RCW ch. 48.43 — Revised Code of Washington Chapter 48.43 RCW — Insurance Reform

RCW 48.43.001 Intent. It is the intent of the legislature to ensure that all enrollees in managed care settings have access to adequate information regarding health care services covered by health carriers' health plans, and provided by health care providers and health care facilities. It is only through such disclosure that Washington state citizens can be fully informed as to the extent of health insurance coverage, availability of health care service options, and necessary treatment. With such information, citizens are able to make knowledgeable decisions regarding their health care. [ 1996 c 312 s 1.] RCW 48.43.005 Definitions. Unless otherwise specifically provided, the definitions in this section apply throughout this chapter. (1) "Adjusted community rate" means the rating method used to establish the premium for health plans adjusted to reflect actuarially demonstrated differences in utilization or cost attributable to geographic region, age, family size, and use of wellness activities. (2) "Adverse benefit determination" means a denial, reduction, or termination of, or a failure to provide or make payment, in whole or in part, for a benefit, including a denial, reduction, termination, or failure to provide or make payment that is based on a determination of an enrollee's or applicant's eligibility to participate in a plan, and including, with respect to group health plans, a denial, reduction, or termination of, or a failure to provide or make payment, in whole or in part, for a benefit resulting from the application of any utilization review, as well as a failure to cover an item or service for which benefits are otherwise provided because it is determined to be experimental or investigational or not medically necessary or appropriate. (3) "Air ambulance service" has the same meaning as defined in section 2799A-2 of the public health service act (42 U.S.C. Sec. 300gg-112) and implementing federal regulations in effect on March 31, 2022. (4) "Allowed amount" means the maximum portion of a billed charge a health carrier will pay, including any applicable enrollee cost-sharing responsibility, for a covered health care service or item rendered by a participating provider or facility or by a nonparticipating provider or facility. (5) "Applicant" means a person who applies for enrollment in an individual health plan as the subscriber or an enrollee, or the dependent or spouse of a subscriber or enrollee. (6) "Balance bill" means a bill sent to an enrollee by a nonparticipating provider or facility for health care services provided to the enrollee after the provider or facility's billed amount is not fully reimbursed by the carrier, exclusive of permitted cost-sharing. (7) "Basic health plan" means the plan described under chapter 70.47 RCW, as revised from time to time. (8) "Basic health plan model plan" means a health plan as required in RCW 70.47.060(2)(e). (9) "Basic health plan services" means that schedule of covered health services, including the description of how those benefits are to be administered, that are required to be delivered to an enrollee under the basic health plan, as revised from time to time. (10) "Behavioral health emergency services provider" means emergency services provided in the following settings: (a) A crisis stabilization unit as defined in RCW 71.05.020; (b) A 23-hour crisis relief center as defined in RCW 71.24.025; (c) An evaluation and treatment facility that can provide directly, or by direct arrangement with other public or private agencies, emergency evaluation and treatment, outpatient care, and timely and appropriate inpatient care to persons suffering from a mental disorder, and which is licensed or certified as such by the department of health; (d) An agency certified by the department of health under chapter 71.24 RCW to provide outpatient crisis services; (e) An agency certified by the department of health under chapter 71.24 RCW to provide medically managed or medically monitored withdrawal management services; or (f) A mobile rapid response crisis team as defined in RCW 71.24.025 that is contracted with a behavioral health administrative services organization operating under RCW 71.24.045 to provide crisis response services in the behavioral health administrative services organization's service area. (11) "Board" means the governing board of the Washington health benefit exchange established in chapter 43.71 RCW. (12)(a) For grandfathered health benefit plans issued before January 1, 2014, and renewed thereafter, "catastrophic health plan" means: (i) In the case of a contract, agreement, or policy covering a single enrollee, a health benefit plan requiring a calendar year deductible of, at a minimum, $1,750 and an annual out-of-pocket expense required to be paid under the plan (other than for premiums) for covered benefits of at least $3,500, both amounts to be adjusted annually by the insurance commissioner; and (ii) In the case of a contract, agreement, or policy covering more than one enrollee, a health benefit plan requiring a calendar year deductible of, at a minimum, $3,500 and an annual out-of-pocket expense required to be paid under the plan (other than for premiums) for covered benefits of at least $6,000, both amounts to be adjusted annually by the insurance commissioner. (b) In July 2008, and in each July thereafter, the insurance commissioner shall adjust the minimum deductible and out-of-pocket expense required for a plan to qualify as a catastrophic plan to reflect the percentage change in the consumer price index for medical care for a preceding 12 months, as determined by the United States department of labor. For a plan year beginning in 2014, the out-of-pocket limits must be adjusted as specified in section 1302(c)(1) of P.L. 111-148 of 2010, as amended. The adjusted amount shall apply on the following January 1st. (c) For health benefit plans issued on or after January 1, 2014, "catastrophic health plan" means: (i) A health benefit plan that meets the definition of catastrophic plan set forth in section 1302(e) of P.L. 111-148 of 2010, as amended; or (ii) A health benefit plan offered outside the exchange marketplace that requires a calendar year deductible or out-of-pocket expenses under the plan, other than for premiums, for covered benefits, that meets or exceeds the commissioner's annual adjustment under (b) of this subsection. (13) "Certification" means a determination by a review organization that an admission, extension of stay, or other health care service or procedure has been reviewed and, based on the information provided, meets the clinical requirements for medical necessity, appropriateness, level of care, or effectiveness under the auspices of the applicable health benefit plan. (14) "Concurrent review" means utilization review conducted during a patient's hospital stay or course of treatment. (15) "Covered person" or "enrollee" means a person covered by a health plan including an enrollee, subscriber, policyholder, beneficiary of a group plan, or individual covered by any other health plan. (16) "Dependent" means, at a minimum, the enrollee's legal spouse and dependent children who qualify for coverage under the enrollee's health benefit plan. (17) "Emergency medical condition" means a medical, mental health, or substance use disorder condition manifesting itself by acute symptoms of sufficient severity including, but not limited to, severe pain or emotional distress, such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical, mental health, or substance use disorder treatment attention to result in a condition (a) placing the health of the individual, or with respect to a pregnant woman, the health of the woman or her unborn child, in serious jeopardy, (b) serious impairment to bodily functions, or (c) serious dysfunction of any bodily organ or part. (18) "Emergency services" means: (a)(i) A medical screening examination, as required under section 1867 of the social security act (42 U.S.C. Sec. 1395dd), that is within the capability of the emergency department of a hospital, including ancillary services routinely available to the emergency department to evaluate that emergency medical condition; (ii) Medical examination and treatment, to the extent they are within the capabilities of the staff and facilities available at the hospital, as are required under section 1867 of the social security act (42 U.S.C. Sec. 1395dd) to stabilize the patient. Stabilize, with respect to an emergency medical condition, has the meaning given in section 1867(e)(3) of the social security act (42 U.S.C. Sec. 1395dd(e)(3)); and (iii) Covered services provided by staff or facilities of a hospital after the enrollee is stabilized and as part of outpatient observation or an inpatient or outpatient stay with respect to the visit during which screening and stabilization services have been furnished. Poststabilization services relate to medical, mental health, or substance use disorder treatment necessary in the short term to avoid placing the health of the individual, or with respect to a pregnant woman, the health of the woman or her unborn child, in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part; or (b)(i) A screening examination that is within the capability of a behavioral health emergency services provider including ancillary services routinely available to the behavioral health emergency services provider to evaluate that emergency medical condition; (ii) Examination and treatment, to the extent they are within the capabilities of the staff and facilities available at the behavioral health emergency services provider, as are required under section 1867 of the social security act (42 U.S.C. Sec. 1395dd) or as would be required under such section if such section applied to behavioral health emergency services providers, to stabilize the patient. Stabilize, with respect to an emergency medical condition, has the meaning given in section 1867(e)(3) of the social security act (42 U.S.C. Sec. 1395dd(e)(3)); and (iii) Covered behavioral health services provided by staff or facilities of a behavioral health emergency services provider after the enrollee is stabilized and as part of outpatient observation or an inpatient or outpatient stay with respect to the visit during which screening and stabilization services have been furnished. Poststabilization services relate to mental health or substance use disorder treatment necessary in the short term to avoid placing the health of the individual, or with respect to a pregnant woman, the health of the woman or her unborn child, in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part. (19) "Employee" has the same meaning given to the term, as of January 1, 2008, under section 3(6) of the federal employee retirement income security act of 1974. (20) "Enrollee point-of-service cost-sharing" or "cost-sharing" means amounts paid to health carriers directly providing services, health care providers, or health care facilities by enrollees and may include copayments, coinsurance, or deductibles. (21) "Essential health benefit categories" means: (a) Ambulatory patient services; (b) Emergency services; (c) Hospitalization; (d) Maternity and newborn care; (e) Mental health and substance use disorder services, including behavioral health treatment; (f) Prescription drugs; (g) Rehabilitative and habilitative services and devices; (h) Laboratory services; (i) Preventive and wellness services and chronic disease management; and (j) Pediatric services, including oral and vision care. (22) "Exchange" means the Washington health benefit exchange established under chapter 43.71 RCW. (23) "Final external review decision" means a determination by an independent review organization at the conclusion of an external review. (24) "Final internal adverse benefit determination" means an adverse benefit determination that has been upheld by a health plan or carrier at the completion of the internal appeals process, or an adverse benefit determination with respect to which the internal appeals process has been exhausted under the exhaustion rules described in RCW 48.43.530 and 48.43.535. (25) "Grandfathered health plan" means a group health plan or an individual health plan that under section 1251 of the patient protection and affordable care act, P.L. 111-148 (2010) and as amended by the health care and education reconciliation act, P.L. 111-152 (2010) is not subject to subtitles A or C of the act as amended. (26) "Grievance" means a written complaint submitted by or on behalf of a covered person regarding service delivery issues other than denial of payment for medical services or nonprovision of medical services, including dissatisfaction with medical care, waiting time for medical services, provider or staff attitude or demeanor, or dissatisfaction with service provided by the health carrier. (27) "Ground ambulance services" means: (a) The rendering of medical treatment and care at the scene of a medical emergency or while transporting a patient from the scene to an appropriate health care facility or behavioral health emergency services provider when the services are provided by one or more ground ambulance vehicles designed for this purpose; and (b) Ground ambulance transport between hospitals or behavioral health emergency services providers, hospitals or behavioral health emergency services providers and other health care facilities or locations, and between health care facilities when the services are medically necessary and are provided by one or more ground ambulance vehicles designed for this purpose. (28) "Ground ambulance services organization" means a public or private organization licensed by the department of health under chapter 18.73 RCW to provide ground ambulance services. For purposes of this chapter, ground ambulance services organizations are not considered providers. (29) "Health care facility" or "facility" means hospices licensed under chapter 70.127 RCW, hospitals licensed under chapter 70.41 RCW, rural health care facilities as defined in RCW 70.175.020, behavioral health hospitals licensed under chapter 71.12 RCW, nursing homes licensed under chapter 18.51 RCW, community mental health centers licensed under chapter 71.05 or 71.24 RCW, kidney disease treatment centers licensed under chapter 70.41 RCW, ambulatory diagnostic, treatment, or surgical facilities licensed under chapter 70.41 or 70.230 RCW, drug and alcohol treatment facilities licensed under chapter * 70.96A RCW, and home health agencies licensed under chapter 70.127 RCW, and includes such facilities if owned and operated by a political subdivision or instrumentality of the state and such other facilities as required by federal law and implementing regulations. (30) "Health care provider" or "provider" means: (a) A person regulated under Title 18 or chapter 70.127 RCW, to practice health or health-related services or otherwise practicing health care services in this state consistent with state law; or (b) An employee or agent of a person described in (a) of this subsection, acting in the course and scope of his or her employment. (31) "Health care service" means that service offered or provided by health care facilities and health care providers relating to the prevention, cure, or treatment of illness, injury, or disease. (32) "Health carrier" or "carrier" means a disability insurer regulated under chapter 48.20 or 48.21 RCW, a health care service contractor as defined in RCW 48.44.010, or a health maintenance organization as defined in RCW 48.46.020, and includes "issuers" as that term is used in the patient protection and affordable care act (P.L. 111-148). (33) "Health plan" or "health benefit plan" means any policy, contract, or agreement offered by a health carrier to provide, arrange, reimburse, or pay for health care services except the following: (a) Long-term care insurance governed by chapter 48.84 or 48.83 RCW; (b) Medicare supplemental health insurance governed by chapter 48.66 RCW; (c) Coverage supplemental to the coverage provided under chapter 55, Title 10, United States Code; (d) Limited health care services offered by limited health care service contractors in accordance with RCW 48.44.035; (e) Disability income; (f) Coverage incidental to a property/casualty liability insurance policy such as automobile personal injury protection coverage and homeowner guest medical; (g) Workers' compensation coverage; (h) Accident only coverage; (i) Specified disease or illness-triggered fixed payment insurance, hospital confinement fixed payment insurance, or other fixed payment insurance offered as an independent, noncoordinated benefit; (j) Employer-sponsored self-funded health plans; (k) Dental only and vision only coverage; (l) Plans deemed by the insurance commissioner to have a short-term limited purpose or duration, or to be a student-only plan that is guaranteed renewable while the covered person is enrolled as a regular full-time undergraduate or graduate student at an accredited higher education institution, after a written request for such classification by the carrier and subsequent written approval by the insurance commissioner; (m) Civilian health and medical program for the veterans affairs administration (CHAMPVA); (n) Stand-alone prescription drug coverage that exclusively supplements medicare part D coverage provided through an employer group waiver plan under federal social security act regulation 42 C.F.R. Sec. 423.458(c); and (o) Beginning January 1, 2027, travel insurance as defined in RCW 48.216.020. (34) "Individual market" means the market for health insurance coverage offered to individuals other than in connection with a group health plan. (35) "In-network" or "participating" means a provider or facility that has contracted with a carrier or a carrier's contractor or subcontractor to provide health care services to enrollees and be reimbursed by the carrier at a contracted rate as payment in full for the health care services, including applicable cost-sharing obligations. (36) "Local governmental entity" means any entity that is authorized to establish or provide ground ambulance services or set rates for ground ambulance services, including those as authorized in RCW 35.27.370, 35.23.456, 52.12.135, chapter 35.21 RCW, or as authorized under any state law. (37) "Material modification" means a change in the actuarial value of the health plan as modified of more than five percent but less than fifteen percent. (38) "Nonemergency health care services performed by nonparticipating providers at certain participating facilities" means covered items or services other than emergency services with respect to a visit at a participating health care facility, as provided in section 2799A-1(b) of the public health service act (42 U.S.C. Sec. 300gg-111(b)), 45 C.F.R. Sec. 149.30, and 45 C.F.R. Sec. 149.120 as in effect on March 31, 2022. (39) "Open enrollment" means a period of time as defined in rule to be held at the same time each year, during which applicants may enroll in a carrier's individual health benefit plan without being subject to health screening or otherwise required to provide evidence of insurability as a condition for enrollment. (40) "Out-of-network" or "nonparticipating" means a provider or facility that has not contracted with a carrier or a carrier's contractor or subcontractor to provide health care services to enrollees. (41) "Out-of-pocket maximum" or "maximum out-of-pocket" means the maximum amount an enrollee is required to pay in the form of cost-sharing for covered benefits in a plan year, after which the carrier covers the entirety of the allowed amount of covered benefits under the contract of coverage. (42) "Preexisting condition" means any medical condition, illness, or injury that existed any time prior to the effective date of coverage. (43) "Premium" means all sums charged, received, or deposited by a health carrier as consideration for a health plan or the continuance of a health plan. Any assessment or any "membership," "policy," "contract," "service," or similar fee or charge made by a health carrier in consideration for a health plan is deemed part of the premium. "Premium" shall not include amounts paid as enrollee point-of-service cost-sharing. (44)(a) "Protected individual" means: (i) An adult covered as a dependent on the enrollee's health benefit plan, including an individual enrolled on the health benefit plan of the individual's registered domestic partner; or (ii) A minor who may obtain health care without the consent of a parent or legal guardian, pursuant to state or federal law. (b) "Protected individual" does not include an individual deemed not competent to provide informed consent for care under **RCW 11.88.010(1)(e). (45) "Review organization" means a disability insurer regulated under chapter 48.20 or 48.21 RCW, health care service contractor as defined in RCW 48.44.010, or health maintenance organization as defined in RCW 48.46.020, and entities affiliated with, under contract with, or acting on behalf of a health carrier to perform a utilization review. (46) "Sensitive health care services" means health services related to reproductive health, sexually transmitted diseases, substance use disorder, gender dysphoria, gender-affirming care, domestic violence, and mental health. (47) "Small employer" or "small group" means any person, firm, corporation, partnership, association, political subdivision, sole proprietor, or self-employed individual that is actively engaged in business that employed an average of at least one but no more than 50 employees, during the previous calendar year and employed at least one employee on the first day of the plan year, is not formed primarily for purposes of buying health insurance, and in which a bona fide employer-employee relationship exists. In determining the number of employees, companies that are affiliated companies, or that are eligible to file a combined tax return for purposes of taxation by this state, shall be considered an employer. Subsequent to the issuance of a health plan to a small employer and for the purpose of determining eligibility, the size of a small employer shall be determined annually. Except as otherwise specifically provided, a small employer shall continue to be considered a small employer until the plan anniversary following the date the small employer no longer meets the requirements of this definition. A self-employed individual or sole proprietor who is covered as a group of one must also: (a) Have been employed by the same small employer or small group for at least twelve months prior to application for small group coverage, and (b) verify that he or she derived at least 75 percent of his or her income from a trade or business through which the individual or sole proprietor has attempted to earn taxable income and for which he or she has filed the appropriate internal revenue service form 1040, schedule C or F, for the previous taxable year, except a self-employed individual or sole proprietor in an agricultural trade or business, must have derived at least 51 percent of his or her income from the trade or business through which the individual or sole proprietor has attempted to earn taxable income and for which he or she has filed the appropriate internal revenue service form 1040, for the previous taxable year. (48) "Special enrollment" means a defined period of time of not less than thirty-one days, triggered by a specific qualifying event experienced by the applicant, during which applicants may enroll in the carrier's individual health benefit plan without being subject to health screening or otherwise required to provide evidence of insurability as a condition for enrollment. (49) "Standard health questionnaire" means the standard health questionnaire designated under chapter 48.41 RCW. (50) "Utilization review" means the prospective, concurrent, or retrospective assessment of the necessity and appropriateness of the allocation of health care resources and services of a provider or facility, given or proposed to be given to an enrollee or group of enrollees. (51) "Wellness activity" means an explicit program of an activity consistent with department of health guidelines, such as, smoking cessation, injury and accident prevention, reduction of alcohol misuse, appropriate weight reduction, exercise, automobile and motorcycle safety, blood cholesterol reduction, and nutrition education for the purpose of improving enrollee health status and reducing health service costs. [ 2026 c 165 s 14; 2024 c 218 s 1; 2023 c 433 s 20. Prior: 2022 c 263 s 2; 2020 c 196 s 1; prior: 2019 c 427 s 2; 2019 c 56 s 2; 2019 c 33 s 1; 2016 c 65 s 2; prior: 2012 c 211 s 17; 2012 c 87 s 1; prior: 2011 c 315 s 2; 2011 c 314 s 3; prior: 2010 c 292 s 1; prior: 2008 c 145 s 20; 2008 c 144 s 1; prior: 2007 c 296 s 1; 2007 c 259 s 32; 2006 c 25 s 16; 2004 c 244 s 2; prior: 2001 c 196 s 5; 2001 c 147 s 1; 2000 c 79 s 18; prior: 1997 c 231 s 202; 1997 c 55 s 1; 1995 c 265 s 4.] NOTES: Reviser's note: RCW 48.43.007 Availability of price and quality information—Transparency tools for members—Requirements. (1) Each carrier offering or renewing a health benefit plan on or after January 1, 2016, must offer member transparency tools with certain price and quality information to enable the member to make treatment decisions based on cost, quality, and patient experience. The transparency tools must aim for best practices and, at a minimum: (a) Must display cost data for common treatments within the following categories: (i) Inpatient treatments; (ii) Outpatient treatments; (iii) Diagnostic tests; and (iv) Office visits; (b) Recognizing integrated health care delivery systems focus on total cost of care, carrier's operating integrated care delivery systems may meet the requirement of (a) of this subsection by providing meaningful consumer data based on the total cost of care. This subsection applies only to the portion of enrollment a carrier offers pursuant to chapter 48.46 RCW and as part of an integrated delivery system, and does not exempt from (a) of this subsection coverage offered pursuant to chapter 48.21, 48.44, or 48.46 RCW if not part of an integrated delivery system; (c) Are encouraged to display the cost for prescription medications on their member website or through a link to a third party that manages the prescription benefits; (d) Must include a patient review option or method for members to provide a rating or feedback on their experience with the medical provider that allows other members to see the patient review, the feedback must be monitored for appropriateness and validity, and the site may include independently compiled quality of care ratings of providers and facilities; (e) Must allow members to access the estimated cost of the treatment, or the total cost of care, as set forth in (a) and (b) of this subsection on a portable electronic device; (f) Must display options based on the selected search criteria for members to compare; (g) Must display the estimated cost of the treatment, or total cost of the care episode, and the estimated out-of-pocket costs of the treatment for the member and display the application of personalized benefits such as deductibles and cost-sharing; (h) Must display quality information on providers when available; and (i) Are encouraged to display alternatives that are more cost-effective when there are alternatives available, such as the use of an ambulatory surgical center when one is available or medical versus surgical alternatives as appropriate. (2) In addition to the required features on cost and quality information, the member transparency tools must include information to allow a provider and hospital search of in-network providers and hospitals with provider information including specialists, distance from patient, the provider's contact information, the provider's education, board certification and other credentials, where to find information on malpractice history and disciplinary actions, affiliated hospitals and other providers in a clinic, and directions to provider offices and hospitals. (3) Each carrier offering or renewing a health benefit plan on or after January 1, 2016, must provide enrollees with the performance information required by section 2717 of the patient protection and affordable care act, P.L. 111-148 (2010), as amended by the health care and education reconciliation act, P.L. 111-152 (2010), and any federal regulations or guidance issued under that section of the affordable care act. (4) Each carrier offering or renewing a health benefit plan on or after January 1, 2016, must, within thirty days from the offer or renewal date, attest to the office of the insurance commissioner that the member transparency tools meet the requirements in this section and access to the tools is available on the home page within the health plan's secured member website. [ 2014 c 224 s 3.] NOTES: Intent— RCW 48.43.008 Enrollment in employer-sponsored health plan—Person eligible for medical assistance. When the health care authority determines that it is cost-effective to enroll a person eligible for medical assistance under chapter 74.09 RCW in an employer-sponsored health plan, a carrier shall permit the enrollment of the person in the health plan for which he or she is otherwise eligible without regard to any open enrollment period restrictions. [ 2011 1st sp.s. c 15 s 77; 2007 c 259 s 24.] NOTES: Effective date— RCW 48.43.009 Health care sharing ministries. Health care sharing ministries are not health carriers as defined in RCW 48.43.005 or insurers as defined in RCW 48.01.050. For purposes of this section, "health care sharing ministry" has the same meaning as in 26 U.S.C. Sec. 5000A. [ 2011 c 314 s 18.] RCW 48.43.012 Health plans—Preexisting conditions—Rules. (1) No carrier may reject an individual for an individual or group health benefit plan based upon preexisting conditions of the individual. (2) No carrier may deny, exclude, or otherwise limit coverage for an individual's preexisting health conditions including, but not limited to, preexisting condition exclusions or waiting periods. (3) No carrier may avoid the requirements of this section through the creation of a new rate classification or the modification of an existing rate classification. A new or changed rate classification will be deemed an attempt to avoid the provisions of this section if the new or changed classification would substantially discourage applications for coverage from individuals who are higher than average health risks. These provisions apply only to individuals who are Washington residents. (4) Unless preempted by federal law, the commissioner shall adopt any rules necessary to implement this section, consistent with federal rules and guidance in effect on January 1, 2017, implementing the patient protection and affordable care act. [ 2019 c 33 s 2; 2011 c 315 s 3; 2001 c 196 s 6; 2000 c 79 s 19.] NOTES: Effective date— RCW 48.43.01211 Health plans—Eligibility—Health status-related factors—Rules. (1) A health carrier or health plan may not establish rules for eligibility, including continued eligibility, of any individual to enroll under the terms of the plan or coverage based on any of the following health status-related factors in relation to the individual or a dependent of the individual: (a) Health status; (b) Medical condition, including both physical and mental illnesses; (c) Claims experience; (d) Receipt of health care; (e) Medical history; (f) Genetic information; (g) Evidence of insurability, including conditions arising out of acts of domestic violence; (h) Disability; or (i) Any other health status-related factor determined appropriate by the commissioner. (2) Unless preempted by federal law, the commissioner shall adopt any rules necessary to implement this section, consistent with federal rules and guidance in effect on January 1, 2017, implementing the patient protection and affordable care act. [ 2019 c 33 s 3.] NOTES: Effective date— RCW 48.43.0122 Individual health benefit plans—Open enrollment and special enrollment periods—Rules—Enforcement. (1) The commissioner shall adopt rules establishing and implementing requirements for the open enrollment periods and special enrollment periods that carriers must follow for individual health benefit plans. (2) The commissioner shall monitor the sale of individual health benefit plans and if a carrier refuses to sell guaranteed issue policies to persons in compliance with rules adopted by the commissioner pursuant to subsection (1) of this section, the commissioner may levy fines or suspend or revoke a certificate of authority as provided in chapter 48.05 RCW. [ 2019 c 33 s 11; 2011 c 315 s 4.] NOTES: Effective date— RCW 48.43.0123 Health plans—Rescission of coverage—Rules. (1) A health plan or health carrier offering group or individual coverage may not rescind such coverage with respect to an enrollee once the enrollee is covered under the plan or coverage involved, except that this section does not apply to a covered person who has performed an act or practice that constitutes fraud or makes an intentional misrepresentation of material fact as prohibited by the terms of the plan or coverage. The plan or coverage may not be canceled except as permitted under RCW 48.43.035 or 48.43.038. (2) The commissioner shall adopt any rules necessary to implement this section, consistent with federal rules and guidance in effect on January 1, 2017, implementing the patient protection and affordable care act. [ 2019 c 33 s 8.] NOTES: Effective date— RCW 48.43.0124 Health plans—Cost sharing for essential health benefits—Rules. (1) For plan years beginning in 2020, the cost sharing incurred under a health plan for the essential health benefits may not exceed the following amounts: (a) For self-only coverage: (i) The amount required under federal law for the calendar year; or (ii) If there are no cost-sharing requirements under federal law, eight thousand two hundred dollars increased by the premium adjustment percentage for the calendar year. (b) For coverage other than self-only coverage: (i) The amount required under federal law for the calendar year; or (ii) If there are no cost-sharing requirements under federal law, sixteen thousand four hundred dollars increased by the premium adjustment percentage for the calendar year. (2) Regardless of whether an enrollee is covered by a self-only plan or a plan that is other than self-only, the enrollee's cost sharing for the essential health benefits may not exceed the self-only annual limitation on cost sharing. (3) For purposes of this section, "the premium adjustment percentage for the calendar year" means the percentage, if any, by which the average per capita premium for health insurance in Washington for the preceding year, as estimated by the commissioner no later than April 1st of such preceding year, exceeds such average per capita premium for 2020 as determined by the commissioner. (4) Unless preempted by federal law, the commissioner shall adopt any rules necessary to implement this section, consistent with federal rules and guidance in effect on January 1, 2017, implementing the patient protection and affordable care act. [ 2019 c 33 s 10.] NOTES: Effective date— RCW 48.43.0125 Essential health benefits—Annual or lifetime dollar limits. A health carrier may not impose annual or lifetime dollar limits on an essential health benefit, other than those permitted as reference-based limitations under rules adopted by the commissioner. [ 2019 c 33 s 12.] NOTES: Effective date— RCW 48.43.0126 Summary of benefits and explanation of coverage—Standards and requirements—Notice of modification—Fines—Standards for definitions of health insurance terms—Rules. (1) The commissioner shall develop standards for use by a health carrier offering individual or group coverage, in compiling and providing to applicants and enrollees a summary of benefits and coverage explanation that accurately describes the benefits and coverage under the applicable plan. In developing the standards, the commissioner must use the standards developed under 42 U.S.C. Sec. 300gg-15 in use on April 17, 2019. (2) The standards must provide for the following: (a) The standards must ensure that the summary of benefits and coverage is presented in a uniform format that does not exceed four pages in length and does not include print smaller than twelve-point font. (b) The standards must ensure that the summary is presented in a culturally and linguistically appropriate manner and utilizes terminology understandable by the average plan enrollee. (c) The standards must ensure that the summary of benefits and coverage includes: (i) Uniform definitions of standard insurance and medical terms, consistent with the standard definitions developed under this section, so that consumers may compare health insurance coverage and understand the terms of coverage, or exceptions to such coverage; (ii) A description of the coverage, including cost sharing for: (A) The essential health benefits; and (B) Other benefits identified by the commissioner; (iii) The exceptions, reductions, and limitations on coverage; (iv) The cost-sharing provisions, including deductible, coinsurance, and copayment obligations; (v) The renewability and continuation of coverage provisions; (vi) A coverage facts label that includes examples to illustrate common benefits scenarios, including pregnancy and serious or chronic medical conditions and related cost sharing. The scenarios must be based on recognized clinical practice guidelines; (vii) A statement of whether the plan: (A) Provides minimum essential coverage under 26 U.S.C. Sec. 5000A(f); and (B) Ensures that the plan share of the total allowed costs of benefits provided under the plan is no less than sixty percent of the costs; (viii) A statement that the outline is a summary of the policy or certificate and that the coverage document itself should be consulted to determine the governing contractual provisions; and (ix) A contact number for the consumer to call with additional questions and a website where a copy of the actual individual coverage policy or group certificate of coverage may be reviewed and obtained. (3) The commissioner shall periodically review and update the standards developed under this section. (4) A health carrier must provide a summary of benefits and coverage explanation to: (a) An applicant at the time of application; (b) An enrollee prior to the time of enrollment or reenrollment, as applicable; and (c) A policyholder or certificate holder at the time of issuance of the policy or delivery of the certificate. (5) A health carrier may provide the summary of benefits and coverage either in paper or electronically. (6) If a health carrier makes any material modification in any of the terms of the plan that is not reflected in the most recently provided summary of benefits and coverage, the carrier shall provide notice of the modification to enrollees no later than sixty days prior to the date on which the modification will become effective. (7) A health carrier that fails to provide the information required under this section is subject to a fine of no more than one thousand dollars for each failure. A failure with respect to each enrollee constitutes a separate offense for purposes of this subsection. (8) The commissioner shall, by rule, provide for the development of standards for the definitions of terms used in health insurance coverage, including the following: (a) Insurance-related terms, including premium; deductible; coinsurance; copayment; out-of-pocket limit; preferred provider; nonpreferred provider; out-of-network copayments; usual, customary, and reasonable fees; excluded services; grievance; appeals; and any other terms the commissioner determines are important to define so that consumers may compare health insurance coverage and understand the terms of their coverage; and (b) Medical terms, including hospitalization, hospital outpatient care, emergency room care, physician services, prescription drug coverage, durable medical equipment, home health care, skilled nursing care, rehabilitation services, hospice services, emergency medical transportation, and any other terms the commissioner determines are important to define so that consumers may compare the medical benefits offered by health insurance and understand the extent of those medical benefits or exceptions to those benefits. (9) Unless preempted by federal law, the commissioner shall adopt any rules necessary to implement this section, consistent with federal rules and guidance in effect on January 1, 2017, implementing the patient protection and affordable care act. [ 2019 c 33 s 13.] NOTES: Effective date— RCW 48.43.0127 Group health plans—Waiting period—Rules. (1) A group health plan and a health carrier offering group health coverage may not apply any waiting period that exceeds ninety days. (2) Unless preempted by federal law, the commissioner shall adopt any rules necessary to implement this section, consistent with federal rules and guidance in effect on January 1, 2017, implementing the patient protection and affordable care act. [ 2019 c 33 s 14.] NOTES: Effective date— RCW 48.43.0128 Nongrandfathered health plans and plans issued or renewed on or after January 1, 2022—Prohibited discrimination—Rules. (1) A health carrier offering a nongrandfathered health plan or a plan deemed by the commissioner to have a short-term limited purpose or duration, or to be a student-only plan that is guaranteed renewable while the covered person is enrolled as a regular, full-time undergraduate student at an accredited higher education institution may not: (a) In its benefit design or implementation of its benefit design, discriminate against individuals because of their age, expected length of life, present or predicted disability, degree of medical dependency, quality of life, or other health conditions; and (b) With respect to the health plan or plan deemed by the commissioner to have a short-term limited purpose or duration, or to be a student-only plan that is guaranteed renewable while the covered person is enrolled as a regular, full-time undergraduate student at an accredited higher education institution, discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, or sexual orientation. (2) Nothing in this section may be construed to prevent a carrier from appropriately utilizing reasonable medical management techniques. (3) For health plans issued or renewed on or after January 1, 2022: (a) A health carrier may not deny or limit coverage for gender-affirming treatment when that treatment is prescribed to an individual because of, related to, or consistent with a person's gender expression or identity, as defined in RCW 49.60.040, is medically necessary, and is prescribed in accordance with accepted standards of care. (b) A health carrier may not apply categorical cosmetic or blanket exclusions to gender-affirming treatment. When prescribed as medically necessary gender-affirming treatment, a health carrier may not exclude as cosmetic services facial feminization surgeries and other facial gender-affirming treatment, such as tracheal shaves, hair electrolysis, and other care such as mastectomies, breast reductions, breast implants, or any combination of gender-affirming procedures, including revisions to prior treatment. (c) A health carrier may not issue an adverse benefit determination denying or limiting access to gender-affirming services, unless a health care provider with experience prescribing or delivering gender-affirming treatment has reviewed and confirmed the appropriateness of the adverse benefit determination. (d) Health carriers must comply with all network access rules and requirements established by the commissioner. (4) For the purposes of this section, "gender-affirming treatment" means a service or product that a health care provider, as defined in RCW 70.02.010, prescribes to an individual to treat any condition related to the individual's gender identity and is prescribed in accordance with generally accepted standards of care. Gender-affirming treatment must be covered in a manner compliant with the federal mental health parity and addiction equity act of 2008 and the federal affordable care act. Gender-affirming treatment can be prescribed to two spirit, transgender, nonbinary, intersex, and other gender diverse individuals. (5) Nothing in this section may be construed to mandate coverage of a service that is not medically necessary. (6) By December 1, 2022, the commissioner, in consultation with the health care authority and the department of health, must issue a report on geographic access to gender-affirming treatment across the state. The report must include the number of gender-affirming providers offering care in each county, the carriers and medicaid managed care organizations those providers have active contracts with, and the types of services provided by each provider in each region. The commissioner must update the report biennially and post the report on its website. (7) The commissioner shall adopt any rules necessary to implement subsections (3), (4), and (5) of this section. (8) Unless preempted by federal law, the commissioner shall adopt any rules necessary to implement subsections (1) and (2) of this section, consistent with federal rules and guidance in effect on January 1, 2017, implementing the patient protection and affordable care act. [ 2025 c 243 s 8; 2021 c 280 s 3; 2020 c 228 s 9; 2019 c 33 s 15.] NOTES: Short title— RCW 48.43.013 Health carriers—Timely payments. (1)(a) Except as provided in (b) of this subsection, for health care services provided to covered persons, a carrier shall pay or deny a claim from a provider or facility as soon as practical, but no later than 30 calendar days after the receipt of a clean claim by the carrier. (b) For claims that are not clean, within 21 calendar days of receipt of the claim, the carrier shall send remittance advice or other electronic notice to the provider or facility acknowledging the date of receipt of the claim and including one of the following: (i) That the carrier is denying payment on all or part of the claim and the specific reason for the denial. The denial shall identify the portion of the claim that is denied and the specific reasons for the denial; or (ii) That additional information or documentation is needed to process the claim. This notice must include a request for the specific information or documentation needed to process the claim. The carrier shall make a good faith effort to request all information or documentation needed to process the claim in a single request and may not make any additional requests for information or documentation for 30 calendar days after receipt of the claim. (c)(i) For claims for which the carrier receives all information or documentation requested by the carrier in a notice issued pursuant to (b)(ii) of this subsection, the carrier shall consider the claim a clean claim and shall pay or deny the claim within 30 calendar days, except as agreed to in writing by the parties on a claim-by-claim basis. The 30 calendar days time period does not apply until the carrier receives all information or documentation requested by the carrier. (ii) For claims for which a provider or facility fails to submit information or documentation requested under subsection (1)(b)(ii) of this section within 21 calendar days of receipt of the carrier's request, the carrier's obligation to pay or deny the claim under this subsection is extended to 40 calendar days following the carrier's receipt of requested information or documentation. (d) The receipt date of a claim or additional information or documentation is the date a carrier receives either written or electronic notice of the claim or additional information or documentation. A carrier must establish a reasonable method for confirming receipt of claims and additional information or documentation and responding to provider and facility inquiries about claims. (2)(a) A carrier shall pay interest on the amount of any claims for which the carrier fails to comply with the timeline and notice requirements of subsection (1) of this section. Interest shall accrue on each such claim until the claim is resolved by payment, denial, or the final outcome of an appeals process. (b) Interest shall be assessed at the following rates and shall be calculated monthly as simple interest prorated for any portion of a month: (i) Beginning on calendar day one and through calendar day 60 following a carrier's failure to comply with any notice or claim settlement requirement in subsection (1)(a) or (b) of this section, interest shall be assessed at the rate of one percent per month on the amount of the unresolved claim. (ii) Beginning on calendar day 61 following a carrier's failure to comply with any notice or claim settlement requirement in subsection (1)(a) or (b) of this section and until the claim is resolved, interest shall be assessed at the rate of one and one-half percent per month on the amount of the unresolved claim. (c) Any interest paid under this subsection shall be the carrier's responsibility and not be applied by the carrier to a covered person's deductible, copayment, coinsurance, or any similar obligation of the covered person. (d) The carrier shall add the interest payable to the amount of the unpaid claim and may not require or request the provider or facility to submit an additional claim. (e) For any claim for which the carrier failed to comply with the requirements of subsection (1)(a) or (b) of this section that is unresolved for more than 90 calendar days, the carrier may be subject to an administrative penalty as determined by the commissioner in rule. In determining the appropriateness of an administrative penalty, the commissioner shall consider whether a carrier has engaged in a pattern of violations of subsection (1)(a) or (b) of this section. (3) The requirements of this section do not apply to claims for which a carrier has documented evidence of fraud or material misrepresentation by providers, facilities, or covered persons, supported by claims review, data analysis, audit activities, or patterns thereof. (4) Providers, facilities, and carriers are not required to comply with the requirements of this section if the failure to comply is occasioned by any act of God, bankruptcy, act of a governmental authority responding to an act of God or other emergency, cybersecurity attack, declaration of a natural disaster, or the result of a strike, lockout, or other labor dispute. (5) Health carriers are responsible for compliance with the provisions of this chapter and are responsible for the compliance of any person or organization acting on behalf of or at the direction of the carrier or acting pursuant to carrier standards or requirements concerning the coverage of, payment for, or provision of health care services. A carrier may not offer as a defense to a violation of any provision of this chapter that the violation arose from the act or omission of a participating provider or facility, network administrator, claims administrator, health care benefit manager, or other person acting on behalf of or at the direction of the carrier, or acting pursuant to carrier standards or requirements under a contract with the carrier rather than from the direct act or omission of the carrier. (6) Nothing in this section limits any existing authority of the office of the insurance commissioner under this title to oversee and enforce carrier compliance with applicable statutes and rules. (7)(a) The requirements of this section apply to health plans filed or renewed on or after January 1, 2027. (b) This section applies only to health carriers offering health plans subject to regulation by the commissioner and to health plans offered through the public employees' benefits board and school employees' benefits board programs. This section does not apply to medicaid managed care plans administered under chapter 74.09 RCW. (c) This section applies only to claims submitted by: (i) A health care provider or health care facility that is a participating provider or facility under a contract with a health carrier; or (ii) An Indian health care provider as defined in RCW 43.71B.010 including those who are not contracted or participating providers. (d) Except as provided in subsection (7)(c)(ii) of this section, nothing in this section is intended to modify or supersede payment requirements applicable to nonparticipating providers or facilities, including those governed by RCW 48.49.160. (8) The commissioner may adopt rules to implement this section. (9) For purposes of this section: (a) "Clean claim" means a claim that has no defect or impropriety, including any lack of any required substantiating documentation, or particular circumstances requiring special treatment that prevents timely payments from being made on the claim. A claim does not lose the status of "clean claim" due to issues related to carrier internal processing or systems. (b) "Remittance advice" means a written or electronic communication issued by a carrier to a provider that explains the outcome of claim adjudication and includes, at a minimum, the amount paid, any amounts denied or adjusted, and the reason codes and explanations supporting the carrier's payment determination. [ 2026 c 158 s 2.] NOTES: Finding— RCW 48.43.016 Utilization management standards and criteria—Health carrier requirements—Definitions. (Effective until January 1, 2027.) (1) A health carrier or its contracted entity that imposes different prior authorization standards and criteria for a covered service among tiers of contracting providers of the same licensed profession in the same health plan shall inform an enrollee which tier an individual provider or group of providers is in by posting the information on its website in a manner accessible to both enrollees and providers. (2)(a) A health carrier or its contracted entity may not require utilization management or review of any kind including, but not limited to, prior, concurrent, or postservice authorization for an initial evaluation and management visit and up to six treatment visits with a contracting provider in a new episode of care for each of the following: Chiropractic, physical therapy, occupational therapy, acupuncture and Eastern medicine, massage therapy, or speech and hearing therapies. Visits for which utilization management or review is prohibited under this section are subject to quantitative treatment limits of the health plan. Notwithstanding RCW 48.43.515(5) this section may not be interpreted to limit the ability of a health plan to require a referral or prescription for the therapies listed in this section. (b) For visits for which utilization management or review is prohibited under this section, a health carrier or its contracted entity may not: (i) Deny or limit coverage on the basis of medical necessity or appropriateness; or (ii) Retroactively deny care or refuse payment for the visits. (3) A health carrier shall post on its website and provide upon the request of a covered person or contracting provider any prior authorization standards, criteria, or information the carrier uses for medical necessity decisions. (4) A health care provider with whom a health carrier consults regarding a decision to deny, limit, or terminate a person's covered health care services must hold a license, certification, or registration, in good standing and must be in the same or related health field as the health care provider being reviewed or of a specialty whose practice entails the same or similar covered health care service. (5) A health carrier may not require a provider to provide a discount from usual and customary rates for health care services not covered under a health plan, policy, or other agreement, to which the provider is a party. (6) Nothing in this section prevents a health carrier from denying coverage based on insurance fraud. (7) For purposes of this section: (a) "New episode of care" means treatment for a new condition or diagnosis for which the enrollee has not been treated by a provider of the same licensed profession within the previous ninety days and is not currently undergoing any active treatment. (b) "Contracting provider" does not include providers employed within an integrated delivery system operated by a carrier licensed under chapter 48.44 or 48.46 RCW. [ 2020 c 193 s 2; 2019 c 308 s 22; 2018 c 193 s 1; 2015 c 251 s 2.] NOTES: Intent— RCW 48.43.0161 Prior authorization practices—Carrier annual reporting requirements—Commissioner's standardized report. (1) By October 1, 2026, and annually thereafter, for individual and group health plans issued by a carrier that has written at least one percent of the total accident and health insurance premiums written by all companies authorized to offer accident and health insurance in Washington in the most recently available year, the carrier shall report to the commissioner the following aggregated and deidentified data related to the carrier's prior authorization practices and experience for the prior plan year: (a) The total number of prior authorization requests, approvals, and denials. The carrier must report these totals separately for approvals or denials made by the carrier directly and for approvals or denials made by a health care benefit manager as defined in RCW 48.200.020 that is delegated to make prior authorization determinations either directly or indirectly on behalf of the carrier. In the report, carriers must also indicate: (i) The percentage of total denials that were aided by artificial intelligence; (ii) The percent of prior authorization determinations made after the standard and expedited authorization request turnaround times stated in RCW 48.43.830; and (iii) The total number of nonelectronic standard and nonelectronic expedited prior authorization requests; (b) Lists of the 10 inpatient medical or surgical codes: (i) With the highest total number of prior authorization requests during the previous plan year, including the total number of prior authorization requests for each code and the percent of approved requests for each code; (ii) With the highest percentage of approved prior authorization requests during the previous plan year, including the total number of prior authorization requests for each code and the percent of approved requests for each code; and (iii) With the highest percentage of prior authorization requests that were initially denied and then subsequently approved on appeal, including the total number of prior authorization requests for each code and the percent of requests that were initially denied and then subsequently approved for each code; (c) Lists of the 10 outpatient medical or surgical codes: (i) With the highest total number of prior authorization requests during the previous plan year, including the total number of prior authorization requests for each code and the percent of approved requests for each code; (ii) With the highest percentage of approved prior authorization requests during the previous plan year, including the total number of prior authorization requests for each code and the percent of approved requests for each code; and (iii) With the highest percentage of prior authorization req