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48.46.240  <<  48.46.243 >>   48.46.245

RCW 48.46.243

Contract — Participant liability. (Effective until July 1, 2017.)

(1) Subject to subsection (2) of this section, every contract between a health maintenance organization and its participating providers of health care services shall be in writing and shall set forth that in the event the health maintenance organization fails to pay for health care services as set forth in the agreement, the enrolled participant shall not be liable to the provider for any sums owed by the health maintenance organization. Every such contract shall provide that this requirement shall survive termination of the contract.

     (2) The provisions of subsection (1) of this section shall not apply:

     (a) To emergency care from a provider who is not a participating provider;

     (b) To out-of-area services;

     (c) To the delivery of covered pediatric oral services that are substantially equal to the essential health benefits benchmark plan; or

     (d) In exceptional situations approved in advance by the commissioner, if the health maintenance organization is unable to negotiate reasonable and cost-effective participating provider contracts.

     (3) No participating provider, or insurance producer, trustee, or assignee thereof, may maintain an action against an enrolled participant to collect sums owed by the health maintenance organization.

[2013 c 325 § 2; 2013 c 277 § 3; 2008 c 217 § 56; 1990 c 119 § 7.]

Notes:

     Reviser's note: This section was amended by 2013 c 277 § 3 and by 2013 c 325 § 2, each without reference to the other. Both amendments are incorporated in the publication of this section under RCW 1.12.025(2). For rule of construction, see RCW 1.12.025(1).

     Expiration date -- 2013 c 277: See note following RCW 48.43.730.

     Severability -- Effective date -- 2008 c 217: See notes following RCW 48.03.020.

     

RCW 48.46.243

Contract — Participant liability — Commissioner's review. (Effective July 1, 2017.)

(1) Subject to subsection (2) of this section, every contract between a health maintenance organization and its participating providers of health care services shall be in writing and shall set forth that in the event the health maintenance organization fails to pay for health care services as set forth in the agreement, the enrolled participant shall not be liable to the provider for any sums owed by the health maintenance organization. Every such contract shall provide that this requirement shall survive termination of the contract.

     (2) The provisions of subsection (1) of this section shall not apply:

     (a) To emergency care from a provider who is not a participating provider;

     (b) To out-of-area services;

     (c) To the delivery of covered pediatric oral services that are substantially equal to the essential health benefits benchmark plan; or

     (d) In exceptional situations approved in advance by the commissioner, if the health maintenance organization is unable to negotiate reasonable and cost-effective participating provider contracts.

     (3)(a) Each participating provider contract form shall be filed with the commissioner fifteen days before it is used.

     (b) Any contract form not affirmatively disapproved within fifteen days of filing shall be deemed approved, except that the commissioner may extend the approval period an additional fifteen days upon giving notice before the expiration of the initial fifteen-day period. The commissioner may approve such a contract form for immediate use at any time. Approval may be subsequently withdrawn for cause.

     (c) Subject to the right of the health maintenance organization to demand and receive a hearing under chapters 48.04 and 34.05 RCW, the commissioner may disapprove such a contract form if it is in any respect in violation of this chapter or if it fails to conform to minimum provisions or standards required by the commissioner by rule under chapter 34.05 RCW.

     (4) No participating provider, or insurance producer, trustee, or assignee thereof, may maintain an action against an enrolled participant to collect sums owed by the health maintenance organization.

[2013 c 325 § 2; 2008 c 217 § 56; 1990 c 119 § 7.]

Notes:

     Severability -- Effective date -- 2008 c 217: See notes following RCW 48.03.020.