RCW 41.05.021 State health care authority—Director—Cost control and delivery strategies—Health information technology—Managed competition—Rules. (1) The Washington state health care authority is created within the executive branch. The authority shall have a director appointed by the governor, with the consent of the senate. The director shall serve at the pleasure of the governor. The director may employ a deputy director, and such assistant directors and special assistants as may be needed to administer the authority, who shall be exempt from chapter 41.06 RCW, and any additional staff members as are necessary to administer this chapter. The director may delegate any power or duty vested in him or her by law, including authority to make final decisions and enter final orders in hearings conducted under chapter 34.05 RCW. The primary duties of the authority shall be to: Administer insurance benefits for employees, retired or disabled state and school employees, and school employees; administer the basic health plan pursuant to chapter 70.47 RCW; administer the children's health program pursuant to chapter 74.09 RCW; study state purchased health care programs in order to maximize cost containment in these programs while ensuring access to quality health care; implement state initiatives, joint purchasing strategies, and techniques for efficient administration that have potential application to all state-purchased health services; and administer grants that further the mission and goals of the authority. The authority's duties include, but are not limited to, the following: (a) To administer health care benefit programs for employees, retired or disabled state and school employees, and school employees as specifically authorized in RCW 41.05.065 and 41.05.740 and in accordance with the methods described in RCW 41.05.075, 41.05.140, and other provisions of this chapter; (b) To analyze state purchased health care programs and to explore options for cost containment and delivery alternatives for those programs that are consistent with the purposes of those programs, including, but not limited to: (i) Creation of economic incentives for the persons for whom the state purchases health care to appropriately utilize and purchase health care services, including the development of flexible benefit plans to offset increases in individual financial responsibility; (ii) Utilization of provider arrangements that encourage cost containment, including but not limited to prepaid delivery systems, utilization review, and prospective payment methods, and that ensure access to quality care, including assuring reasonable access to local providers, especially for employees and school employees residing in rural areas; (iii) Coordination of state agency efforts to purchase drugs effectively as provided in RCW 70.14.050; (iv) Development of recommendations and methods for purchasing medical equipment and supporting services on a volume discount basis; (v) Development of data systems to obtain utilization data from state purchased health care programs in order to identify cost centers, utilization patterns, provider and hospital practice patterns, and procedure costs, utilizing the information obtained pursuant to RCW 41.05.031; and (vi) In collaboration with other state agencies that administer state purchased health care programs, private health care purchasers, health care facilities, providers, and carriers: (A) Use evidence-based medicine principles to develop common performance measures and implement financial incentives in contracts with insuring entities, health care facilities, and providers that: (I) Reward improvements in health outcomes for individuals with chronic diseases, increased utilization of appropriate preventive health services, and reductions in medical errors; and (II) Increase, through appropriate incentives to insuring entities, health care facilities, and providers, the adoption and use of information technology that contributes to improved health outcomes, better coordination of care, and decreased medical errors; (B) Through state health purchasing, reimbursement, or pilot strategies, promote and increase the adoption of health information technology systems, including electronic medical records, by hospitals as defined in RCW 70.41.020, integrated delivery systems, and providers that: (I) Facilitate diagnosis or treatment; (II) Reduce unnecessary duplication of medical tests; (III) Promote efficient electronic physician order entry; (IV) Increase access to health information for consumers and their providers; and (V) Improve health outcomes; (C) Coordinate a strategy for the adoption of health information technology systems; (c) To analyze areas of public and private health care interaction; (d) To provide information and technical and administrative assistance to the board; (e) To review and approve or deny applications from counties, municipalities, and other political subdivisions of the state to provide state-sponsored insurance or self-insurance programs to their employees in accordance with the provisions of RCW 41.04.205 and (g) of this subsection, setting the premium contribution for approved groups as outlined in RCW 41.05.050; (f) To review and approve or deny the application when the governing body of a tribal government or tribal school applies to transfer their employees to an insurance or self-insurance program administered by the public employees' benefits board or by the school employees' benefits board. In the event of an employee transfer pursuant to this subsection (1)(f), members of the governing body are eligible to be included in such a transfer if the members are authorized by the tribal government or tribal school to participate in the insurance program being transferred from and subject to payment by the members of all costs of insurance for the members. The authority shall: (i) Establish the conditions for participation; (ii) have the sole right to reject the application; and (iii) set the premium contribution for approved groups as outlined in RCW 41.05.050. Approval of the application by the authority transfers the employees and dependents involved to the insurance, self-insurance, or health care program administered by the public employees' benefits board or the school employees' benefits board; (g) To ensure the continued status of the employee insurance or self-insurance programs administered under this chapter as a governmental plan under section 3(32) of the employee retirement income security act of 1974, as amended, the authority shall limit the participation of employer groups, including providing for the participation of those employees whose services are substantially all in the performance of essential governmental functions, but not in the performance of commercial activities. Charter schools established under chapter 28A.710 RCW are employers and are school employees' benefits board organizations unless: (i) The authority receives guidance from the internal revenue service or the United States department of labor that participation jeopardizes the status of plans offered under this chapter as governmental plans under the federal employees' retirement income security act or the internal revenue code; or (ii) The charter schools are not in compliance with regulations issued by the internal revenue service and the United States treasury department pertaining to section 414(d) of the federal internal revenue code; (h) To establish billing procedures and collect funds from school employees' benefits board organizations in a way that minimizes the administrative burden on districts; (i) Through December 31, 2019, to publish and distribute to nonparticipating school districts and educational service districts by October 1st of each year a description of health care benefit plans available through the authority and the estimated cost if school districts and educational service district employees were enrolled; (j) To apply for, receive, and accept grants, gifts, and other payments, including property and service, from any governmental or other public or private entity or person, and make arrangements as to the use of these receipts to implement initiatives and strategies developed under this section; (k) To issue, distribute, and administer grants that further the mission and goals of the authority; (l) To adopt rules consistent with this chapter as described in RCW 41.05.160 including, but not limited to: (i) Setting forth the criteria established by the public employees' benefits board under RCW 41.05.065, and by the school employees' benefits board under RCW 41.05.740, for determining whether a public employee is eligible for benefits; (ii) Establishing an appeal process in accordance with chapter 34.05 RCW by which a public employee may appeal an eligibility determination; (iii) Establishing a process to assure that the eligibility determinations of an employing agency comply with the criteria under this chapter, including the imposition of penalties as may be authorized by the board; (m)(i) To administer the medical services programs established under chapter 74.09 RCW as the designated single state agency for purposes of Title XIX of the federal social security act; (ii) To administer the state children's health insurance program under chapter 74.09 RCW for purposes of Title XXI of the federal social security act; (iii) To enter into agreements with the department of social and health services for administration of medical care services programs under Titles XIX and XXI of the social security act and programs under chapters 71.05, 71.24, and 71.34 RCW. The agreements shall establish the division of responsibilities between the authority and the department with respect to mental health, substance use disorders, and long-term care services, including services for persons with developmental disabilities. The agreements shall be revised as necessary, to comply with the final implementation plan adopted under section 116, chapter 15, Laws of 2011 1st sp. sess.; (iv) To adopt rules to carry out the purposes of chapter 74.09 RCW; (v) To appoint such advisory committees or councils as may be required by any federal statute or regulation as a condition to the receipt of federal funds by the authority. The director may appoint statewide committees or councils in the following subject areas: (A) Health facilities; (B) children and youth services; (C) blind services; (D) medical and health care; (E) drug abuse and alcoholism; (F) rehabilitative services; and (G) such other subject matters as are or come within the authority's responsibilities. The statewide councils shall have representation from both major political parties and shall have substantial consumer representation. Such committees or councils shall be constituted as required by federal law or as the director in his or her discretion may determine. The members of the committees or councils shall hold office for three years except in the case of a vacancy, in which event appointment shall be only for the remainder of the unexpired term for which the vacancy occurs. No member shall serve more than two consecutive terms. Members of such state advisory committees or councils may be paid their travel expenses in accordance with RCW 43.03.050 and 43.03.060 as now existing or hereafter amended; (n) To review and approve or deny the application from the governing board of the Washington health benefit exchange to provide public employees' benefits board state-sponsored insurance or self-insurance programs to employees of the exchange. The authority shall (i) establish the conditions for participation; (ii) have the sole right to reject an application; and (iii) set the premium contribution for approved groups as outlined in RCW 41.05.050. (2) The public employees' benefits board and the school employees' benefits board may implement strategies to promote managed competition among employee and school employee health benefit plans. Strategies may include but are not limited to: (a) Standardizing the benefit package; (b) Soliciting competitive bids for the benefit package; (c) Limiting the state's contribution to a percent of the lowest priced qualified plan within a geographical area; (d) Monitoring the impact of the approach under this subsection with regards to: Efficiencies in health service delivery, cost shifts to subscribers, access to and choice of managed care plans statewide, and quality of health services. The health care authority shall also advise on the value of administering a benchmark employer-managed plan to promote competition among managed care plans. [ 2023 c 51 s 6; 2023 c 13 s 3. Prior: 2018 c 260 s 6; 2018 c 201 s 7002; 2017 3rd sp.s. c 13 s 803; 2012 c 87 s 23; 2011 1st sp.s. c 15 s 56; 2009 c 537 s 4; prior: 2007 c 274 s 1; 2007 c 114 s 3; 2006 c 103 s 2; 2005 c 446 s 1; 2002 c 142 s 1; 1999 c 372 s 4; 1997 c 274 s 1; 1995 1st sp.s. c 6 s 7; 1994 c 309 s 1; prior: 1993 c 492 s 215; 1993 c 386 s 6; 1990 c 222 s 3; 1988 c 107 s 4.] NOTES: Reviser's note: RCW 41.05.022 State agent for purchasing health services—Single community-rated risk pool. (1) The health care authority is hereby designated as the single state agent for purchasing health services. (2) On and after January 1, 1995, at least the following state-purchased health services programs shall be merged into a single, community-rated risk pool: Health benefits for groups of employees of school districts and educational service districts that voluntarily purchase health benefits as provided in RCW 41.05.011 through December 31, 2019; health benefits for employees; health benefits for eligible retired or disabled school employees not eligible for parts A and B of medicare; and health benefits for eligible state retirees not eligible for parts A and B of medicare. (3) On and after January 1, 2020, health benefits for groups of school employees of school employees' benefits board organizations shall be merged into a single, community-rated risk pool separate and distinct from the pool described in subsection (2) of this section. (4) By December 15, 2018, the health care authority, in consultation with the board, shall submit to the appropriate committees of the legislature a complete analysis of the most appropriate risk pool for the retired and disabled school employees, to include at a minimum an analysis of the size of the nonmedicare and medicare retiree enrollment pools, the impacts on cost for state and school district retirees of moving retirees from one pool to another, the need for and the amount of an ongoing retiree subsidy allocation from the active school employees, and the timing and suggested approach for a transition from one risk pool to another. (5) At a minimum, and regardless of other legislative enactments, the state health services purchasing agent shall: (a) Require that a public agency that provides subsidies for a substantial portion of services now covered under the basic health plan use uniform eligibility processes, insofar as may be possible, and ensure that multiple eligibility determinations are not required; (b) Require that a health care provider or a health care facility that receives funds from a public program provide care to state residents receiving a state subsidy who may wish to receive care from them, and that an insuring entity that receives funds from a public program accept enrollment from state residents receiving a state subsidy who may wish to enroll with them; (c) Strive to integrate purchasing for all publicly sponsored health services in order to maximize the cost control potential and promote the most efficient methods of financing and coordinating services; (d) Consult regularly with the governor, the legislature, and state agency directors whose operations are affected by the implementation of this section; and (e) Ensure the control of benefit costs under managed competition by adopting rules to prevent an employing agency from entering into an agreement with employees or employee organizations when the agreement would result in increased utilization in board plans or reduce the expected savings of managed competition. [ 2018 c 260 s 7; 2017 3rd sp.s. c 13 s 804; 1995 1st sp.s. c 6 s 3; 1994 c 153 s 3; 1993 c 492 s 227.] NOTES: Intent— RCW 41.05.023 Chronic care management program—Uniform medical plan—Definitions. (1) The health care authority, in collaboration with the department of health, shall design and implement a chronic care management program for employees and school employees enrolled in the state's self-insured uniform medical plan. Programs must be evidence based, facilitating the use of information technology to improve quality of care and must improve coordination of primary, acute, and long-term care for those enrollees with multiple chronic conditions. The authority shall consider expansion of existing medical home and chronic care management programs. The authority shall use best practices in identifying those employees and school employees best served under a chronic care management model using predictive modeling through claims or other health risk information. (2) For purposes of this section: (a) "Medical home" means a site of care that provides comprehensive preventive and coordinated care centered on the patient needs and assures high quality, accessible, and efficient care. (b) "Chronic care management" means the authority's program that provides care management and coordination activities for health plan enrollees determined to be at risk for high medical costs. "Chronic care management" provides education and training and/or coordination that assist program participants in improving self-management skills to improve health outcomes and reduce medical costs by educating clients to better utilize services. [ 2018 c 260 s 8; 2007 c 259 s 6.] NOTES: Subheadings not law— RCW 41.05.026 Contracts—Proprietary data, trade secrets, actuarial formulas, statistics, cost and utilization data—Exemption from public inspection—Executive sessions. (1) When soliciting proposals for the purpose of awarding contracts for goods or services, the director shall, upon written request by the bidder, exempt from public inspection and copying such proprietary data, trade secrets, or other information contained in the bidder's proposal that relate to the bidder's unique methods of conducting business or of determining prices or premium rates to be charged for services under terms of the proposal. (2) When soliciting information for the development, acquisition, or implementation of state purchased health care services, the director shall, upon written request by the respondent, exempt from public inspection and copying such proprietary data, trade secrets, or other information submitted by the respondent that relate to the respondent's unique methods of conducting business, data unique to the product or services of the respondent, or to determining prices or rates to be charged for services. (3) Actuarial formulas, statistics, cost and utilization data, or other proprietary information submitted upon request of the director, board, or a technical review committee created to facilitate the development, acquisition, or implementation of state purchased health care under this chapter by a contracting insurer, health care service contractor, health maintenance organization, vendor, or other health services organization may be withheld at any time from public inspection when necessary to preserve trade secrets or prevent unfair competition. (4) The board or a technical review committee created to facilitate the development, acquisition, or implementation of state purchased health care under this chapter, may hold an executive session in accordance with chapter 42.30 RCW during any regular or special meeting to discuss information submitted in accordance with subsections (1) through (3) of this section. (5) A person who challenges a request for or designation of information as exempt under this section is entitled to seek judicial review pursuant to chapter 42.56 RCW. [ 2018 c 260 s 9; 2017 3rd sp.s. c 13 s 805; 2005 c 274 s 277; 2003 c 277 s 2; 1991 c 79 s 1; 1990 c 222 s 6.] NOTES: Intent— RCW 41.05.028 Health plan reimbursement rates. (1) For purposes of this section: (a) "Contractor" means a health carrier that provides medical insurance offered to public employees and their covered dependents under this chapter, or a third-party administrator contracted by the authority to provide medical coverage to public employees under this chapter. (b) "The total amount medicare would have reimbursed for the same or similar services" means the amount of reimbursement for a claim that would be paid as if the centers for medicare and medicaid services reimbursed the claim, including applicable postclaim settlements. (2)(a) Claims submitted for reimbursement under this section must include all the current year centers for medicare and medicaid services required modifiers so that all rebates, incentives, or adjustments that would have applied if reimbursed by medicare apply. (b) The authority shall adopt rules to determine the equivalent amount of reimbursement for services with a low volume of medicare experience or for which there is no applicable centers for medicare and medicaid services reimbursement for a service. (3) Beginning January 1, 2027, each contractor, for its health plans that provide medical coverage offered to public employees and their covered dependents, must meet the following requirements: (a) Except as provided in (b) of this subsection, reimbursement to any in-network hospital licensed under chapter 70.41 RCW located in Washington for inpatient and outpatient hospital services shall be the lesser of billed charges, the contractor's contracted rate for the hospital, or 200 percent of the total amount medicare would have reimbursed for the same or similar services; (b) Reimbursement for inpatient and outpatient hospital services to any in-network hospital licensed under chapter 70.41 RCW primarily engaged in the care and treatment of children located in: (i) King county, shall be the lesser of billed charges, the contractor's contracted rate for the hospital, or 150 percent of the hospital-specific medicaid inpatient ratio of cost to charges as determined by the authority; and (ii) Pierce county, shall be the lesser of billed charges, the contractor's contracted rate for the hospital, or 190 percent of the hospital-specific medicaid inpatient ratio of cost to charges as determined by the authority; (c) Reimbursement for services provided by rural hospitals certified by the centers for medicare and medicaid services as critical access hospitals may not be less than 101 percent of allowable costs as defined by the United States centers for medicare and medicaid services for purposes of medicare cost reporting; (d) Reimbursement for in-network primary care services, as defined by the authority, may not be less than 150 percent of the total amount medicare would have reimbursed for the same or similar services; (e) Reimbursement for in-network nonfacility-based behavioral health services, as defined by the authority, may not be less than 150 percent of the total amount medicare would have reimbursed for the same or similar services; (f) Except as provided in (g) of this subsection, reimbursement to any out-of-network hospital licensed under chapter 70.41 RCW located in Washington for inpatient and outpatient hospital services shall be the lesser of billed charges or 185 percent of the total amount medicare would have reimbursed for the same or similar services; (g) Reimbursement for inpatient and outpatient hospital services provided by a hospital licensed under chapter 70.41 RCW and located in Washington to any out-of-network hospital primarily engaged in the care and treatment of children located in: (i) King county, shall be the lesser of billed charges or 135 percent of the hospital-specific medicaid inpatient ratio of cost to charges as determined by the authority; and (ii) Pierce county, shall be the lesser of billed charges or 175 percent of the hospital-specific medicaid inpatient ratio of cost to charges as determined by the authority; and (h) A provider who is reimbursed in accordance with (f) or (g) of this subsection may not charge to or collect from the patient or a person who is financially responsible for the patient an amount in addition to the reimbursement paid under (f) or (g) of this subsection other than cost-sharing amounts authorized by the terms of the health plan. (4) Except as provided in subsection (3)(c) of this section, this section does not apply to: (a) Rural hospitals certified by the centers for medicare and medicaid services as sole community hospitals or critical access hospitals except for hospitals that are owned or operated by a health system that owns or operates more than two acute care hospitals licensed under chapter 70.41 RCW; (b) Hospitals located on an island operating within a public hospital district in Skagit county; or (c) Hospitals that are not currently designated as a critical access hospital, do not meet current federal eligibility requirements for designation as a critical access hospital, have combined medicaid and medicare inpatient days greater than 60 percent of all hospital inpatient days, and are located on the land of a federally recognized Indian tribe. (5) Nothing in this section prohibits a contractor from reimbursing a hospital through a nonfee-for-service payment methodology, so long as the payments incentivize higher quality or improved health outcomes and the contractor continues to comply with the reimbursement requirements in this section. (6) Premiums must take into account changes in reimbursement for hospital, primary care, and behavioral health services anticipated to result from the application of this section. (7) At the request of the authority for monitoring, enforcement, or program and quality improvement activities, a contractor must provide cost and quality of care information and data to the authority and may not enter into an agreement with a provider or third party that would restrict the contractor from providing this information or data. (8)(a) By December 31, 2030, the authority, in consultation with the office of the insurance commissioner, shall provide a report to the governor's office and relevant committees of the legislature analyzing the initial impacts of this section on network access, enrollee premiums and cost sharing, and state expenditures for medical coverage offered to public employees under this chapter. The report may include recommendations for legislative changes to the policy established in this section. (b) By December 31, 2034, the authority, in consultation with the office of the insurance commissioner, shall provide a second report to the governor's office and relevant committees of the legislature providing an updated analysis on the impacts of this section on network access, enrollee premiums and cost sharing, and state expenditures for medical coverage offered to public employees under this chapter. The report may include recommendations for legislative changes to the policy established in this section. (9) For the purposes of this section, reimbursement for inpatient and outpatient services does not include charges for professional services. (10) The authority may adopt rules to implement this section, including rules for levying fines and taking other contract actions it deems necessary to enforce compliance with this section. [ 2025 c 373 s 1.] RCW 41.05.031 Health information technology office—Agencies to establish health care information systems. The Washington state health information technology office is located within the authority. The following state agencies are directed to cooperate with the authority to establish appropriate health care information systems in their programs: The department of social and health services, the department of health, the department of labor and industries, the basic health plan, the department of veterans affairs, the department of corrections, the department of children, youth, and families, and the superintendent of public instruction. The authority, in conjunction with these agencies and in collaboration with Washington technology solutions, shall determine: (1) Definitions of health care services; (2) Health care data elements common to all agencies; (3) Health care data elements unique to each agency; and (4) A mechanism for program and budget review of health care data. [ 2024 c 54 s 34; 2023 c 51 s 7; 1990 c 222 s 4; 1988 c 107 s 5.] RCW 41.05.035 Exchange of health information—Advisory board, discretionary—Director's authority. (1) The director shall design, implement, and maintain a consumer-centric health information infrastructure and the state electronic health record repositories that will facilitate the secure exchange of health information when and where needed and shall: (a) Complete the plan of initial implementation, including but not limited to determining the technical infrastructure for the state electronic health record repositories and the account locator service, setting criteria and standards for health record repositories, and determining oversight of the state health records service; (b) Implement the first state health record repositories as funding allows; (c) Involve health care consumers in meaningful ways in the design, implementation, oversight, and dissemination of information on the state health record repositories system; and (d) Promote adoption of electronic medical records and health information exchange through continuation of the Washington health information collaborative, and by working with private payors and other organizations in restructuring reimbursement to provide incentives for providers to adopt electronic medical records in their practices. (2) The director may establish an advisory board, a stakeholder committee, and subcommittees to assist in carrying out the duties under this section. The director may reappoint health information infrastructure advisory board members to assure continuity and shall appoint any additional representatives that may be required for their expertise and experience. (a) The director shall appoint the chair of the advisory board, chairs, and cochairs of the stakeholder committee, if formed; (b) Meetings of the board, stakeholder committee, and any advisory group are subject to chapter 42.30 RCW, the open public meetings act, including RCW 42.30.110(1)(l), which authorizes an executive session during a regular or special meeting to consider proprietary or confidential nonpublished information; and (c) The members of the board, stakeholder committee, and any advisory group: (i) Shall agree to the terms and conditions imposed by the director regarding conflicts of interest as a condition of appointment; (ii) Are immune from civil liability for any official acts performed in good faith as members of the board, stakeholder committee, or any advisory group. (3) Members of the board may be compensated for participation in accordance with a personal services contract to be executed after appointment and before commencement of activities related to the work of the board. Members of the stakeholder committee shall not receive compensation but shall be reimbursed under RCW 43.03.050 and 43.03.060. (4) The director may work with public and private entities to develop and encourage the use of personal health records which are portable, interoperable, secure, and respectful of patients' privacy. (5) The director may enter into contracts to issue, distribute, and administer grants that are necessary or proper to carry out this section. [ 2023 c 51 s 8; 2007 c 259 s 10.] NOTES: Subheadings not law— RCW 41.05.036 Health information—Definitions. The definitions in this section apply throughout RCW 41.05.039 through 41.05.046 unless the context clearly requires otherwise. (1) "Director" means the director of the state health care authority under this chapter. (2) "Exchange" means the methods or medium by which health care information may be electronically and securely exchanged among authorized providers, payors, and patients within Washington state. (3) "Health care provider" or "provider" has the same meaning as in RCW 48.43.005. (4) "Health data provider" means an organization that is a primary source for health-related data for Washington residents, including but not limited to: (a) The children's health immunizations linkages and development profile immunization registry provided by the department of health pursuant to chapter 43.70 RCW; (b) Commercial laboratories providing medical laboratory testing results; (c) Prescription drugs clearinghouses, such as the national patient health information network; and (d) Diagnostic imaging centers. (5) "Lead organization" means a private sector organization or organizations designated by the director to lead development of processes, guidelines, and standards under chapter 300, Laws of 2009. (6) "Payor" means public purchasers, as defined in this section, carriers licensed under chapters 48.20, 48.21, 48.44, 48.46, and 48.62 RCW, and the Washington state health insurance pool established in chapter 48.41 RCW. (7) "Public purchaser" means the department of social and health services, the department of labor and industries, and the health care authority. (8) "Secretary" means the secretary of the department of health. [ 2011 1st sp.s. c 15 s 57; 2009 c 300 s 2.] NOTES: Effective date— RCW 41.05.037 Nurse hotline, when funded. To the extent that funding is provided specifically for this purpose, the director shall provide all persons enrolled in health plans under this chapter and chapters 70.47 and 74.09 RCW with access to a twenty-four hour, seven day a week nurse hotline. [ 2011 1st sp.s. c 15 s 58; 2007 c 259 s 15.] NOTES: Effective date— RCW 41.05.039 Health information—Secure access—Lead organization—Director's duties. (1) By August 1, 2009, the director shall designate on