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Chapter 41.05 RCW

STATE HEALTH CARE AUTHORITY
(Formerly State employees' insurance and health care)

RCW Sections

41.05.006Purpose.
41.05.008Duties of employing agencies.
41.05.009Determination of employee eligibility for benefits.
41.05.0091Eligibility exists prior to January 1, 2010.
41.05.011Definitions.
41.05.013State purchased health care programs -- Uniform policies -- Report to the legislature.
41.05.014Applications and enrollment forms -- Signatures.
41.05.015Medical director -- Appointment of personnel.
41.05.017Provisions applicable to health plans offered under this chapter.
41.05.019Direct patient-provider primary care practices -- Plan.
41.05.021State health care authority -- Director--Cost control and delivery strategies--Health information technology -- Managed competition -- Rules.
41.05.022State agent for purchasing health services--Single community-rated risk pool.
41.05.023Chronic care management program -- Uniform medical plan -- Definitions.
41.05.026Contracts -- Proprietary data, trade secrets, actuarial formulas, statistics, cost and utilization data -- Exemption from public inspection -- Executive sessions.
41.05.031Agencies to establish health care information systems.
41.05.033Shared decision-making demonstration project -- Preference-sensitive care.
41.05.035Exchange of health information -- Pilot -- Advisory board, discretionary -- Administrator's authority.
41.05.036Health information -- Definitions.
41.05.037Nurse hotline, when funded.
41.05.039Health information -- Secure access -- Lead organization -- Administrator's duties.
41.05.042Health information -- Processes, guidelines, and standards.
41.05.046Health information -- Conflict with federal requirements.
41.05.050Contributions for employees and dependents -- Definitions.
41.05.055Public employees' benefits board -- Members.
41.05.065Public employees' benefits board -- Duties -- Eligibility -- Definitions -- Penalties.
41.05.066Same sex domestic partner benefits.
41.05.068Federal employer incentive program -- Authority to participate.
41.05.075Employee benefit plans -- Contracts with insuring entities -- Performance measures -- Financial incentives -- Health information technology.
41.05.080Participation in insurance plans and contracts--Retired, disabled, or separated employees--Certain surviving spouses or surviving domestic partners and dependent children (as amended by 2009 c 522).
41.05.080Participation in insurance plans and contracts--Retired, disabled, or separated employees--Certain surviving spouses, domestic partners, and dependent children (as amended by 2009 c 523).
41.05.085Retired or disabled school employee health insurance subsidy.
41.05.090Continuation of coverage of employee, spouse, or covered dependent ineligible under state plan -- Exceptions.
41.05.095Unmarried dependents under the age of twenty-five.
41.05.100Chapter not applicable to certain employees of Cooperative Extension Service.
41.05.110Chapter not applicable to officers and employees of state convention and trade center.
41.05.120Public employees' and retirees' insurance account.
41.05.123Flexible spending administrative account -- Salary reduction account.
41.05.130State health care authority administrative account.
41.05.140Payment of claims -- Self-insurance--Insurance reserve fund created.
41.05.143Uniform medical plan benefits administration account -- Uniform dental plan benefits administration account -- Public employees' benefits board medical benefits administration account.
41.05.160Rules.
41.05.165Rules -- Insurance benefit reimbursement.
41.05.170Neurodevelopmental therapies -- Employer-sponsored group contracts.
41.05.175Prescribed, self-administered anticancer medication.
41.05.177Prostate cancer screening -- Required coverage.
41.05.180Mammograms -- Insurance coverage.
41.05.183General anesthesia services for dental procedures--Public employee benefit plans.
41.05.185Diabetes benefits -- State purchased health care.
41.05.188Eosinophilic gastrointestinal associated disorder -- Elemental formula.
41.05.195Medicare supplemental insurance policies.
41.05.197Medicare supplemental insurance policies.
41.05.205Tricare supplemental insurance policy -- Authority to offer -- Rules.
41.05.220Community and migrant health centers--Maternity health care centers--People of color--Underserved populations.
41.05.225Blind licensees in the business enterprises program -- Plan of health insurance.
41.05.230Multicultural health care technical assistance program.
41.05.240American Indian health care delivery plan.
41.05.280Department of corrections -- Inmate health care.
41.05.295Dependent care assistance program -- Health care authority -- Powers, duties, and functions.
41.05.300Salary reduction agreements -- Authorized.
41.05.310Salary reduction plan -- Policies and procedures -- Plan document.
41.05.320Salary reduction plan -- Eligibility -- Participation, withdrawal.
41.05.330Salary reduction plan -- Accounts and records.
41.05.340Salary reduction plan -- Termination -- Amendment.
41.05.350Salary reduction plan -- Rules.
41.05.360Salary reduction plan -- Construction.
41.05.400Plan of health care coverage -- Available funds -- Components -- Eligibility -- Administrator's duties.
41.05.520Pharmacy connection program -- Notice.
41.05.530Prescription drug assistance, education -- Rules.
41.05.540State employee health program -- Requirements -- Report.
41.05.550Prescription drug assistance foundation -- Nonprofit and tax-exempt corporation -- Liability.
41.05.600Mental health services -- Definition -- Coverage required, when.
41.05.601Mental health services -- Rules.
41.05.630Annual report of customer service complaints and appeals.
41.05.650Community health care collaborative grant program -- Grants -- Administrative support -- Eligibility.
41.05.651Rules -- 2009 c 299.
41.05.655School district health benefits -- Report.
41.05.660Community health care collaborative grant program -- Award and disbursement of grants.
41.05.670Chronic care management incentives -- Provider reimbursement methods.
41.05.680Report -- Chronic care management.
41.05.690Performance measures committee -- Membership -- Selection of performance measures -- Benchmarks for purchasing decisions -- Public process for evaluation of measures.
41.05.800Community of health pilot projects -- Designation -- Grants -- Rules.
41.05.900Short title.
41.05.901Implementation -- Effective dates -- 1988 c 107.

Notes:

Hospitalization and health care for county, municipal and other political subdivision employees: RCW 41.04.180.

Monitoring enrollee level in basic health plan and medicaid caseload of children -- Funding levels adjustment: RCW 43.41.260.

Prepaid chiropractic, pilot projects: RCW 18.25.200.



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 state employees and officials and 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 state 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, its employees, and its charges, while at the same time allowing the state to provide the most comprehensive health care options possible.

[2006 c 299 § 1; 1988 c 107 § 2.]




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 § 1; 2005 c 143 § 4.]

Notes:

     Effective date -- 2009 c 537: "This act takes effect January 1, 2010." [2009 c 537 § 9.]




41.05.009
Determination of employee eligibility for benefits.

(1) The authority, or at the authority's direction, an employing agency shall initially determine and periodically review whether an employee is eligible for benefits pursuant to the criteria established under this chapter.

     (2) An employing agency shall inform an 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 employee's right to an appeal.

[2009 c 537 § 2.]

Notes:

     Effective date -- 2009 c 537: See note following RCW 41.05.008.




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 § 10.]

Notes:

     Effective date -- 2009 c 537: See note following RCW 41.05.008.




41.05.011
Definitions.

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.

     (3) "Dependent care assistance program" means a benefit plan whereby state and public 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) "Employee" 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: (a) 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 seeks and receives the approval of the authority to provide any of its insurance programs by contract with the authority, as provided in RCW 41.04.205 and 41.05.021(1)(g); (b) employees of employee organizations representing state civil service employees, at the option of each such employee organization, and, effective October 1, 1995, employees of employee organizations currently pooled with employees of school districts for the purpose of purchasing insurance benefits, at the option of each such employee organization; (c) 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; (d) 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); (e) 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 (f) employees of a charter school established under chapter 28A.710 RCW. "Employee" does not include: Adult family homeowners; unpaid volunteers; patients of state hospitals; inmates; employees of the Washington state convention and trade center as provided in RCW 41.05.110; 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.

     (7) "Employer" means the state of Washington.

     (8) "Employing agency" means a division, department, or separate agency of state government, including an institution of higher education; a county, municipality, school district, educational service district, or other political subdivision; charter school; and a tribal government covered by this chapter.

     (9) "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.

     (10) "Flexible benefit plan" means a benefit plan that allows employees to choose the level of health care coverage provided and the amount of employee contributions from among a range of choices offered by the authority.

     (11) "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.

     (12) "Medical flexible spending arrangement" means a benefit plan whereby state and 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.

     (13) "Participant" means an individual who fulfills the eligibility and enrollment requirements under the salary reduction plan.

     (14) "Plan year" means the time period established by the authority.

     (15) "Premium payment plan" means a benefit plan whereby state and 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.

     (16) "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.

     (17) "Salary" means a state employee's monthly salary or wages.

     (18) "Salary reduction plan" means a benefit plan whereby state and public employees may agree to a reduction of salary on a pretax basis to participate in the dependent care assistance program, medical flexible spending arrangement, or premium payment plan offered pursuant to 26 U.S.C. Sec. 125 or other sections of the internal revenue code.

     (19) "Seasonal employee" means an 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.

     (20) "Separated employees" means persons who separate from employment with an employer as defined in:

     (a) RCW 41.32.010(17) on or after July 1, 1996; or

     (b) RCW 41.35.010 on or after September 1, 2000; or

     (c) 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.

     (21) "State purchased health care" or "health care" means medical and 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.

     (22) "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.

[2013 c 2 § 306 (Initiative Measure No. 1240, approved November 6, 2012); 2012 c 87 § 22. Prior: 2011 1st sp.s. c 15 § 54; 2009 c 537 § 3; 2008 c 229 § 2; prior: 2007 c 488 § 2; 2007 c 114 § 2; 2005 c 143 § 1; 2001 c 165 § 2; prior: 2000 c 247 § 604; 2000 c 230 § 3; 1998 c 341 § 706; 1996 c 39 § 21; 1995 1st sp.s. c 6 § 2; 1994 c 153 § 2; prior: 1993 c 492 § 214; 1993 c 386 § 5; 1990 c 222 § 2; 1988 c 107 § 3.]

Notes:

     Findings -- 2013 c 2 (Initiative Measure No. 1240): See RCW 28A.710.005.

     Effective date -- 2012 c 87 §§ 4, 16, 18, and 19-23: See note following RCW 43.71.030.

     Spiritual care services -- 2012 c 87: See RCW 43.71.901.

     Effective date -- Findings -- Intent -- Report -- Agency transfer -- References to head of health care authority -- Draft legislation -- 2011 1st sp.s. c 15: See notes following RCW 74.09.010.

     Effective date -- 2009 c 537: See note following RCW 41.05.008.

     Effective date -- 2008 c 229: See note following RCW 41.05.295.

     Short title--2007 c 488: See note following RCW 43.43.285.

     Intent -- 2007 c 114: "Consistent with the centennial accord, the new millennium agreement, related treaties, and federal and state law, it is the intent of the legislature to authorize tribal governments to participate in public employees' benefits board programs to the same extent that counties, municipalities, and other political subdivisions of the state are authorized to do so." [2007 c 114 § 1.]

     Effective date -- 2007 c 114: "This act takes effect January 1, 2009." [2007 c 114 § 8.]

     Effective date -- 2001 c 165 § 2: "Section 2 of this act takes effect March 1, 2002." [2001 c 165 § 5.]

     Effective date--Application -- 2001 c 165: "This act is necessary for the immediate preservation of the public peace, health, or safety, or support of the state government and its existing public institutions, and except for section 2 of this act takes effect immediately [May 7, 2001]. This act applies to all surviving spouses and dependent children of (1) emergency service personnel and (2) members of the law enforcement officers' and firefighters' retirement system plan 2, killed in the line of duty." [2006 c 345 § 2; 2001 c 165 § 6.]

     Reviser's note: Contractual right not granted -- 2006 c 345: See note following RCW 41.26.510.

     Effective date -- 2000 c 230: See note following RCW 41.35.630.

     Effective date -- 1998 c 341: See RCW 41.35.901.

     Effective dates -- 1996 c 39: See note following RCW 41.32.010.

     Effective date -- 1995 1st sp.s. c 6: See note following RCW 28A.400.410.

     Intent -- 1994 c 153: "It is the intent of the legislature to increase access to health insurance for retired and disabled state and school district employees and to increase equity between state and school employees and between state and school retirees." [1994 c 153 § 1.]

     Effective dates -- 1994 c 153: "This act shall take effect January 1, 1995, except section 15 of this act, which takes effect October 1, 1995." [1994 c 153 § 16.]

     Findings -- Intent--1993 c 492: See notes following RCW 43.20.050.

     Short title--Severability -- Savings--Captions not law--Reservation of legislative power--Effective dates--1993 c 492: See RCW 43.72.910 through 43.72.915.

     Intent -- 1993 c 386: See note following RCW 28A.400.391.

     Effective date -- 1993 c 386 §§ 1, 2, 4-6, 8-10, and 12-16: See note following RCW 28A.400.391.




41.05.013
State purchased health care programs — Uniform policies — Report to the legislature.

(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. On January 1, 2007, and January 1, 2009, the authority shall issue a status report to the legislature summarizing any results it attains in exploring and coordinating strategies for asthma, diabetes, heart disease, and other chronic diseases.

     (2) The administrator 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.

[2006 c 307 § 8; 2005 c 462 § 3; 2003 c 276 § 1.]

Notes:

     Captions not law -- Conflict with federal requirements -- 2006 c 307: See notes following RCW 70.14.080.

     Findings -- 2005 c 462: See note following RCW 28A.210.370.

     Rule making -- 2003 c 276: "Agencies administering state purchased health care programs shall cooperatively adopt rules necessary to implement this act." [2003 c 276 § 2.]




41.05.014
Applications and enrollment forms — Signatures.

(1) The administrator may require applications, enrollment forms, and eligibility certification documents for benefits that are administered by the authority under this chapter and chapters 70.47 and 70.47A RCW to be signed by the person submitting them. The administrator may accept electronic signatures.

     (2) For the purpose of this section, "electronic signature" means a signature in electronic form attached to or logically associated with an electronic record including, but not limited to, a digital signature.

[2009 c 201 § 2.]




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 chapter 74.09 RCW. The medical screeners must be supervised by one or more physicians whom the director or the director's designee shall appoint.

[2011 1st sp.s. c 15 § 55; 2000 c 5 § 16.]

Notes:

     Effective date -- Findings -- Intent -- Report -- Agency transfer -- References to head of health care authority -- Draft legislation -- 2011 1st sp.s. c 15: See notes following RCW 74.09.010.

     Intent -- Purpose -- 2000 c 5: See RCW 48.43.500.

     Application -- Short title -- Captions not law -- Construction--Severability -- Application to contracts -- Effective dates -- 2000 c 5: See notes following RCW 48.43.500.




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 through48.43.535 , 43.70.235, 48.43.545, 48.43.550, 70.02.110, 70.02.900,48.43.190 , and 48.43.083.

[2008 c 304 § 2; 2007 c 502 § 2; 2000 c 5 § 20.]

Notes:

     Savings -- Severability -- Effective date -- 2007 c 502: See notes following RCW 48.43.083.

     Intent -- Purpose -- 2000 c 5: See RCW 48.43.500.

     Application -- Short title -- Captions not law -- Construction -- Severability -- Application to contracts -- Effective dates -- 2000 c 5: See notes following RCW 48.43.500.




41.05.019
Direct patient-provider primary care practices — Plan.

(1) The Washington state health care authority shall develop a plan to incorporate direct patient-provider primary care practices as provided in chapter 48.150 RCW into one or more of the choices of health benefit programs made available to participants in the public employees' benefits board system beginning no later than the open enrollment period beginning November 1, 2012.

     (2) The plan will be developed in consultation with the board and interested parties, will identify statutory barriers to implementation, and will include proposed legislation to address those barriers and implement the plan. The plan will be submitted to the board and to the house of representatives and senate health care committees by December 1, 2011.

[2011 1st sp.s. c 8 § 2.]




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 state employees' insurance benefits and retired or disabled school employees' insurance benefits; 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 and retired or disabled school employees as specifically authorized in RCW 41.05.065 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 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(4), 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 using the final health information technology report and recommendations developed under chapter 261, Laws of 2005;

     (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 applies to transfer their employees to an insurance or self-insurance program administered under this chapter. 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 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 approved by the authority;

     (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 employees of a county, municipal, school district, educational service district, or other political subdivision, the Washington health benefit exchange, or a tribal government, 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;

     (h) To establish billing procedures and collect funds from school districts in a way that minimizes the administrative burden on districts;

     (i) 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 board under RCW 41.05.065 for determining whether an employee is eligible for benefits;

     (ii) Establishing an appeal process in accordance with chapter 34.05 RCW by which an 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. The agreements shall establish the division of responsibilities between the authority and the department with respect to mental health, chemical dependency, 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 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) On and after January 1, 1996, the public employees' benefits board may implement strategies to promote managed competition among 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.

[2012 c 87 § 23; 2011 1st sp.s. c 15 § 56; 2009 c 537 § 4. Prior: 2007 c 274 § 1; 2007 c 114 § 3; 2006 c 103 § 2; 2005 c 446 § 1; 2002 c 142 § 1; 1999 c 372 § 4; 1997 c 274 § 1; 1995 1st sp.s. c 6 § 7; 1994 c 309 § 1; prior: 1993 c 492 § 215; 1993 c 386 § 6; 1990 c 222 § 3; 1988 c 107 § 4.]

Notes:

     Effective date -- 2012 c 87 §§ 4, 16, 18, and 19-23: See note following RCW 43.71.030.

     Spiritual care services -- 2012 c 87: See RCW 43.71.901.

     Effective date -- Findings -- Intent -- Report -- Agency transfer -- References to head of health care authority -- Draft legislation -- 2011 1st sp.s. c 15: See notes following RCW 74.09.010.

     Effective date -- 2009 c 537: See note following RCW 41.05.008.

     Intent -- Effective date -- 2007 c 114: See notes following RCW 41.05.011.

     Intent -- 2006 c 103: "(1) The legislature recognizes that improvements in the quality of health care lead to better health care outcomes for the residents of Washington state and contain health care costs. The improvements are facilitated by the adoption of electronic medical records and other health information technologies.

     (2) It is the intent of the legislature to encourage all hospitals, integrated delivery systems, and providers in the state of Washington to adopt health information technologies by the year 2012." [2006 c 103 § 1.]

     Effective date -- 1997 c 274: "This act is necessary for the immediate preservation of the public peace, health, or safety, or support of the state government and its existing public institutions, and takes effect July 1, 1997." [1997 c 274 § 10.]

     Effective date -- 1995 1st sp.s. c 6: See note following RCW 28A.400.410.

     Findings -- Intent--1993 c 492: See notes following RCW 43.20.050.

     Short title--Severability -- Savings--Captions not law--Reservation of legislative power--Effective dates--1993 c 492: See RCW 43.72.910 through 43.72.915.

     Intent -- 1993 c 386: See note following RCW 28A.400.391.

     Effective date -- 1993 c 386 §§ 1, 2, 4-6, 8-10, and 12-16: See note following RCW 28A.400.391.




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; health benefits for state 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) 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 employers from entering into an agreement with employees or employee organizations when the agreement would result in increased utilization in public employees' benefits board plans or reduce the expected savings of managed competition.

[1995 1st sp.s. c 6 § 3; 1994 c 153 § 3; 1993 c 492 § 227.]

Notes:

     Effective date -- 1995 1st sp.s. c 6: See note following RCW 28A.400.410.

     Intent -- Effective dates -- 1994 c 153: See notes following RCW 41.05.011.

     Findings -- Intent--1993 c 492: See notes following RCW 43.20.050.

     Short title--Severability -- Savings--Captions not law--Reservation of legislative power--Effective dates--1993 c 492: See RCW 43.72.910 through 43.72.915.




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 state 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 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.

[2007 c 259 § 6.]

Notes:

     Severability -- Subheadings not law -- 2007 c 259: See notes following RCW 41.05.033.




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 administrator 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 administrator 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 administrator, 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.

[2005 c 274 § 277; 2003 c 277 § 2; 1991 c 79 § 1; 1990 c 222 § 6.]

Notes:

     Part headings not law -- Effective date -- 2005 c 274: See RCW 42.56.901 and 42.56.902.




41.05.031
Agencies to establish health care information systems.

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, and the superintendent of public instruction.

     The authority, in conjunction with these agencies, 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.

[1990 c 222 § 4; 1988 c 107 § 5.]




41.05.033
Shared decision-making demonstration project — Preference-sensitive care.

(1) The legislature finds that there is growing evidence that, for preference-sensitive care involving elective surgery, patient-practitioner communication is improved through the use of high-quality decision aids that detail the benefits, harms, and uncertainty of available treatment options. Improved communication leads to more fully informed patient decisions. The legislature intends to increase the extent to which patients make genuinely informed, preference-based treatment decisions, by promoting public/private collaborative efforts to broaden the development, certification, use, and evaluation of effective decision aids and by recognition of shared decision making and patient decision aids in the state's laws on informed consent.

     (2) The health care authority shall implement a shared decision-making demonstration project. The demonstration project shall be conducted at one or more multispecialty group practice sites providing state purchased health care in the state of Washington, and may include other practice sites providing state purchased health care. The demonstration project shall include the following elements:

     (a) Incorporation into clinical practice of one or more decision aids for one or more identified preference-sensitive care areas combined with ongoing training and support of involved practitioners and practice teams, preferably at sites with necessary supportive health information technology;

     (b) An evaluation of the impact of the use of shared decision making with decision aids, including the use of preference-sensitive health care services selected for the demonstration project and expenditures for those services, the impact on patients, including patient understanding of the treatment options presented and concordance between patient values and the care received, and patient and practitioner satisfaction with the shared decision-making process; and

     (c) As a condition of participating in the demonstration project, a participating practice site must bear the cost of selecting, purchasing, and incorporating the chosen decision aids into clinical practice.

     (3) The health care authority may solicit and accept funding and in-kind contributions to support the demonstration and evaluation, and may scale the evaluation to fall within resulting resource parameters.

[2007 c 259 § 2.]

Notes:

Severability -- 2007 c 259: "If any provision of this act or its application to any person or circumstance is held invalid, the remainder of the act or the application of the provision to other persons or circumstances is not affected." [2007 c 259 § 68.]

     Subheadings not law -- 2007 c 259: "Subheadings used in this act are not any part of the law." [2007 c 259 § 71.]




41.05.035
Exchange of health information — Pilot — Advisory board, discretionary — Administrator's authority.

(1) The administrator shall design and pilot a consumer-centric health information infrastructure and the first health record banks 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 health record banks and the account locator service, setting criteria and standards for health record banks, and determining oversight of health record banks;

     (b) Implement the first health record banks in pilot sites as funding allows;

     (c) Involve health care consumers in meaningful ways in the design, implementation, oversight, and dissemination of information on the health record bank 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 administrator may establish an advisory board, a stakeholder committee, and subcommittees to assist in carrying out the duties under this section. The administrator 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 administrator 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 administrator 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 administrator 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 administrator may enter into contracts to issue, distribute, and administer grants that are necessary or proper to carry out this section.

[2007 c 259 § 10.]

Notes:

     Severability -- Subheadings not law -- 2007 c 259: See notes following RCW 41.05.033.




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 § 57; 2009 c 300 § 2.]

Notes:

     Effective date -- Findings -- Intent -- Report -- Agency transfer -- References to head of health care authority -- Draft legislation -- 2011 1st sp.s. c 15: See notes following RCW 74.09.010.

     Finding -- 2009 c 300: "The legislature finds that:

     (1) The inability to securely share critical health information between practitioners inhibits the delivery of safe, efficient care, as evidenced by:

     (a) Adverse drug events that result in an average of seven hundred seventy thousand injuries and deaths each year; and

     (b) Duplicative services that add to costs and jeopardize patient well-being;

     (2) Consumers are unable to act as fully informed participants in their care unless they have ready access to their own health information;

     (3) The blue ribbon commission on health care costs and access found that the development of a system to provide electronic access to patient information anywhere in the state was a key to improving health care; and

     (4) In 2005, the legislature established a health information infrastructure advisory board to develop a strategy for the adoption and use of health information technologies that are consistent with emerging national standards and promote interoperability of health information systems." [2009 c 300 § 1.]




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 § 58; 2007 c 259 § 15.]

Notes:

     Effective date -- Findings -- Intent -- Report -- Agency transfer -- References to head of health care authority -- Draft legislation -- 2011 1st sp.s. c 15: See notes following RCW 74.09.010.

     Severability -- Subheadings not law -- 2007 c 259: See notes following RCW 41.05.033.




41.05.039
Health information — Secure access — Lead organization — Administrator's duties.

(1) By August 1, 2009, the *administrator shall designate one or more lead organizations to coordinate development of processes, guidelines, and standards to:

     (a) Improve patient access to and control of their own health care information and thereby enable their active participation in their own care; and

     (b) Implement methods for the secure exchange of clinical data as a means to promote:

     (i) Continuity of care;

     (ii) Quality of care;

     (iii) Patient safety; and

     (iv) Efficiency in medical practices.

     (2) The lead organization designated by the *administrator under this section shall:

     (a) Be representative of health care privacy advocates, providers, and payors across the state;

     (b) Have expertise and knowledge in the major disciplines related to the secure exchange of health data;

     (c) Be able to support the costs of its work without recourse to state funding. The *administrator and the lead organization are authorized and encouraged to seek federal funds, including funds from the federal American recovery and reinvestment act, as well as solicit, receive, contract for, collect, and hold grants, donations, and gifts to support the implementation of this section and RCW
41.05.042;

     (d) In collaboration with the *administrator, identify and convene work groups, as needed, to accomplish the goals of this section and RCW 41.05.042;

     (e) Conduct outreach and communication efforts to maximize the adoption of the guidelines, standards, and processes developed by the lead organization;

     (f) Submit regular updates to the *administrator on the progress implementing the requirements of this section and RCW 41.05.042; and

     (g) With the *administrator, report to the legislature December 1, 2009, and on December 1st of each year through December 1, 2012, on progress made, the time necessary for completing tasks, and identification of future tasks that should be prioritized for the next improvement cycle.

     (3) Within available funds as specified in subsection (2)(c) of this section, the *administrator shall:

     (a) Participate in and review the work and progress of the lead organization, including the establishment and operation of work groups for this section and RCW 41.05.042; and

     (b) Consult with the office of the attorney general to determine whether:

     (i) An antitrust safe harbor is necessary to enable licensed carriers and providers to develop common rules and standards; and, if necessary, take steps, such as implementing rules or requesting legislation, to establish a safe harbor; and

     (ii) Legislation is needed to limit provider liability if their health records are missing health information despite their participation in the exchange of health information.

     (4) The lead organization or organizations shall take steps to minimize the costs that implementation of the processes, guidelines, and standards may have on participating entities, including providers.

[2009 c 300 § 3.]

Notes:

     *Reviser's note: The definition for "administrator" was changed to "director" by 2011 1st sp.s. c 15 § 57.

     Findings -- 2009 c 300: See note following RCW 41.05.036.




41.05.042
Health information — Processes, guidelines, and standards.

By December 1, 2011, the lead organization shall, consistent with the federal health insurance portability and accountability act, develop processes, guidelines, and standards that address:

     (1) Identification and prioritization of high value health data from health data providers. High value health data include:

     (a) Prescriptions;

     (b) Immunization records;

     (c) Laboratory results;

     (d) Allergies; and

     (e) Diagnostic imaging;

     (2) Processes to request, submit, and receive data;

     (3) Data security, including:

     (a) Storage, access, encryption, and password protection;

     (b) Secure methods for accepting and responding to requests for data;

     (c) Handling unauthorized access to or disclosure of individually identifiable patient health information, including penalties for unauthorized disclosure; and

     (d) Authentication of individuals, including patients and providers, when requesting access to health information, and maintenance of a permanent audit trail of such requests, including:

     (i) Identification of the party making the request;

     (ii) The data elements reported; and

     (iii) Transaction dates;

     (4) Materials written in plain language that explain the exchange of health information and how patients can effectively manage such information, including the use of online tools for that purpose;

     (5) Materials for health care providers that explain the exchange of health information and the secure management of such information.

[2009 c 300 § 4.]

Notes:

     Findings -- 2009 c 300: See note following RCW 41.05.036.




41.05.046
Health information — Conflict with federal requirements.

If any provision in RCW 41.05.036, 41.05.039, and 41.05.042 conflicts with existing or new federal requirements, the *administrator shall recommend modifications, as needed, to assure compliance with the aims of RCW 41.05.036, 41.05.039, and 41.05.042 and federal requirements.

[2009 c 300 § 5.]

Notes:

     *Reviser's note: The definition for "administrator" was changed to "director" by 2011 1st sp.s. c 15 § 57.

     Findings -- 2009 c 300: See note following RCW 41.05.036.




41.05.050
Contributions for employees and dependents — Definitions.

(1) Every: (a) Department, division, or separate agency of state government; (b) county, municipal, school district, educational service district, or other political subdivisions; and (c) tribal governments as are covered by this chapter, shall provide contributions to insurance and health care plans for its employees and their dependents, the content of such plans to be determined by the authority. Contributions, paid by the county, the municipality, other political subdivision, or a tribal government for their employees, shall include an amount determined by the authority to pay such administrative expenses of the authority as are necessary to administer the plans for employees of those groups, except as provided in subsection (4) of this section.

     (2) If the authority at any time determines that the participation of a county, municipal, other political subdivision, or a tribal government covered under this chapter adversely impacts insurance rates for state employees, the authority shall implement limitations on the participation of additional county, municipal, other political subdivisions, or a tribal government.

     (3) The contributions of any: (a) Department, division, or separate agency of the state government; (b) county, municipal, or other political subdivisions; and (c) any tribal government as are covered by this chapter, shall be set by the authority, subject to the approval of the governor for availability of funds as specifically appropriated by the legislature for that purpose. Insurance and health care contributions for ferry employees shall be governed by RCW
47.64.270.

     (4)(a) The authority shall collect from each participating school district and educational service district an amount equal to the composite rate charged to state agencies, plus an amount equal to the employee premiums by plan and family size as would be charged to state employees, for groups of district employees enrolled in authority plans. The authority may collect these amounts in accordance with the district fiscal year, as described in RCW 28A.505.030.

     (b) For all groups of district employees enrolling in authority plans for the first time after September 1, 2003, the authority shall collect from each participating school district an amount equal to the composite rate charged to state agencies, plus an amount equal to the employee premiums by plan and by family size as would be charged to state employees, only if the authority determines that this method of billing the districts will not result in a material difference between revenues from districts and expenditures made by the authority on behalf of districts and their employees. The authority may collect these amounts in accordance with the district fiscal year, as described in RCW 28A.505.030.

     (c) If the authority determines at any time that the conditions in (b) of this subsection cannot be met, the authority shall offer enrollment to additional groups of district employees on a tiered rate structure until such time as the authority determines there would be no material difference between revenues and expenditures under a composite rate structure for all district employees enrolled in authority plans.

     (d) The authority may charge districts a one-time set-up fee for employee groups enrolling in authority plans for the first time.

     (e) For the purposes of this subsection:

     (i) "District" means school district and educational service district; and

     (ii) "Tiered rates" means the amounts the authority must pay to insuring entities by plan and by family size.

     (f) Notwithstanding this subsection and RCW 41.05.065(4), the authority may allow districts enrolled on a tiered rate structure prior to September 1, 2002, to continue participation based on the same rate structure and under the same conditions and eligibility criteria.

     (5) The authority shall transmit a recommendation for the amount of the employer contribution to the governor and the director of financial management for inclusion in the proposed budgets submitted to the legislature.

[2009 c 537 § 5; 2007 c 114 § 4; 2005 c 518 § 919; 2003 c 158 § 1. Prior: 2002 c 319 § 4; 2002 c 142 § 2; prior: 1995 1st sp.s. c 6 § 22; 1994 c 309 § 2; 1994 c 153 § 4; prior: 1993 c 492 § 216; 1993 c 386 § 7; 1988 c 107 § 18; 1987 c 122 § 4; 1984 c 107 § 1; 1983 c 15 § 20; 1983 c 2 § 9; prior: 1982 1st ex.s. c 34 § 2; 1981 c 344 § 6; 1979 c 151 § 55; 1977 ex.s. c 136 § 4; 1975-'76 2nd ex.s. c 106 § 4; 1975 1st ex.s. c 38 § 2; 1973 1st ex.s. c 147 § 3; 1970 ex.s. c 39 § 5.]

Notes:

     Effective date -- 2009 c 537: See note following RCW 41.05.008.

     Intent -- Effective date -- 2007 c 114: See notes following RCW 41.05.011.

     Severability -- Effective date -- 2005 c 518: See notes following RCW 28A.500.030.

     Intent -- 2002 c 319: See note following RCW 41.04.208.

     Effective date -- 1995 1st sp.s. c 6: See note following RCW 28A.400.410.

     Intent -- Effective dates -- 1994 c 153: See notes following RCW 41.05.011.

     Findings -- Intent--1993 c 492: See notes following RCW 43.20.050.

     Short title--Severability -- Savings--Captions not law--Reservation of legislative power--Effective dates--1993 c 492: See RCW 43.72.910 through 43.72.915.

     Effective date -- 1993 c 386 §§ 3, 7, and 11: See note following RCW 41.04.205.

     Intent -- 1993 c 386: See note following RCW 28A.400.391.

     Severability -- 1983 c 15: See RCW 47.64.910.

     Severability -- 1983 c 2: See note following RCW 18.71.030.

     Severability -- 1981 c 344: "If any provision of this act or its application to any person or circumstance is held invalid, the remainder of the act or the application of the provision to other persons or circumstances is not affected." [1981 c 344 § 8.]

     Effective date -- Conditions prerequisite to implementing sections -- 1977 ex.s. c 136: "This 1977 amendatory act is necessary for the immediate preservation of the public peace, health, and safety, the support of the state government and its existing public institutions, and shall take effect on July 1, 1977: PROVIDED, That if the state operating budget appropriations act does not contain the funds necessary for the implementation of this 1977 amendatory act in an appropriated amount sufficient to fully fund the employer's contribution to the state employee insurance benefits program which is established by the board in accordance with RCW 41.05.050 (2) and (3) as now or hereafter amended, sections 1, 5, and 6 of this 1977 amendatory act shall be null and void." [1977 ex.s. c 136 § 8.]

     Effective date -- Effect of veto -- 1973 1st ex.s. c 147: "This bill shall not take effect until the funds necessary for its implementation have been specifically appropriated by the legislature and such appropriation itself has become law. It is the intention of the legislature that if the governor shall veto this section or any item thereof, none of the provisions of this bill shall take effect." [1973 1st ex.s. c 147 § 10.]

     Savings -- 1973 1st ex.s. c 147: "Nothing contained in this 1973 amendatory act shall be deemed to amend, alter or affect the provisions of Chapter 23, Laws of 1972, Extraordinary Session, and RCW 28B.10.840 through 28B.10.844 as now or hereafter amended." [1973 1st ex.s. c 147 § 13.]

     Severability -- 1973 1st ex.s. c 147: "If any provision of this 1973 amendatory act, or its application to any person or circumstances is held invalid, the remainder of the act, or the application of the provision to other persons or circumstances is not affected." [1973 1st ex.s. c 147 § 9.]

     Severability -- 1970 ex.s. c 39: "If any provision of this act, or its application to any person or circumstance is held invalid, the remainder of the act, or the application of the provision to other persons or circumstances is not affected." [1970 ex.s. c 39 § 14.]




41.05.055
Public employees' benefits board — Members.

(1) The public employees' benefits board is created within the authority. The function of the board is to design and approve insurance benefit plans for employees and to establish eligibility criteria for participation in insurance benefit plans.

     (2) The board shall be composed of nine members appointed by the governor as follows:

     (a) Two representatives of state employees, one of whom shall represent an employee union certified as exclusive representative of at least one bargaining unit of classified employees, and one of whom is retired, is covered by a program under the jurisdiction of the board, and represents an organized group of retired public employees;

     (b) Two representatives of school district employees, one of whom shall represent an association of school employees and one of whom is retired, and represents an organized group of retired school employees;

     (c) Four members with experience in health benefit management and cost containment; and

     (d) The administrator.

     (3) The member who represents an association of school employees and one member appointed pursuant to subsection (2)(c) of this section shall be nonvoting members until such time that there are no less than twelve thousand school district employee subscribers enrolled with the authority for health care coverage.

     (4) The governor shall appoint the initial members of the board to staggered terms not to exceed four years. Members appointed thereafter shall serve two-year terms. Members of the board shall be compensated in accordance with RCW
43.03.250 and shall be reimbursed for their travel expenses while on official business in accordance with RCW 43.03.050 and 43.03.060. The board shall prescribe rules for the conduct of its business. The administrator shall serve as chair of the board. Meetings of the board shall be at the call of the chair.

[2009 c 537 § 6; 1995 1st sp.s. c 6 § 4; 1994 c 36 § 1; 1993 c 492 § 217; 1989 c 324 § 1; 1988 c 107 § 7.]

Notes:

     Effective date -- 2009 c 537: See note following RCW 41.05.008.

     Effective date -- 1995 1st sp.s. c 6: See note following RCW 28A.400.410.

     Effective date -- 1994 c 36: "This act is necessary for the immediate preservation of the public peace, health, or safety, or support of the state government and its existing public institutions, and shall take effect immediately [March 21, 1994]." [1994 c 36 § 2.]

     Findings -- Intent--1993 c 492: See notes following RCW 43.20.050.

     Short title--Severability -- Savings--Captions not law--Reservation of legislative power--Effective dates--1993 c 492: See RCW 43.72.910 through 43.72.915.




41.05.065
Public employees' benefits board — Duties — Eligibility — Definitions — Penalties.

(1) The board shall study all matters connected with the provision of health care coverage, life insurance, liability insurance, accidental death and dismemberment insurance, and disability income insurance or any of, or a combination of, the enumerated types of insurance for employees and their dependents on the best basis possible with relation both to the welfare of the employees and to the state. However, liability insurance shall not be made available to dependents.

     (2) The board shall develop employee benefit plans that include comprehensive health care benefits for employees. In developing these plans, the board shall consider the following elements:

     (a) Methods of maximizing cost containment while ensuring access to quality health care;

     (b) Development of provider arrangements that encourage cost containment and ensure access to quality care, including but not limited to prepaid delivery systems and prospective payment methods;

     (c) Wellness incentives that focus on proven strategies, 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;

     (d) Utilization review procedures including, but not limited to a cost-efficient method for prior authorization of services, hospital inpatient length of stay review, requirements for use of outpatient surgeries and second opinions for surgeries, review of invoices or claims submitted by service providers, and performance audit of providers;

     (e) Effective coordination of benefits; and

     (f) Minimum standards for insuring entities.

     (3) To maintain the comprehensive nature of employee health care benefits, benefits provided to employees shall be substantially equivalent to the state employees' health benefits plan in effect on January 1, 1993. Nothing in this subsection shall prohibit changes or increases in employee point-of-service payments or employee premium payments for benefits or the administration of a high deductible health plan in conjunction with a health savings account. The board may establish employee eligibility criteria which are not substantially equivalent to employee eligibility criteria in effect on January 1, 1993.

     (4) Except if bargained for under chapter
41.80 RCW, the board shall design benefits and determine the terms and conditions of employee and retired employee participation and coverage, including establishment of eligibility criteria subject to the requirements of this chapter. Employer groups obtaining benefits through contractual agreement with the authority for employees defined in RCW 41.05.011(6) (a) through (d) may contractually agree with the authority to benefits eligibility criteria which differs from that determined by the board. The eligibility criteria established by the board shall be no more restrictive than the following:

     (a) Except as provided in (b) through (e) of this subsection, an employee is eligible for benefits from the date of employment if the employing agency anticipates he or she will work an average of at least eighty hours per month and for at least eight hours in each month for more than six consecutive months. An employee determined ineligible for benefits at the beginning of his or her employment shall become eligible in the following circumstances:

     (i) An employee who works an average of at least eighty hours per month and for at least eight hours in each month and whose anticipated duration of employment is revised from less than or equal to six consecutive months to more than six consecutive months becomes eligible when the revision is made.

     (ii) An employee who works an average of at least eighty hours per month over a period of six consecutive months and for at least eight hours in each of those six consecutive months becomes eligible at the first of the month following the six-month averaging period.

     (b) A seasonal employee is eligible for benefits from the date of employment if the employing agency anticipates that he or she will work an average of at least eighty hours per month and for at least eight hours in each month of the season. A seasonal employee determined ineligible at the beginning of his or her employment who works an average of at least half-time, as defined by the board, per month over a period of six consecutive months and at least eight hours in each of those six consecutive months becomes eligible at the first of the month following the six-month averaging period. A benefits-eligible seasonal employee who works a season of less than nine months shall not be eligible for the employer contribution during the off season, but may continue enrollment in benefits during the off season by self-paying for the benefits. A benefits-eligible seasonal employee who works a season of nine months or more is eligible for the employer contribution through the off season following each season worked.

     (c) Faculty are eligible as follows:

     (i) Faculty who the employing agency anticipates will work half–time or more for the entire instructional year or equivalent nine-month period are eligible for benefits from the date of employment. Eligibility shall continue until the beginning of the first full month of the next instructional year, unless the employment relationship is terminated, in which case eligibility shall cease the first month following the notice of termination or the effective date of the termination, whichever is later.

     (ii) Faculty who the employing agency anticipates will not work for the entire instructional year or equivalent nine-month period are eligible for benefits at the beginning of the second consecutive quarter or semester of employment in which he or she is anticipated to work, or has actually worked, half-time or more. Such an employee shall continue to receive uninterrupted employer contributions for benefits if the employee works at least half-time in a quarter or semester. Faculty who the employing agency anticipates will not work for the entire instructional year or equivalent nine-month period, but who actually work half-time or more throughout the entire instructional year, are eligible for summer or off-quarter coverage. Faculty who have met the criteria of this subsection (4)(c)(ii), who work at least two quarters of the academic year with an average academic year workload of half-time or more for three quarters of the academic year, and who have worked an average of half-time or more in each of the two preceding academic years shall continue to receive uninterrupted employer contributions for benefits if he or she works at least half-time in a quarter or semester or works two quarters of the academic year with an average academic workload each academic year of half-time or more for three quarters. Eligibility under this section ceases immediately if this criteria is not met.

     (iii) Faculty may establish or maintain eligibility for benefits by working for more than one institution of higher education. When faculty work for more than one institution of higher education, those institutions shall prorate the employer contribution costs, or if eligibility is reached through one institution, that institution will pay the full employer contribution. Faculty working for more than one institution must alert his or her employers to his or her potential eligibility in order to establish eligibility.

     (iv) The employing agency must provide written notice to faculty who are potentially eligible for benefits under this subsection (4)(c) of their potential eligibility.

     (v) To be eligible for maintenance of benefits through averaging under (c)(ii) of this subsection, faculty must provide written notification to his or her employing agency or agencies of his or her potential eligibility.

     (d) A legislator is eligible for benefits on the date his or her term begins. All other elected and full-time appointed officials of the legislative and executive branches of state government are eligible for benefits on the date his or her term begins or they take the oath of office, whichever occurs first.

     (e) A justice of the supreme court and judges of the court of appeals and the superior courts become eligible for benefits on the date he or she takes the oath of office.

     (f) Except as provided in (c)(i) and (ii) of this subsection, eligibility ceases for any employee the first of the month following termination of the employment relationship.

     (g) In determining eligibility under this section, the employing agency may disregard training hours, standby hours, or temporary changes in work hours as determined by the authority under this section.

     (h) Insurance coverage for all eligible employees begins on the first day of the month following the date when eligibility for benefits is established. If the date eligibility is established is the first working day of a month, insurance coverage begins on that date.

     (i) Eligibility for an employee whose work circumstances are described by more than one of the eligibility categories in (a) through (e) of this subsection shall be determined solely by the criteria of the category that most closely describes the employee's work circumstances.

     (j) Except for an employee eligible for benefits under (b) or (c)(ii) of this subsection, an employee who has established eligibility for benefits under this section shall remain eligible for benefits each month in which he or she is in pay status for eight or more hours, if (i) he or she remains in a benefits-eligible position and (ii) leave from the benefits-eligible position is approved by the employing agency. A benefits-eligible seasonal employee is eligible for the employer contribution in any month of his or her season in which he or she is in pay status eight or more hours during that month. Eligibility ends if these conditions are not met, the employment relationship is terminated, or the employee voluntarily transfers to a noneligible position.

     (k) For the purposes of this subsection:

     (i) "Academic year" means summer, fall, winter, and spring quarters or semesters;

     (ii) "Half-time" means one-half of the full-time academic workload as determined by each institution, except that half-time for community and technical college faculty employees shall have the same meaning as "part-time" under RCW 28B.50.489;

     (iii) "Benefits-eligible position" shall be defined by the board.

     (5) The board may authorize premium contributions for an employee and the employee's dependents in a manner that encourages the use of cost-efficient managed health care systems.

     (6)(a) For any open enrollment period following August 24, 2011, the board shall offer a health savings account option for employees that conforms to section 223, Part VII of subchapter B of chapter 1 of the internal revenue code of 1986. The board shall comply with all applicable federal standards related to the establishment of health savings accounts.

     (b) By November 30, 2015, and each year thereafter, the authority shall submit a report to the relevant legislative policy and fiscal committees that includes the following:

     (i) Public employees' benefits board health plan cost and service utilization trends for the previous three years, in total and for each health plan offered to employees;

     (ii) For each health plan offered to employees, the number and percentage of employees and dependents enrolled in the plan, and the age and gender demographics of enrollees in each plan;

     (iii) Any impact of enrollment in alternatives to the most comprehensive plan, including the high deductible health plan with a health savings account, upon the cost of health benefits for those employees who have chosen to remain enrolled in the most comprehensive plan.

     (7) Notwithstanding any other provision of this chapter, for any open enrollment period following August 24, 2011, the board shall offer a high deductible health plan in conjunction with a health savings account developed under subsection (6) of this section.

     (8) Employees shall choose participation in one of the health care benefit plans developed by the board and may be permitted to waive coverage under terms and conditions established by the board.

     (9) The board shall review plans proposed by insuring entities that desire to offer property insurance and/or accident and casualty insurance to state employees through payroll deduction. The board may approve any such plan for payroll deduction by insuring entities holding a valid certificate of authority in the state of Washington and which the board determines to be in the best interests of employees and the state. The board shall adopt rules setting forth criteria by which it shall evaluate the plans.

     (10) Before January 1, 1998, the public employees' benefits board shall make available one or more fully insured long-term care insurance plans that comply with the requirements of chapter 48.84 RCW. Such programs shall be made available to eligible employees, retired employees, and retired school employees as well as eligible dependents which, for the purpose of this section, includes the parents of the employee or retiree and the parents of the spouse of the employee or retiree. Employees of local governments, political subdivisions, and tribal governments not otherwise enrolled in the public employees' benefits board sponsored medical programs may enroll under terms and conditions established by the administrator, if it does not jeopardize the financial viability of the public employees' benefits board's long-term care offering.

     (a) Participation of eligible employees or retired employees and retired school employees in any long-term care insurance plan made available by the public employees' benefits board is voluntary and shall not be subject to binding arbitration under chapter 41.56 RCW. Participation is subject to reasonable underwriting guidelines and eligibility rules established by the public employees' benefits board and the health care authority.

     (b) The employee, retired employee, and retired school employee are solely responsible for the payment of the premium rates developed by the health care authority. The health care authority is authorized to charge a reasonable administrative fee in addition to the premium charged by the long-term care insurer, which shall include the health care authority's cost of administration, marketing, and consumer education materials prepared by the health care authority and the office of the insurance commissioner.

     (c) To the extent administratively possible, the state shall establish an automatic payroll or pension deduction system for the payment of the long-term care insurance premiums.

     (d) The public employees' benefits board and the health care authority shall establish a technical advisory committee to provide advice in the development of the benefit design and establishment of underwriting guidelines and eligibility rules. The committee shall also advise the board and authority on effective and cost-effective ways to market and distribute the long-term care product. The technical advisory committee shall be comprised, at a minimum, of representatives of the office of the insurance commissioner, providers of long-term care services, licensed insurance agents with expertise in long-term care insurance, employees, retired employees, retired school employees, and other interested parties determined to be appropriate by the board.

     (e) The health care authority shall offer employees, retired employees, and retired school employees the option of purchasing long-term care insurance through licensed agents or brokers appointed by the long-term care insurer. The authority, in consultation with the public employees' benefits board, shall establish marketing procedures and may consider all premium components as a part of the contract negotiations with the long-term care insurer.

     (f) In developing the long-term care insurance benefit designs, the public employees' benefits board shall include an alternative plan of care benefit, including adult day services, as approved by the office of the insurance commissioner.

     (g) The health care authority, with the cooperation of the office of the insurance commissioner, shall develop a consumer education program for the eligible employees, retired employees, and retired school employees designed to provide education on the potential need for long-term care, methods of financing long-term care, and the availability of long-term care insurance products including the products offered by the board.

     (11) The board may establish penalties to be imposed by the authority when the eligibility determinations of an employing agency fail to comply with the criteria under this chapter.

[2011 1st sp.s. c 8 § 1; 2009 c 537 § 7. Prior: 2007 c 156 § 10; 2007 c 114 § 5; 2006 c 299 § 2; prior: 2005 c 518 § 920; 2005 c 195 § 1; 2003 c 158 § 2; 2002 c 142 § 3; 1996 c 140 § 1; 1995 1st sp.s. c 6 § 5; 1994 c 153 § 5; prior: 1993 c 492 § 218; 1993 c 386 § 9; 1988 c 107 § 8.]

Notes:

     Effective date -- 2009 c 537: See note following RCW 41.05.008.

     Intent -- Effective date -- 2007 c 114: See notes following RCW 41.05.011.

     Severability -- Effective date -- 2005 c 518: See notes following RCW 28A.500.030.

     Effective date -- 2005 c 195: "This act is necessary for the immediate preservation of the public peace, health, or safety, or support of the state government and its existing public institutions, and takes effect July 1, 2005." [2005 c 195 § 4.]

     Effective date -- 1995 1st sp.s. c 6: See note following RCW 28A.400.410.

     Intent -- Effective dates -- 1994 c 153: See notes following RCW 41.05.011.

     Findings -- Intent -- 1993 c 492: See notes following RCW 43.20.050.

     Short title -- Severability -- Savings -- Captions not law -- Reservation of legislative power -- Effective dates -- 1993 c 492: See RCW 43.72.910 through 43.72.915.

     Intent -- 1993 c 386: See note following RCW 28A.400.391.

     Effective date -- 1993 c 386 §§ 1, 2, 4-6, 8-10, and 12-16: See note following RCW 28A.400.391.




41.05.066
Same sex domestic partner benefits.

A certificate of domestic partnership issued to a couple of the same sex under the provisions of RCW 26.60.030 shall be recognized as evidence of a qualified same sex domestic partnership fulfilling all necessary eligibility criteria for the partner of the employee to receive benefits. Nothing in this section affects the requirements of same sex domestic partners to complete documentation related to federal tax status that may currently be required by the board for employees choosing to make premium payments on a pretax basis.

[2007 c 156 § 9.]




41.05.068
Federal employer incentive program — Authority to participate.

The authority may participate as an employer-sponsored program established in section 1860D-22 of the medicare prescription drug, improvement, and modernization act of 2003, P.L. 108-173 et seq., to receive federal employer subsidy funds for continuing to provide retired employee health coverage, including a pharmacy benefit. The administrator, in consultation with the office of financial management, shall evaluate participation in the employer incentive program, including but not limited to any necessary program changes to meet the eligibility requirements that employer-sponsored retiree health coverage provide prescription drug coverage at least equal to the actuarial value of standard prescription drug coverage under medicare part D. Any employer subsidy moneys received from participation in the federal employer incentive program shall be deposited in the state general fund.

[2009 c 479 § 25; 2005 c 195 § 2.]

Notes:

     Effective date -- 2009 c 479: See note following RCW 2.56.030.

     Effective date -- 2005 c 195: See note following RCW 41.05.065.




41.05.075
Employee benefit plans — Contracts with insuring entities — Performance measures — Financial incentives — Health information technology.

(1) The administrator shall provide benefit plans designed by the board through a contract or contracts with insuring entities, through self-funding, self-insurance, or other methods of providing insurance coverage authorized by RCW 41.05.140.

     (2) The administrator shall establish a contract bidding process that:

     (a) Encourages competition among insuring entities;

     (b) Maintains an equitable relationship between premiums charged for similar benefits and between risk pools including premiums charged for retired state and school district employees under the separate risk pools established by RCW 41.05.022 and 41.05.080 such that insuring entities may not avoid risk when establishing the premium rates for retirees eligible for medicare;

     (c) Is timely to the state budgetary process; and

     (d) Sets conditions for awarding contracts to any insuring entity.

     (3) The administrator shall establish a requirement for review of utilization and financial data from participating insuring entities on a quarterly basis.

     (4) The administrator shall centralize the enrollment files for all employee and retired or disabled school employee health plans offered under chapter 41.05 RCW and develop enrollment demographics on a plan-specific basis.

     (5) All claims data shall be the property of the state. The administrator may require of any insuring entity that submits a bid to contract for coverage all information deemed necessary including:

     (a) Subscriber or member demographic and claims data necessary for risk assessment and adjustment calculations in order to fulfill the administrator's duties as set forth in this chapter; and

     (b) Subscriber or member demographic and claims data necessary to implement performance measures or financial incentives related to performance under subsection (7) of this section.

     (6) All contracts with insuring entities for the provision of health care benefits shall provide that the beneficiaries of such benefit plans may use on an equal participation basis the services of practitioners licensed pursuant to chapters 18.22, 18.25, 18.32, 18.53, 18.57, 18.71, 18.74, 18.83, and 18.79 RCW, as it applies to registered nurses and advanced registered nurse practitioners. However, nothing in this subsection may preclude the administrator from establishing appropriate utilization controls approved pursuant to RCW 41.05.065(2) (a), (b), and (d).

     (7) The administrator shall, 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(4), 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 using the final health information technology report and recommendations developed under chapter 261, Laws of 2005.

     (8) The administrator may permit the Washington state health insurance pool to contract to utilize any network maintained by the authority or any network under contract with the authority.

[2007 c 259 § 34; 2006 c 103 § 3; 2005 c 446 § 2; 2002 c 142 § 4. Prior: 1994 sp.s. c 9 § 724; 1994 c 309 § 3; 1994 c 153 § 6; 1993 c 386 § 10; 1988 c 107 § 9.]

Notes:

     Severability -- Subheadings not law -- 2007 c 259: See notes following RCW 41.05.033.

     Intent -- 2006 c 103: See note following RCW 41.05.021.

     Severability -- Headings and captions not law -- Effective date -- 1994 sp.s. c 9: See RCW 18.79.900 through 18.79.902.

     Intent -- Effective dates -- 1994 c 153: See notes following RCW 41.05.011.

     Intent -- 1993 c 386: See note following RCW 28A.400.391.

     Effective date -- 1993 c 386 §§ 1, 2, 4-6, 8-10, and 12-16: See note following RCW 28A.400.391.




41.05.080
Participation in insurance plans and contracts — Retired, disabled, or separated employees — Certain surviving spouses or surviving domestic partners and dependent children (as amended by 2009 c 522).

(1) Under the qualifications, terms, conditions, and benefits set by the board:

     (a) Retired or disabled state employees, retired or disabled school employees, retired or disabled employees of county, municipal, or other political subdivisions, or retired or disabled employees of tribal governments covered by this chapter may continue their participation in insurance plans and contracts after retirement or disablement;

     (b) Separated employees may continue their participation in insurance plans and contracts if participation is selected immediately upon separation from employment;

     (c) Surviving spouses, surviving spouses or surviving domestic partners in the case of members of the Washington state patrol retirement system, and dependent children of emergency service personnel killed in the line of duty may participate in insurance plans and contracts.

     (2) Rates charged surviving spouses, or surviving spouses or surviving domestic partners in the case of members of the Washington state patrol retirement system, of emergency service personnel killed in the line of duty, retired or disabled employees, separated employees, spouses, or dependent children who are not eligible for parts A and B of medicare shall be based on the experience of the community rated risk pool established under RCW
41.05.022.

     (3) Rates charged to surviving spouses, or surviving spouses or surviving domestic partners in the case of members of the Washington state patrol retirement system, of emergency service personnel killed in the line of duty, retired or disabled employees, separated employees, spouses, or children who are eligible for parts A and B of medicare shall be calculated from a separate experience risk pool comprised only of individuals eligible for parts A and B of medicare; however, the premiums charged to medicare-eligible retirees and disabled employees shall be reduced by the amount of the subsidy provided under RCW 41.05.085.

     (4) Surviving spouses, surviving spouses or surviving domestic partners in the case of members of the Washington state patrol retirement system, and dependent children of emergency service personnel killed in the line of duty and retired or disabled and separated employees shall be responsible for payment of premium rates developed by the authority which shall include the cost to the authority of providing insurance coverage including any amounts necessary for reserves and administration in accordance with this chapter. These self pay rates will be established based on a separate rate for the employee, the spouse, the spouse or domestic partner in the case of members of the Washington state patrol retirement system, and the children.

     (5) The term "retired state employees" for the purpose of this section shall include but not be limited to members of the legislature whether voluntarily or involuntarily leaving state office.

[2009 c 522 § 9; 2007 c 114 § 6; 2001 c 165 § 3; 1996 c 39 § 22; 1994 c 153 § 7; 1993 c 386 § 11; 1977 ex.s. c 136 § 6; 1975-'76 2nd ex.s. c 106 § 6; 1973 1st ex.s. c 147 § 7; 1970 ex.s. c 39 § 8.]

41.05.080
Participation in insurance plans and contracts — Retired, disabled, or separated employees — Certain surviving spouses, domestic partners, and dependent children (as amended by 2009 c 523).

(1) Under the qualifications, terms, conditions, and benefits set by the board:

     (a) Retired or disabled state employees, retired or disabled school employees, retired or disabled employees of county, municipal, or other political subdivisions, or retired or disabled employees of tribal governments covered by this chapter may continue their participation in insurance plans and contracts after retirement or disablement;

     (b) Separated employees may continue their participation in insurance plans and contracts if participation is selected immediately upon separation from employment;

     (c) Surviving spouses, domestic partners, and dependent children of emergency service personnel killed in the line of duty may participate in insurance plans and contracts.

     (2) Rates charged surviving spouses and domestic partners of emergency service personnel killed in the line of duty, retired or disabled employees, separated employees, spouses, or dependent children who are not eligible for parts A and B of medicare shall be based on the experience of the community rated risk pool established under RCW
41.05.022.

     (3) Rates charged to surviving spouses and domestic partners of emergency service personnel killed in the line of duty, retired or disabled employees, separated employees, spouses, or children who are eligible for parts A and B of medicare shall be calculated from a separate experience risk pool comprised only of individuals eligible for parts A and B of medicare; however, the premiums charged to medicare-eligible retirees and disabled employees shall be reduced by the amount of the subsidy provided under RCW 41.05.085.

     (4) Surviving spouses, domestic partners, and dependent children of emergency service personnel killed in the line of duty and retired or disabled and separated employees shall be responsible for payment of premium rates developed by the authority which shall include the cost to the authority of providing insurance coverage including any amounts necessary for reserves and administration in accordance with this chapter. These self pay rates will be established based on a separate rate for the employee, the spouse, and the children.

     (5) The term "retired state employees" for the purpose of this section shall include but not be limited to members of the legislature whether voluntarily or involuntarily leaving state office.

[2009 c 523 § 1; 2007 c 114 § 6; 2001 c 165 § 3; 1996 c 39 § 22; 1994 c 153 § 7; 1993 c 386 § 11; 1977 ex.s. c 136 § 6; 1975-'76 2nd ex.s. c 106 § 6; 1973 1st ex.s. c 147 § 7; 1970 ex.s. c 39 § 8.]

Notes:

     Reviser's note: RCW 41.05.080 was amended twice during the 2009 legislative session, each without reference to the other. For rule of construction concerning sections amended more than once during the same legislative session, see RCW 1.12.025.

     Intent -- Effective date -- 2007 c 114: See notes following RCW 41.05.011.

     Effective date--Application -- 2001 c 165: See note following RCW 41.05.011.

     Effective dates -- 1996 c 39: See note following RCW 41.32.010.

     Intent -- Effective dates -- 1994 c 153: See notes following RCW 41.05.011.

     Effective date -- 1993 c 386 §§ 3, 7, and 11: See note following RCW 41.04.205.

     Intent -- 1993 c 386: See note following RCW 28A.400.391.

     Effective date -- Conditions prerequisite to implementing sections -- 1977 ex.s. c 136: See note following RCW 41.05.050.

     Effective date -- Effect of veto -- Savings -- Severability -- 1973 1st ex.s. c 147: See notes following RCW 41.05.050.

     Severability -- 1970 ex.s. c 39: See note following RCW 41.05.050.




41.05.085
Retired or disabled school employee health insurance subsidy.

(1) Beginning with the appropriations act for the 2005-2007 biennium, the legislature shall establish as part of both the state employees' and the school and educational service district employees' insurance benefit allocation the portion of the allocation to be used to provide a prescription drug subsidy to reduce the health care insurance premiums charged to retired or disabled school district and educational service district employees, or retired state employees, who are eligible for parts A and B of medicare. The legislature may also establish a separate health care subsidy to reduce insurance premiums charged to individuals who select a medicare supplemental insurance policy option established in RCW 41.05.195.

     (2) The amount of any premium reduction shall be established by the board. The amount established shall not result in a premium reduction of more than fifty percent, except as provided in subsection (3) of this section. The board may also determine the amount of any subsidy to be available to spouses and dependents.

     (3) The amount of the premium reduction in subsection (2) of this section may exceed fifty percent, if the administrator, in consultation with the office of financial management, determines that it is necessary in order to meet eligibility requirements to participate in the federal employer incentive program as provided in RCW 41.05.068.

[2005 c 195 § 3; 1994 c 153 § 8.]

Notes:

     Effective date -- 2005 c 195: See note following RCW 41.05.065.

     Intent -- Effective dates -- 1994 c 153: See notes following RCW 41.05.011.




41.05.090
Continuation of coverage of employee, spouse, or covered dependent ineligible under state plan — Exceptions.

(1) When an employee, spouse, or covered dependent becomes ineligible under the state plan and wishes to continue coverage on an individual basis with the same provider under the state plan, such employee, spouse, or covered dependent shall be entitled to immediately transfer and shall not be required to undergo any waiting period before obtaining individual coverage.

     (2) Entitlement to a conversion contract under the terms of this section shall not apply to any employee, spouse, or covered dependent who is:

     (a) Eligible for federal medicare coverage; or

     (b) Covered under another group plan, policy, contract, or agreement providing benefits for hospital or medical care.

     (3) Entitlement to conversion under the terms of this section shall not apply to any employee terminated for misconduct, except that conversion shall be offered to the spouse and covered dependents of the terminated employee.

[1990 c 222 § 5; 1979 c 125 § 3.]




41.05.095
Unmarried dependents under the age of twenty-five.

(1) Any plan offered to employees under this chapter must offer each employee the option of covering any unmarried dependent of the employee under the age of twenty-five.

     (2) Any employee choosing under subsection (1) of this section to cover a dependent who is: (a) Age twenty through twenty-three and not a registered student at an accredited secondary school, college, university, vocational school, or school of nursing; or (b) age twenty-four, shall be required to pay the full cost of such coverage.

     (3) Any employee choosing under subsection (1) of this section to cover a dependent with disabilities, mental illness, or intellectual or other developmental disabilities, who is incapable of self-support, may continue covering that dependent under the same premium and payment structure as for dependents under the age of twenty, irrespective of age.

[2010 c 94 § 11; 2007 c 259 § 18.]

Notes:

     Purpose -- 2010 c 94: See note following RCW 44.04.280.

     Effective date -- 2007 c 259 §§ 18-22: "Sections 18 through 22 of this act take effect January 1, 2009." [2007 c 259 § 72.]

     Severability -- Subheadings not law -- 2007 c 259: See notes following RCW 41.05.033.




41.05.100
Chapter not applicable to certain employees of Cooperative Extension Service.

The provisions of this chapter shall not be applicable to any employee of the Washington State University Cooperative Extension Service who holds a federal civil service appointment and is thereby eligible for insurance coverage under the regulations of the United States Department of Agriculture and the United States Civil Service Commission, and which employee elects participation in the federal programs in lieu of the programs established pursuant to this chapter. Such election may be made only once.

[1979 ex.s. c 9 § 1.]




41.05.110
Chapter not applicable to officers and employees of state convention and trade center.

The provisions of this chapter shall not be applicable to the officers and employees of the nonprofit corporation formed under *chapter 67.40 RCW.

[1984 c 210 § 3.]

Notes:

     *Reviser's note: A majority of chapter 67.40 RCW was repealed by 2010 1st sp.s. c 15 § 14, effective November 30, 2010. RCW 67.40.020 was repealed by 2010 1st sp.s. c 15 § 15, effective December 30, 2010.

     Savings -- Severability -- 1984 c 210: See notes following RCW 43.01.045.




41.05.120
Public employees' and retirees' insurance account.

(1) The public employees' and retirees' insurance account is hereby established in the custody of the state treasurer, to be used by the administrator for the deposit of contributions, the remittance paid by school districts and educational service districts under RCW 28A.400.410, reserves, dividends, and refunds, for payment of premiums for employee and retiree insurance benefit contracts and subsidy amounts provided under RCW 41.05.085, and transfers from the *medical flexible spending account as authorized in RCW 41.05.123. Moneys from the account shall be disbursed by the state treasurer by warrants on vouchers duly authorized by the administrator. Moneys from the account may be transferred to the *medical flexible spending account to provide reserves and start-up costs for the operation of the *medical flexible spending account program.

     (2) The state treasurer and the state investment board may invest moneys in the public employees' and retirees' insurance account. All such investments shall be in accordance with RCW 43.84.080 or 43.84.150, whichever is applicable. The administrator shall determine whether the state treasurer or the state investment board or both shall invest moneys in the public employees' [and retirees'] insurance account.

     (3) During the 2005-07 fiscal biennium, the legislature may transfer from the public employees' and retirees' insurance account such amounts as reflect the excess fund balance of the fund.

[2005 c 518 § 921; 2005 c 143 § 3; 1994 c 153 § 9; 1993 c 492 § 219; 1991 sp.s. c 13 § 100; 1988 c 107 § 10.]

Notes:

     Reviser's note: *(1) The "medical flexible spending account" was renamed the "flexible spending administrative account" by 2008 c 229 § 6.

     (2) This section was amended by 2005 c 143 § 3 and by 2005 c 518 § 921, 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).

     Severability -- Effective date -- 2005 c 518: See notes following RCW 28A.500.030.

     Intent -- Effective dates -- 1994 c 153: See notes following RCW 41.05.011.

     Findings -- Intent--1993 c 492: See notes following RCW 43.20.050.

     Short title--Severability -- Savings--Captions not law--Reservation of legislative power--Effective dates--1993 c 492: See RCW 43.72.910 through 43.72.915.

     Effective dates -- Severability -- 1991 sp.s. c 13: See notes following RCW 18.08.240.




41.05.123
Flexible spending administrative account — Salary reduction account.

(1) The flexible spending administrative account is created in the custody of the state treasurer. All receipts from the following must be deposited in the account: (a) Revenues from employing agencies for costs associated with operating the medical flexible spending arrangement program and the dependent care assistance program provided through the salary reduction plan authorized under this chapter; (b) funds transferred from the dependent care administrative account; and (c) unclaimed moneys at the end of the plan year after all timely submitted claims for that plan year have been processed. Expenditures from the account may be used only for administrative and other expenses related to operating the medical flexible spending arrangement program and the dependent care assistance program provided through the salary reduction plan authorized under this chapter. Only the administrator or the administrator's designee may authorize expenditures from the account. The account is subject to allotment procedures under chapter 43.88 RCW, but an appropriation is not required for expenditures.

     (2) The salary reduction account is established in the state treasury. Employee salary reductions paid to reimburse participants or service providers for benefits provided by the medical flexible spending arrangement program and the dependent care assistance program provided through the salary reduction plan authorized under this chapter shall be paid from the salary reduction account. The funds held by the state to pay for benefits provided by the medical flexible spending arrangement program and the dependent care assistance program provided through the salary reduction plan authorized under this chapter shall be deposited in the salary reduction account. Unclaimed moneys remaining in the salary reduction account at the end of a plan year after all timely submitted claims for that plan year have been processed shall become a part of the flexible spending administrative account. Only the administrator or the administrator's designee may authorize expenditures from the account. The account is not subject to allotment procedures under chapter 43.88 RCW and an appropriation is not required for expenditures.

     (3) Program claims reserves and money necessary for start-up costs transferred from the public employees' and retirees' insurance account established in RCW 41.05.120 may be deposited in the flexible spending administrative account. Moneys in excess of the amount necessary for administrative and operating expenses of the medical flexible spending arrangement program may be transferred to the public employees' and retirees' insurance account.

     (4) The authority may periodically bill employing agencies for costs associated with operating the medical flexible spending arrangement program and the dependent care assistance program provided through the salary reduction plan authorized under this chapter.

[2008 c 229 § 6; 2005 c 143 § 2.]

Notes:

     Effective date -- 2008 c 229: See note following RCW 41.05.295.




41.05.130
State health care authority administrative account.

The state health care authority administrative account is hereby created in the state treasury. Moneys in the account, including unanticipated revenues under RCW 43.79.270, may be spent only after appropriation by statute, and may be used only for operating expenses of the authority, and during the 2013-2015 fiscal biennium, for health care related analysis provided to the legislature by the office of the state actuary.

[2014 c 221 § 914; 1988 c 107 § 11.]

Notes:

     Effective date -- 2014 c 221: See note following RCW 28A.710.260.




41.05.140
Payment of claims — Self-insurance — Insurance reserve fund created.

(1) Except for property and casualty insurance, the authority may self-fund, self-insure, or enter into other methods of providing insurance coverage for insurance programs under its jurisdiction, including the basic health plan as provided in chapter 70.47 RCW. The authority shall contract for payment of claims or other administrative services for programs under its jurisdiction. If a program does not require the prepayment of reserves, the authority shall establish such reserves within a reasonable period of time for the payment of claims as are normally required for that type of insurance under an insured program. The authority shall endeavor to reimburse basic health plan health care providers under this section at rates similar to the average reimbursement rates offered by the statewide benchmark plan determined through the request for proposal process.

     (2) Reserves established by the authority for employee and retiree benefit programs shall be held in a separate account in the custody of the state treasurer and shall be known as the public employees' and retirees' insurance reserve fund. The state treasurer may invest the moneys in the reserve fund pursuant to RCW 43.79A.040.

     (3) Any savings realized as a result of a program created for employees and retirees under this section shall not be used to increase benefits unless such use is authorized by statute.

     (4) Any program created under this section shall be subject to the examination requirements of chapter 48.03 RCW as if the program were a domestic insurer. In conducting an examination, the commissioner shall determine the adequacy of the reserves established for the program.

     (5) The authority shall keep full and adequate accounts and records of the assets, obligations, transactions, and affairs of any program created under this section.

     (6) The authority shall file a quarterly statement of the financial condition, transactions, and affairs of any program created under this section in a form and manner prescribed by the insurance commissioner. The statement shall contain information as required by the commissioner for the type of insurance being offered under the program. A copy of the annual statement shall be filed with the speaker of the house of representatives and the president of the senate.

     (7) The provisions of this section do not apply to the administration of chapter 74.09 RCW.

[2013 c 251 § 10; 2012 c 187 § 10; 2011 1st sp.s. c 15 § 59; 2000 c 80 § 5; 2000 c 79 § 44; 1994 c 153 § 10. Prior: 1993 c 492 § 220; 1993 c 386 § 12; 1988 c 107 § 12.]

Notes:

     Residual balance of funds -- Effective date -- 2013 c 251: See notes following RCW 41.06.280.

     Effective date -- Findings -- Intent -- Report -- Agency transfer -- References to head of health care authority -- Draft legislation -- 2011 1st sp.s. c 15: See notes following RCW 74.09.010.

     Effective date -- Severability -- 2000 c 79: See notes following RCW 48.04.010.

     Intent -- Effective dates -- 1994 c 153: See notes following RCW 41.05.011.

     Findings -- Intent--1993 c 492: See notes following RCW 43.20.050.

     Short title--Severability -- Savings--Captions not law--Reservation of legislative power--Effective dates--1993 c 492: See RCW 43.72.910 through 43.72.915.

     Intent -- 1993 c 386: See note following RCW 28A.400.391.

     Effective date -- 1993 c 386 §§ 1, 2, 4-6, 8-10, and 12-16: See note following RCW 28A.400.391.




41.05.143
Uniform medical plan benefits administration account — Uniform dental plan benefits administration account — Public employees' benefits board medical benefits administration account.

(1) The uniform medical plan benefits administration account is created in the custody of the state treasurer. Only the administrator or the administrator's designee may authorize expenditures from the account. Moneys in the account shall be used exclusively for contracted expenditures for uniform medical plan claims administration, data analysis, utilization management, preferred provider administration, and activities related to benefits administration where the level of services provided pursuant to a contract fluctuate as a direct result of changes in uniform medical plan enrollment. Moneys in the account may also be used for administrative activities required to respond to new and unforeseen conditions that impact the uniform medical plan, but only when the authority and the office of financial management jointly agree that such activities must be initiated prior to the next legislative session.

     (2) Receipts from amounts due from or on behalf of uniform medical plan enrollees for expenditures related to benefits administration, including moneys disbursed from the public employees' and retirees' insurance account, shall be deposited into the account. The account is subject to allotment procedures under chapter
43.88 RCW, but no appropriation is required for expenditures. All proposals for allotment increases shall be provided to the house of representatives appropriations committee and to the senate ways and means committee at the same time as they are provided to the office of financial management.

     (3) The uniform dental plan benefits administration account is created in the custody of the state treasurer. Only the administrator or the administrator's designee may authorize expenditures from the account. Moneys in the account shall be used exclusively for contracted expenditures related to benefits administration for the uniform dental plan as established under RCW 41.05.140. Receipts from amounts due from or on behalf of uniform dental plan enrollees for expenditures related to benefits administration, including moneys disbursed from the public employees' and retirees' insurance account, shall be deposited into the account. The account is subject to allotment procedures under chapter 43.88 RCW, but no appropriation is required for expenditures.

     (4) The public employees' benefits board medical benefits administration account is created in the custody of the state treasurer. Only the administrator or the administrator's designee may authorize expenditures from the account. Moneys in the account shall be used exclusively for contracted expenditures related to claims administration, data analysis, utilization management, preferred provider administration, and other activities related to benefits administration for self-insured medical plans other than the uniform medical plan. Receipts from amounts due from or on behalf of enrollees for expenditures related to benefits administration, including moneys disbursed from the public employees' and retirees' insurance account, shall be deposited into the account. The account is subject to allotment procedures under chapter 43.88 RCW, but an appropriation is not required for expenditures.

[2007 c 507 § 1; 2000 2nd sp.s. c 1 § 901.]

Notes:

     Severability -- 2000 2nd sp.s. c 1: "If any provision of this act or its application to any person or circumstance is held invalid, the remainder of the act or the application of the provision to other persons or circumstances is not affected." [2000 2nd sp.s. c 1 § 1047.]

     Effective date -- 2000 2nd sp.s. c 1: "This act is necessary for the immediate preservation of the public peace, health, or safety, or support of the state government and its existing public institutions, and takes effect immediately [May 2, 2000]." [2000 2nd sp.s. c 1 § 1048.]




41.05.160
Rules.

The administrator may promulgate and adopt rules consistent with this chapter to carry out the purposes of this chapter. All rules shall be adopted in accordance with chapter 34.05 RCW.

[1988 c 107 § 15.]




41.05.165
Rules — Insurance benefit reimbursement.

The authority shall adopt rules that provide for members of the legislature who choose reimbursement under RCW 44.04.230 in lieu of insurance benefits under this chapter.

[1998 c 62 § 2.]

Notes:

     Effective date -- 1998 c 62: See note following RCW 44.04.230.




41.05.170
Neurodevelopmental therapies — Employer-sponsored group contracts.

(1) Each health plan offered to public employees and their covered dependents under this chapter which is not subject to the provisions of Title 48 RCW and is established or renewed on or after twelve months after July 23, 1989, shall include coverage for neurodevelopmental therapies for covered individuals age six and under.

     (2) Benefits provided under this section shall cover the services of those authorized to deliver occupational therapy, speech therapy, and physical therapy. Benefits shall be payable only where the services have been delivered pursuant to the referral and periodic review of a holder of a license issued pursuant to chapter 18.71 or 18.57 RCW or where covered services have been rendered by such licensee. Nothing in this section shall preclude a self-funded plan authorized under this chapter from negotiating rates with qualified providers.

     (3) Benefits provided under this section shall be for medically necessary services as determined by the self-funded plan authorized under this chapter. Benefits shall be payable for services for the maintenance of a covered individual in cases where significant deterioration in the patient's condition would result without the service. Benefits shall be payable to restore and improve function.

     (4) It is the intent of this section that the state, as an employer providing comprehensive health coverage including the benefits required by this section, retains the authority to design and employ utilization and cost controls. Therefore, benefits delivered under this section may be subject to contractual provisions regarding deductible amounts and/or copayments established by the self-funded plan authorized under this chapter. Benefits provided under this section may be subject to standard waiting periods for preexisting conditions, and may be subject to the submission of written treatment plans.

     (5) In recognition of the intent expressed in subsection (4) of this section, benefits provided under this section may be subject to contractual provisions establishing annual and/or lifetime benefit limits. Such limits may define the total dollar benefits available, or may limit the number of services delivered as established by the self-funded plan authorized under this chapter.

[1989 c 345 § 4.]




41.05.175
Prescribed, self-administered anticancer medication.

(1) Each health plan offered to public employees and their covered dependents under this chapter, including those subject to the provision of Title 48 RCW, and is issued or renewed beginning January 1, 2012, and provides coverage for cancer chemotherapy treatment must provide coverage for prescribed, self-administered anticancer medication that is used to kill or slow the growth of cancerous cells on a basis at least comparable to cancer chemotherapy medications administered by a health care provider or facility as defined in *RCW 48.43.005 (15) and (16).

     (2) Nothing in this section may be interpreted to prohibit a health plan from administering a formulary or preferred drug list, requiring prior authorization, or imposing other appropriate utilization controls in approving coverage for any chemotherapy.

[2011 c 159 § 2.]

Notes:

     *Reviser's note: RCW 48.43.005 was amended by 2011 c 314 § 3 and by 2011 c 315 § 2, changing subsections (15) and (16) to subsections (20) and (21). RCW 48.43.005 was subsequently amended by 2012 c 87 § 1, changing subsections (20) and (21) to subsections (22) and (23).

     Findings -- 2011 c 159: "The Washington state legislature finds that for cancer patients, there is an inequity in how much they have to pay toward the cost of a self-administered oral medication and how much they have to pay for an intravenous product that is administered in a physician's office or clinic. The legislature further finds that when these inequities exist, patients' access to medically necessary, appropriate treatment is often unfairly restricted. The legislature also acknowledges that self-administered chemotherapy is the only treatment for some types of cancer where there is no intravenous alternative. The legislature declares that in order to reduce the out-of-pocket costs for cancer patients whose diagnosis requires treatment through self-administered anticancer medication, the cost-sharing responsibilities for these patients must be on a basis at least comparable to those of patients receiving intravenously administered anticancer medication." [2011 c 159 § 1.]




41.05.177
Prostate cancer screening — Required coverage.

(1) Each plan offered to public employees and their covered dependents under this chapter that is not subject to the provisions of Title 48 RCW and is issued or renewed after December 31, 2006, shall provide coverage for prostate cancer screening, provided that the screening is delivered upon the recommendation of the patient's physician, advanced registered nurse practitioner, or physician assistant.

     (2) This section shall not be construed to prevent the application of standard policy provisions applicable to other benefits, such as deductible or copayment provisions. This section does not limit the authority of the health care authority to negotiate rates and contract with specific providers for the delivery of prostate cancer screening services. This section shall not apply to medicare supplemental policies or supplemental contracts covering a specified disease or other limited benefits.

[2006 c 367 § 1.]




41.05.180
Mammograms — Insurance coverage.

Each health plan offered to public employees and their covered dependents under this chapter that is not subject to the provisions of Title 48 RCW and is established or renewed after January 1, 1990, and that provides benefits for hospital or medical care shall provide benefits for screening or diagnostic mammography services, provided that such services are delivered upon the recommendation of the patient's physician or advanced registered nurse practitioner as authorized by the nursing care quality assurance commission pursuant to chapter 18.79 RCW or physician assistant pursuant to chapter 18.71A RCW.

     This section shall not be construed to prevent the application of standard health plan provisions applicable to other benefits such as deductible or copayment provisions. This section does not limit the authority of the state health care authority to negotiate rates and contract with specific providers for the delivery of mammography services. This section shall not apply to medicare supplement policies or supplemental contracts covering a specified disease or other limited benefits.

[1994 sp.s. c 9 § 725; 1989 c 338 § 5.]

Notes:

     Severability -- Headings and captions not law -- Effective date -- 1994 sp.s. c 9: See RCW 18.79.900 through 18.79.902.




41.05.183
General anesthesia services for dental procedures — Public employee benefit plans.

(1) Each employee benefit plan offered to public employees that provides coverage for hospital, medical, or ambulatory surgery center services must cover general anesthesia services and related facility charges in conjunction with any dental procedure performed in a hospital or ambulatory surgical center if such anesthesia services and related facility charges are medically necessary because the covered person:

     (a) Is under the age of seven, or physically or developmentally disabled, with a dental condition that cannot be safely and effectively treated in a dental office; or

     (b) Has a medical condition that the person's physician determines would place the person at undue risk if the dental procedure were performed in a dental office. The procedure must be approved by the person's physician.

     (2) Each employee benefit plan offered to public employees that provides coverage for dental services must cover general anesthesia services in conjunction with any covered dental procedure performed in a dental office if the general anesthesia services are medically necessary because the covered person is under the age of seven or physically or developmentally disabled.

     (3) This section does not prohibit an employee benefit plan from:

     (a) Applying cost-sharing requirements, maximum annual benefit limitations, and prior authorization requirements to the services required under this section; or

     (b) Covering only those services performed by a health care provider, or in a health care facility, that is part of its provider network; nor does it limit the authority in negotiating rates and contracts with specific providers.

     (4) This section does not apply to medicare supplement policies, or supplemental contracts covering a specified disease or other limited benefits.

     (5) For the purpose of this section, "general anesthesia services" means services to induce a state of unconsciousness accompanied by a loss of protective reflexes, including the ability to maintain an airway independently and respond purposefully to physical stimulation or verbal command.

     (6) This section applies to employee benefit plans issued or renewed on or after January 1, 2002.

[2001 c 321 § 1.]




41.05.185
Diabetes benefits — State purchased health care.

The legislature finds that diabetes imposes a significant health risk and tremendous financial burden on the citizens and government of the state of Washington, and that access to the medically accepted standards of care for diabetes, its treatment and supplies, and self-management training and education is crucial to prevent or delay the short and long-term complications of diabetes and its attendant costs.

     (1) The definitions in this subsection apply throughout this section unless the context clearly requires otherwise.

     (a) "Person with diabetes" means a person diagnosed by a health care provider as having insulin using diabetes, noninsulin using diabetes, or elevated blood glucose levels induced by pregnancy; and

     (b) "Health care provider" means a health care provider as defined in RCW
48.43.005.

     (2) All state purchased health care purchased or renewed after January 1, 1998, except the basic health plan described in chapter 70.47 RCW, shall provide benefits for at least the following services and supplies for persons with diabetes:

     (a) For state purchased health care that includes coverage for pharmacy services, appropriate and medically necessary equipment and supplies, as prescribed by a health care provider, that includes but is not limited to insulin, syringes, injection aids, blood glucose monitors, test strips for blood glucose monitors, visual reading and urine test strips, insulin pumps and accessories to the pumps, insulin infusion devices, prescriptive oral agents for controlling blood sugar levels, foot care appliances for prevention of complications associated with diabetes, and glucagon emergency kits; and

     (b) For all state purchased health care, outpatient self-management training and education, including medical nutrition therapy, as ordered by the health care provider. Diabetes outpatient self-management training and education may be provided only by health care providers with expertise in diabetes. Nothing in this section prevents any state agency purchasing health care according to this section from restricting patients to seeing only health care providers who have signed participating provider agreements with that state agency or an insuring entity under contract with that state agency.

     (3) Coverage required under this section may be subject to customary cost-sharing provisions established for all other similar services or supplies within a policy.

     (4) Health care coverage may not be reduced or eliminated due to this section.

     (5) Services required under this section shall be covered when deemed medically necessary by the medical director, or his or her designee, subject to any referral and formulary requirements.

[1997 c 276 § 1.]

Notes:

     Effective date -- 1997 c 276: "This act takes effect January 1, 1998." [1997 c 276 § 6.]




41.05.188
Eosinophilic gastrointestinal associated disorder — Elemental formula.

(1) Each health benefit plan offered to public employees and their covered dependents under this chapter that is not subject to chapter 48.43 RCW and that is issued or renewed after December 31, 2015, must offer benefits or coverage for medically necessary elemental formula, regardless of delivery method, when a licensed physician or other health care provider with prescriptive authority:

     (a) Diagnoses a patient with an eosinophilic gastrointestinal associated disorder; and

     (b) Orders and supervises the use of the elemental formula.

     (2) Nothing in this section prohibits a health benefit plan from requiring prior authorization or imposing other appropriate utilization controls in approving coverage for medically necessary elemental formula.

[2014 c 115 § 1.]




41.05.195
Medicare supplemental insurance policies.

Notwithstanding any other provisions of this chapter or rules or procedures adopted by the authority, the authority shall make available to retired or disabled employees who are enrolled in parts A and B of medicare one or more medicare supplemental insurance policies that conform to the requirements of chapter 48.66 RCW. The policies shall be chosen in consultation with the public employees' benefits board. These policies shall be made available to retired or disabled state employees; retired or disabled school district employees; retired employees of county, municipal, or other political subdivisions or retired employees of tribal governments eligible for coverage available under the authority; or surviving spouses or domestic partners of emergency service personnel killed in the line of duty.

[2009 c 523 § 2; 2007 c 114 § 7; 2005 c 47 § 1; 1993 c 492 § 222.]

Notes:

     Intent -- Effective date -- 2007 c 114: See notes following RCW 41.05.011.

     Findings -- Intent--1993 c 492: See notes following RCW 43.20.050.

     Short title--Severability -- Savings--Captions not law--Reservation of legislative power--Effective dates--1993 c 492: See RCW 43.72.910 through 43.72.915.




41.05.197
Medicare supplemental insurance policies.

The medicare supplemental insurance policies authorized under RCW 41.05.195 shall be made available to any resident of the state who:

     (1) Is enrolled in parts A and B of medicare; and

     (2) Is not eligible to purchase coverage as a retired or disabled employee under RCW 41.05.195. State residents purchasing a medicare supplemental insurance policy under this section shall be required to pay the full cost of any such policy.

[2005 c 47 § 2; 1993 c 492 § 223.]

Notes:

     Findings -- Intent -- 1993 c 492: See notes following RCW 43.20.050.

     Short title -- Severability -- Savings -- Captions not law -- Reservation of legislative power -- Effective dates -- 1993 c 492: See RCW 43.72.910 through 43.72.915.




41.05.205
Tricare supplemental insurance policy — Authority to offer — Rules.

(1) Notwithstanding any other provisions of this chapter or rules or procedures adopted by the authority under this chapter, the authority may make available a tricare supplemental insurance policy, 32 C.F.R. Sec. 199.17 (2004), to employees who are eligible. This supplemental policy may be offered as one of the board's health coverage options. Employee selection of this supplemental policy is exclusive of selecting any other medical coverage offered through the board. If offered by the board, this supplemental policy shall be made available to employees, and retired or disabled employees, eligible for coverage available under the authority, but not eligible for medicare parts A and B.

     (2) The administrator may adopt rules to carry out the purposes of this section.

[2005 c 46 § 1.]




41.05.220
Community and migrant health centers — Maternity health care centers — People of color — Underserved populations.

(1) State general funds appropriated to the department of health for the purposes of funding community health centers to provide primary health and dental care services, migrant health services, and maternity health care services shall be transferred to the state health care authority. Any related administrative funds expended by the department of health for this purpose shall also be transferred to the health care authority. The health care authority shall exclusively expend these funds through contracts with community health centers to provide primary health and dental care services, migrant health services, and maternity health care services. The administrator of the health care authority shall establish requirements necessary to assure community health centers provide quality health care services that are appropriate and effective and are delivered in a cost-efficient manner. The administrator shall further assure that community health centers have appropriate referral arrangements for acute care and medical specialty services not provided by the community health centers.

     (2) The authority, in consultation with the department of health, shall work with community and migrant health clinics and other providers of care to underserved populations, to ensure that the number of people of color and underserved people receiving access to managed care is expanded in proportion to need, based upon demographic data.

[1998 c 245 § 38; 1993 c 492 § 232.]

Notes:

     Findings -- Intent--1993 c 492: See notes following RCW 43.20.050.

     Short title--Severability -- Savings--Captions not law--Reservation of legislative power--Effective dates--1993 c 492: See RCW 43.72.910 through 43.72.915.




41.05.225
Blind licensees in the business enterprises program — Plan of health insurance.

(1) The board shall offer a plan of health insurance to blind licensees who are actively operating facilities and participating in the business enterprises program established in RCW 74.18.200 through 74.18.230, and maintained by the department of services for the blind. The plan of health insurance benefits must be the same or substantially similar to the plan of health insurance benefits offered to state employees under this chapter. Enrollment will be at the option of each individual licensee or vendor, under rules established by the board.

     (2) All costs incurred by the state or the board for providing health insurance coverage to active blind vendors, excluding family participation, under subsection (1) of this section may be paid for from net proceeds from vending machine operations in public buildings under RCW 74.18.230.

     (3) Money from the business enterprises program under the federal Randolph-Sheppard Act may not be used for family participation in the health insurance benefits provided under this section. Family insurance benefits are the sole responsibility of the individual blind vendors.

[2002 c 71 § 1.]




41.05.230
Multicultural health care technical assistance program.

(1) Consistent with funds appropriated specifically for this purpose, the authority shall provide matching grants to support community-based multicultural health care technical assistance programs. The purpose of the programs shall be to promote technical assistance through community and migrant health clinics and other appropriate health care providers who serve underserved populations and persons of color.

     The technical assistance provided shall include, but is not limited to: (a) Collaborative research and data analysis on health care outcomes that disproportionately affect persons of color; (b) design and development of model health education and promotion strategies aimed at modifying unhealthy health behaviors or enhancing the use of the health care delivery system by persons of color; (c) provision of technical information and assistance on program planning and financial management; (d) administration, public policy development, and analysis in health care issues affecting people of color; and (e) enhancement and promotion of health care career opportunities for persons of color.

     (2) Consistent with appropriated funds, the programs shall be available on a statewide basis.

[1993 c 492 § 272.]

Notes:

     Finding -- 1993 c 492: See note following RCW 28B.115.080.

     Findings -- Intent--1993 c 492: See notes following RCW 43.20.050.

     Short title--Severability -- Savings--Captions not law--Reservation of legislative power--Effective dates--1993 c 492: See RCW 43.72.910 through 43.72.915.




41.05.240
American Indian health care delivery plan.

[1993 c 492 § 468.] Recodified as RCW 43.70.590 pursuant to 1995 c 43 § 5; and also repealed by 1995 1st sp.s. c 6 § 9.

Notes:

     Reviser's note: RCW 41.05.240 was recodified as RCW 43.70.590 pursuant to 1995 c 43 § 5 and amended by 1995 c 43 § 4, without cognizance of its repeal by 1995 1st sp.s. c 6 § 9. For rule of construction concerning sections amended and repealed in the same legislative session, see RCW 1.12.025.




41.05.280
Department of corrections — Inmate health care.

The department of corrections shall consult with the state health care authority to identify how the department of corrections shall develop a working plan to correspond to the health care reform measures that require all departments to place all state purchased health services in a community-rated, single risk pool under the direct administrative authority of the state purchasing agent by July 1, 1997.

[1998 c 245 § 39; 1993 c 504 § 3.]

Notes:

     Findings -- 1993 c 504: "The legislature finds that Washington state government purchases approximately one-fourth of all the health care statewide. In addition to this huge expenditure, the state also faces health care inflation rates, far exceeding the growth rate of the economy as a whole and the general inflationary rate. Together these factors are straining state resources beyond our capability to pay.

     The legislature finds that the department of corrections is responsible for providing health care to a large and growing number of offenders. It is also facing rapidly escalating medical, dental, and mental health care expenditures. As a result of this, the department must review its entire inmate health care system and take steps to reduce health care expenditures.

     The legislature further finds that efforts to achieve statewide health care reform should also include the department of correction's health care facilities. In this light, the department must develop an appropriate plan that will correspond to the changing health care environment." [1993 c 504 § 1.]

     Effective date -- 1993 c 504: "This act is necessary for the immediate preservation of the public peace, health, or safety, or support of the state government and its existing public institutions, and shall take effect immediately [May 18, 1993]." [1993 c 504 § 4.]




41.05.295
Dependent care assistance program — Health care authority — Powers, duties, and functions.

(1) All powers, duties, and functions of the department of retirement systems pertaining to the dependent care assistance program are transferred to the health care authority.

     (2)(a) All reports, documents, surveys, books, records, files, papers, or written material in the possession of the department of retirement systems pertaining to the powers, functions, and duties transferred shall be delivered to the custody of the health care authority. All funds, credits, or other assets held in connection with the powers, functions, and duties transferred shall be assigned to the health care authority.

     (b) Whenever any question arises as to the transfer of any funds, books, documents, records, papers, files, 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 retirement systems pertaining to the powers, functions, and duties 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, and functions of the department of retirement systems shall not affect the validity of any act performed before January 1, 2009.

     (5) Nothing contained in this section may be construed to alter any existing collective bargaining unit or the provisions of any existing collective bargaining agreement until the agreement has expired or until the bargaining unit has been modified by action of the public employment relations commission as provided by law.

[2008 c 229 § 1.]

Notes:

     Effective date -- 2008 c 229: "This act takes effect January 1, 2009." [2008 c 229 § 15.]




41.05.300
Salary reduction agreements — Authorized.

(1) The state of Washington may enter into salary reduction agreements with employees of the state pursuant to the internal revenue code, for the purpose of making it possible for employees of the state to select on a "before-tax basis" certain taxable and nontaxable benefits. The purpose of the salary reduction plan established in this chapter is to attract and retain individuals in governmental service by permitting them to enter into agreements with the state to provide for benefits pursuant to 26 U.S.C. Sec. 125, 26 U.S.C. Sec. 129, and other applicable sections of the internal revenue code.

     (2) Nothing in the salary reduction plan constitutes an employment agreement between the participant and the state, and nothing contained in the participant's salary reduction agreement, the plan, this section, or RCW
41.05.123, 41.05.310 through 41.05.360, and 41.05.295 gives a participant any right to be retained in state employment.

[2008 c 229 § 3; 1995 1st sp.s. c 6 § 11.]

Notes:

     Effective date -- 2008 c 229: See note following RCW 41.05.295.

     Effective date -- 1995 1st sp.s. c 6: See note following RCW 28A.400.410.




41.05.310
Salary reduction plan — Policies and procedures — Plan document.

The authority shall have responsibility for the formulation and adoption of a plan, policies, and procedures designed to guide, direct, and administer the salary reduction plan. For the plan year beginning January 1, 1996, the administrator may establish a premium only plan. Expansion of the salary reduction plan or cafeteria plan during subsequent plan years shall be subject to approval by the director of the office of financial management.

     (1) A plan document describing the benefits offered under the salary reduction plan shall be adopted and administered by the authority. The authority shall represent the state in all matters concerning the administration of the plan. The state, through the authority, may engage the services of a professional consultant or administrator on a contractual basis to serve as an agent to assist the authority or perform the administrative functions necessary in carrying out the purposes of RCW
41.05.123, 41.05.300 through 41.05.350, and 41.05.295.

     (2) The authority shall formulate and establish policies and procedures for the administration of the salary reduction plan that are consistent with existing state law, the internal revenue code, and the regulations adopted by the internal revenue service as they may apply to the benefits offered to participants under the plan.

     (3) Every action taken by the authority in administering RCW 41.05.123, 41.05.300 through 41.05.350, and 41.05.295 shall be presumed to be a fair and reasonable exercise of the authority vested in or the duties imposed upon it. The authority shall be presumed to have exercised reasonable care, diligence, and prudence and to have acted impartially as to all persons interested unless the contrary be proved by clear and convincing affirmative evidence.

[2008 c 229 § 4; 1995 1st sp.s. c 6 § 12.]

Notes:

     Effective date -- 2008 c 229: See note following RCW 41.05.295.

     Effective date -- 1995 1st sp.s. c 6: See note following RCW 28A.400.410.




41.05.320
Salary reduction plan — Eligibility — Participation, withdrawal.

(1) Elected officials and permanent employees of the state are eligible to participate in the salary reduction plan and reduce their salary by agreement with the authority. The authority may adopt rules to: (a) Limit the participation of employing agencies and their employees in the plan; and (b) permit participation in the plan by temporary employees of the state.

     (2) Persons eligible under subsection (1) of this section may enter into salary reduction agreements with the state.

     (3)(a) An eligible person may become a participant of the salary reduction plan for a full plan year with annual benefit plan selection for each new plan year made before the beginning of the plan year, as determined by the authority, or upon becoming eligible.

     (b) Once an eligible person elects to participate in the salary reduction plan and determines the amount his or her gross salary shall be reduced and the benefit plan for which the funds are to be used during the plan year, the agreement shall be irrevocable and may not be amended during the plan year except as provided in (c) of this subsection. Prior to making an election to participate in the salary reduction plan, the eligible person shall be informed in writing of all the benefits and reductions that will occur as a result of such election.

     (c) The authority shall provide in the salary reduction plan that a participant may enroll, terminate, or change his or her election after the plan year has begun if there is a significant change in a participant's status, as provided by 26 U.S.C. Sec. 125 and the regulations adopted under that section and defined by the authority.

     (4) The authority shall establish as part of the salary reduction plan the procedures for and effect of withdrawal from the plan by reason of retirement, death, leave of absence, or termination of employment. To the extent possible under federal law, the authority shall protect participants from forfeiture of rights under the plan.

     (5) Any reduction of salary under the salary reduction plan shall not reduce the reportable compensation for the purpose of computing the state retirement and pension benefits earned by the employee pursuant to chapters
41.26, 41.32, 41.35, 41.37, 41.40, and 43.43 RCW.

[2008 c 229 § 5; 2007 c 492 § 6; 1995 1st sp.s. c 6 § 13.]

Notes:

     Effective date -- 2008 c 229: See note following RCW 41.05.295.

     Effective date -- 1995 1st sp.s. c 6: See note following RCW 28A.400.410.




41.05.330
Salary reduction plan — Accounts and records.

The authority shall keep or cause to be kept full and adequate accounts and records of the assets, obligations, transactions, and affairs of a salary reduction plan created under RCW 41.05.300.

[2008 c 229 § 7; 1995 1st sp.s. c 6 § 14.]

Notes:

     Effective date -- 2008 c 229: See note following RCW 41.05.295.

     Effective date -- 1995 1st sp.s. c 6: See note following RCW 28A.400.410.




41.05.340
Salary reduction plan — Termination — Amendment.

(1) The state may terminate the salary reduction plan at the end of the plan year or upon notification of federal action affecting the status of the plan.

     (2) The authority may amend the salary reduction plan at any time if the amendment does not affect the rights of the participants to receive eligible reimbursement from the participants' accounts.

[2008 c 229 § 8; 1995 1st sp.s. c 6 § 15.]

Notes:

     Effective date -- 2008 c 229: See note following RCW 41.05.295.

     Effective date -- 1995 1st sp.s. c 6: See note following RCW 28A.400.410.




41.05.350
Salary reduction plan — Rules.

The authority shall adopt rules necessary to implement RCW 41.05.123, 41.05.300 through 41.05.340, and 41.05.295.

[2008 c 229 § 9; 1995 1st sp.s. c 6 § 16.]

Notes:

     Effective date -- 2008 c 229: See note following RCW 41.05.295.

     Effective date -- 1995 1st sp.s. c 6: See note following RCW 28A.400.410.




41.05.360
Salary reduction plan — Construction.

RCW 41.05.123, 41.05.300 through 41.05.350, and 41.05.295 shall be construed to effectuate the purposes of 26 U.S.C. Sec. 125 and other applicable sections of the internal revenue code as required.

[2008 c 229 § 10; 1995 1st sp.s. c 6 § 17.]

Notes:

     Effective date -- 2008 c 229: See note following RCW 41.05.295.

     Effective date -- 1995 1st sp.s. c 6: See note following RCW 28A.400.410.




41.05.400
Plan of health care coverage — Available funds — Components — Eligibility — Administrator's duties.

(1) The administrator shall design and offer a plan of health care coverage as described in subsection (2) of this section, for any person eligible under subsection (3) of this section. The health care coverage shall be designed and offered only to the extent that state funds are specifically appropriated for this purpose.

     (2) The plan of health care coverage shall have the following components:

     (a) Services covered more limited in scope than those contained in RCW
48.41.110(3);

     (b) Enrollee cost-sharing that may include but not be limited to point-of-service cost-sharing for covered services;

     (c) Deductibles of three thousand dollars on a per person per calendar year basis, and four thousand dollars on a per family per calendar year basis. The deductible shall be applied to the first three thousand dollars, or four thousand dollars, of eligible expenses incurred by the covered person or family, respectively, except that the deductible shall not be applied to clinical preventive services as recommended by the United States public health service. Enrollee out-of-pocket expenses required to be paid under the plan for cost-sharing and deductibles shall not exceed five thousand dollars per person, or six thousand dollars per family;

     (d) Payment methodologies for network providers may include but are not limited to resource-based relative value fee schedules, capitation payments, diagnostic related group fee schedules, and other similar strategies including risk-sharing arrangements; and

     (e) Other appropriate care management and cost-containment measures determined appropriate by the administrator, including but not limited to care coordination, provider network limitations, preadmission certification, and utilization review.

     (3) Any person is eligible for coverage in the plan who resides in a county of the state where no carrier, as defined in RCW 48.43.005, or insurer regulated under chapter 48.15 RCW offers to the public an individual health benefit plan as defined in RCW 48.43.005 other than a catastrophic health plan as defined in RCW 48.43.005 at the time of application to the administrator. Such eligibility may terminate pursuant to subsection (8) of this section.

     (4) The administrator may not reject an individual for coverage based upon preexisting conditions of the individual or deny, exclude, or otherwise limit coverage for an individual's preexisting health conditions; except that it shall impose a nine-month benefit waiting period for preexisting conditions for which medical advice was given, or for which a health care provider recommended or provided treatment, or for which a prudent layperson would have sought advice or treatment, within six months before the effective date of coverage. The preexisting condition waiting period shall not apply to prenatal care services. Credit against the waiting period shall be provided pursuant to subsections (5) and (6) of this section.

     (5) Except for persons to whom subsection (6) of this section applies, the administrator shall credit any preexisting condition waiting period in the plan for a person who was enrolled at any time during the sixty-three day period immediately preceding the date of application for the plan in a group health benefit plan or an individual health benefit plan other than a catastrophic health plan. The administrator must credit the period of coverage the person was continuously covered under the immediately preceding health plan toward the waiting period of the new health plan. For the purposes of this subsection, a preceding health plan includes an employer-provided self-funded health plan.

     (6) The administrator shall waive any preexisting condition waiting period in the plan for a person who is an eligible individual as defined in section 2741(b) of the federal health insurance portability and accountability act of 1996 (42 U.S.C. 300gg-41(b)).

     (7) The administrator shall set the rates to be charged plan enrollees.

     (8) When a carrier, as defined in RCW 48.43.005, or an insurer regulated under chapter 48.15 RCW, begins to offer an individual health benefit plan as defined in RCW 48.43.005 in a county where no carrier or insurer had been offering an individual health benefit plan:

     (a) If the health benefit plan offered is other than a catastrophic health plan as defined in RCW 48.43.005, any person enrolled in the plan under subsection (3) of this section in that county shall no longer be eligible;

     (b) The administrator shall provide written notice to any person who is no longer eligible for coverage under the plan within thirty days of the administrator's determination that the person is no longer eligible. The notice shall: (i) Indicate that coverage under the plan will cease ninety days from the date that the notice is dated; (ii) describe any other coverage options available to the person; and (iii) describe the enrollment process for the available options.

[2000 c 80 § 7; 2000 c 79 § 46.]

Notes:

     Effective date -- Severability -- 2000 c 79: See notes following RCW 48.04.010.




41.05.520
Pharmacy connection program — Notice.

(1) The administrator shall establish and advertise a pharmacy connection program through which health care providers and members of the public can obtain information about manufacturer-sponsored prescription drug assistance programs. The administrator shall ensure that the program has staff available who can assist persons in procuring free or discounted medications from manufacturer-sponsored prescription drug assistance programs by:

     (a) Determining whether an assistance program is offered for the needed drug or drugs;

     (b) Evaluating the likelihood of a person obtaining drugs from an assistance program under the guidelines formulated;

     (c) Assisting persons with the application and enrollment in an assistance program;

     (d) Coordinating and assisting physicians and others authorized to prescribe medications with communications, including applications, made on behalf of a person to a participating manufacturer to obtain approval of the person in an assistance program; and

     (e) Working with participating manufacturers to simplify the system whereby eligible persons access drug assistance programs, including development of a single application form and uniform enrollment process.

     (2) Notice regarding the pharmacy connection program shall initially target senior citizens, but the program shall be available to anyone, and shall include a toll-free telephone number, available during regular business hours, that may be used to obtain information.

     (3) The administrator may apply for and accept grants or gifts and may enter into interagency agreements or contracts with other state agencies or private organizations to assist with the implementation of this program including, but not limited to, contracts, gifts, or grants from pharmaceutical manufacturers to assist with the direct costs of the program.

     (4) The administrator shall notify pharmaceutical companies doing business in Washington of the pharmacy connection program. Any pharmaceutical company that does business in this state and that offers a pharmaceutical assistance program shall notify the administrator of the existence of the program, the drugs covered by the program, and all information necessary to apply for assistance under the program.

     (5) For purposes of this section, "manufacturer-sponsored prescription drug assistance program" means a program offered by a pharmaceutical company through which the company provides a drug or drugs to eligible persons at no charge or at a reduced cost. The term does not include the provision of a drug as part of a clinical trial.

[2003 1st sp.s. c 29 § 7.]

Notes:

     Finding -- Intent -- Severability -- Conflict with federal requirements -- Effective date -- 2003 1st sp.s. c 29: See notes following RCW 74.09.650.




41.05.530
Prescription drug assistance, education — Rules.

The authority may adopt rules to implement chapter 29, Laws of 2003 1st sp. sess.

[2003 1st sp.s. c 29 § 10.]

Notes:

     Finding -- Intent -- Severability -- Conflict with federal requirements -- Effective date -- 2003 1st sp.s. c 29: See notes following RCW 74.09.650.




41.05.540
State employee health program — Requirements — Report.

(1) The health care authority, in coordination with the department of health, health plans participating in public employees' benefits board programs, and the University of Washington's center for health promotion, shall establish and maintain a state employee health program focused on reducing the health risks and improving the health status of state employees, dependents, and retirees enrolled in the public employees' benefits board. The program shall use public and private sector best practices to achieve goals of measurable health outcomes, measurable productivity improvements, positive impact on the cost of medical care, and positive return on investment. The program shall establish standards for health promotion and disease prevention activities, and develop a mechanism to update standards as evidence-based research brings new information and best practices forward.

     (2) The state employee health program shall:

     (a) Provide technical assistance and other services as needed to wellness staff in all state agencies and institutions of higher education;

     (b) Develop effective communication tools and ongoing training for wellness staff;

     (c) Contract with outside vendors for evaluation of program goals;

     (d) Strongly encourage the widespread completion of online health assessment tools for all state employees, dependents, and retirees. The health assessment tool must be voluntary and confidential. Health assessment data and claims data shall be used to:

     (i) Engage state agencies and institutions of higher education in providing evidence-based programs targeted at reducing identified health risks;

     (ii) Guide contracting with third-party vendors to implement behavior change tools for targeted high-risk populations; and

     (iii) Guide the benefit structure for state employees, dependents, and retirees to include covered services and medications known to manage and reduce health risks.

     (3) The health care authority shall report to the legislature in December 2008 and December 2010 on outcome goals for the employee health program.

[2007 c 259 § 40; 2005 c 360 § 8.]

Notes:

     Severability -- Subheadings not law -- 2007 c 259: See notes following RCW 41.05.033.

     Findings -- Intent -- 2005 c 360: See note following RCW 36.70A.070.




41.05.550
Prescription drug assistance foundation — Nonprofit and tax-exempt corporation — Liability.

(1) The definitions in this subsection apply throughout this section unless the context clearly requires otherwise.

     (a) "Federal poverty level" means the official poverty level based on family size established and adjusted under section 673(2) of the omnibus budget reconciliation act of 1981 (P.L. 97-35; 42 U.S.C. Sec. 9902(2), as amended).

     (b) "Foundation" means the prescription drug assistance foundation established in this section, a nonprofit corporation organized under the laws of this state to provide assistance in accessing prescription drugs to qualified uninsured individuals.

     (c) "Health insurance coverage including prescription drugs" means prescription drug coverage under a private insurance plan, the medicaid program, the state children's health insurance program ("SCHIP"), the medicare program, the basic health plan, or any employer-sponsored health plan that includes a prescription drug benefit.

     (d) "Qualified uninsured individual" means an uninsured person who is a resident of this state and has an income below three hundred percent of the federal poverty level.

     (e) "Uninsured" means an individual who lacks health insurance coverage including prescription drugs.

     (2)(a) The administrator shall establish the foundation as a nonprofit corporation, organized under the laws of this state. The foundation shall assist qualified uninsured individuals in obtaining prescription drugs at little or no cost.

     (b) The foundation shall be administered in a manner that:

     (i) Begins providing assistance to qualified uninsured individuals by January 1, 2006;

     (ii) Defines the population that may receive assistance in accordance with this section; and

     (iii) Complies with the eligibility requirements necessary to obtain and maintain tax-exempt status under federal law.

     (c) The board of directors of the foundation consists of up to eleven with a minimum of five members appointed by the governor to staggered terms of three years. The governor shall select as members of the board individuals who (i) will represent the interests of persons who lack prescription drug coverage; and (ii) have demonstrated expertise in business management and in the administration of a not-for-profit organization.

     (d) The foundation shall apply for and comply with all federal requirements necessary to obtain and maintain tax-exempt status with respect to the federal tax obligations of the foundation's donors.

     (e) The foundation is authorized, subject to the direction and ratification of the board, to receive, solicit, contract for, collect, and hold in trust for the purposes of this section, donations, gifts, grants, and bequests in the form of money paid or promised, services, materials, equipment, or other things tangible or intangible that may be useful for helping the foundation to achieve its purpose. The foundation may use all sources of public and private financing to support foundation activities. No general fund-state funds shall be used for the ongoing operation of the foundation.

     (f) No liability on the part of, and no cause of action of any nature, shall arise against any member of the board of directors of the foundation or against an employee or agent of the foundation for any lawful action taken by them in the performance of their administrative powers and duties under this section.

[2008 c 87 § 1; 2005 c 267 § 1.]




41.05.600
Mental health services — Definition — Coverage required, when.

(1) For the purposes of this section, "mental health services" means medically necessary outpatient and inpatient services provided to treat mental disorders covered by the diagnostic categories listed in the most current version of the diagnostic and statistical manual of mental disorders, published by the American psychiatric association, on July 24, 2005, or such subsequent date as may be provided by the administrator by rule, consistent with the purposes of chapter 6, Laws of 2005, with the exception of the following categories, codes, and services: (a) Substance related disorders; (b) life transition problems, currently referred to as "V" codes, and diagnostic codes 302 through 302.9 as found in the diagnostic and statistical manual of mental disorders, 4th edition, published by the American psychiatric association; (c) skilled nursing facility services, home health care, residential treatment, and custodial care; and (d) court ordered treatment unless the authority's or contracted insuring entity's medical director determines the treatment to be medically necessary.

     (2) All health benefit plans offered to public employees and their covered dependents under this chapter that provide coverage for medical and surgical services shall provide:

     (a) For all health benefit plans established or renewed on or after January 1, 2006, coverage for:

     (i) Mental health services. The copayment or coinsurance for mental health services may be no more than the copayment or coinsurance for medical and surgical services otherwise provided under the health benefit plan. Wellness and preventive services that are provided or reimbursed at a lesser copayment, coinsurance, or other cost sharing than other medical and surgical services are excluded from this comparison; and

     (ii) Prescription drugs intended to treat any of the disorders covered in subsection (1) of this section to the same extent, and under the same terms and conditions, as other prescription drugs covered by the health benefit plan.

     (b) For all health benefit plans established or renewed on or after January 1, 2008, coverage for:

     (i) Mental health services. The copayment or coinsurance for mental health services may be no more than the copayment or coinsurance for medical and surgical services otherwise provided under the health benefit plan. Wellness and preventive services that are provided or reimbursed at a lesser copayment, coinsurance, or other cost sharing than other medical and surgical services are excluded from this comparison. If the health benefit plan imposes a maximum out-of-pocket limit or stop loss, it shall be a single limit or stop loss for medical, surgical, and mental health services; and

     (ii) Prescription drugs intended to treat any of the disorders covered in subsection (1) of this section to the same extent, and under the same terms and conditions, as other prescription drugs covered by the health benefit plan.

     (c) For all health benefit plans established or renewed on or after July 1, 2010, coverage for:

     (i) Mental health services. The copayment or coinsurance for mental health services may be no more than the copayment or coinsurance for medical and surgical services otherwise provided under the health benefit plan. Wellness and preventive services that are provided or reimbursed at a lesser copayment, coinsurance, or other cost sharing than other medical and surgical services are excluded from this comparison. If the health benefit plan imposes a maximum out-of-pocket limit or stop loss, it shall be a single limit or stop loss for medical, surgical, and mental health services. If the health benefit plan imposes any deductible, mental health services shall be included with medical and surgical services for the purpose of meeting the deductible requirement. Treatment limitations or any other financial requirements on coverage for mental health services are only allowed if the same limitations or requirements are imposed on coverage for medical and surgical services; and

     (ii) Prescription drugs intended to treat any of the disorders covered in subsection (1) of this section to the same extent, and under the same terms and conditions, as other prescription drugs covered by the health benefit plan.

     (3) In meeting the requirements of subsection (2)(a) and (b) of this section, health benefit plans may not reduce the number of mental health outpatient visits or mental health inpatient days below the level in effect on July 1, 2002.

     (4) This section does not prohibit a requirement that mental health services be medically necessary as determined by the medical director or designee, if a comparable requirement is applicable to medical and surgical services.

     (5) Nothing in this section shall be construed to prevent the management of mental health services.

     (6) The administrator will consider care management techniques for mental health services, including but not limited to: (a) Authorized treatment plans; (b) preauthorization requirements based on the type of service; (c) concurrent and retrospective utilization review; (d) utilization management practices; (e) discharge coordination and planning; and (f) contracting with and using a network of participating providers.

[2005 c 6 § 2.]

Notes:

     Findings -- Intent -- 2005 c 6: "The legislature finds that the costs of leaving mental disorders untreated or undertreated are significant, and often include: Decreased job productivity, loss of employment, increased disability costs, deteriorating school performance, increased use of other health services, treatment delays leading to more costly treatments, suicide, family breakdown and impoverishment, and institutionalization, whether in hospitals, juvenile detention, jails, or prisons.

     Treatable mental disorders are prevalent and often have a high impact on health and productive life. The legislature finds that the potential benefits of improved access to mental health services are significant. Additionally, the legislature declares that it is not cost-effective to treat persons with mental disorders differently than persons with medical and surgical disorders.

     Therefore, the legislature intends to require that insurance coverage be at parity for mental health services, which means this coverage be delivered under the same terms and conditions as medical and surgical services." [2005 c 6 § 1.]

Severability -- 2005 c 6: "If any provision of this act or its application to any person or circumstance is held invalid, the remainder of the act or the application of the provision to other persons or circumstances is not affected." [2005 c 6 § 13.]




41.05.601
Mental health services — Rules.

The administrator may adopt rules to implement RCW 41.05.600.

[2005 c 6 § 12.]

Notes:

     Findings -- Intent -- Severability -- 2005 c 6: See notes following RCW 41.05.600.




41.05.630
Annual report of customer service complaints and appeals.

Beginning in 2011, the state health care authority must process as a complaint an enrollee's expression of dissatisfaction about customer service or the quality or availability of a health service. The agency must require that 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 must submit a summary of customer service complaints and appeals to the agency to be included in an annual report to the legislature. Each annual report must summarize the complaints and appeals processed by the state health care authority and contracted carriers in the preceding twelve months, and include an analysis of any trends identified. The report must be complete by September 30th of each year.

[2010 c 293 § 1.]




41.05.650
Community health care collaborative grant program — Grants — Administrative support — Eligibility.

(1) The community health care collaborative grant program is established to further the efforts of community-based coalitions to increase access to appropriate, affordable health care for Washington residents, particularly employed low-income persons and children in school who are uninsured and underinsured, through local programs addressing one or more of the following: (a) Access to medical treatment; (b) the efficient use of health care resources; and (c) quality of care.

     (2) Consistent with funds appropriated for community health care collaborative grants specifically for this purpose, two-year grants may be awarded pursuant to RCW
41.05.660 by the administrator of the health care authority.

     (3) The health care authority shall provide administrative support for the program. Administrative support activities may include health care authority facilitation of statewide discussions regarding best practices and standardized performance measures among grantees, or subcontracting for such discussions.

     (4) Eligibility for community health care collaborative grants shall be limited to nonprofit organizations established to serve a defined geographic region or organizations with public agency status under the jurisdiction of a local, county, or tribal government. To be eligible, such entities must have a formal collaborative governance structure and decision-making process that includes representation by the following health care providers: Hospitals, public health, behavioral health, community health centers, rural health clinics, and private practitioners that serve low-income persons in the region, unless there are no such providers within the region, or providers decline or refuse to participate or place unreasonable conditions on their participation. The nature and format of the application, and the application procedure, shall be determined by the administrator of the health care authority. At a minimum, each application shall: (a) Identify the geographic region served by the organization; (b) show how the structure and operation of the organization reflects the interests of, and is accountable to, this region and members providing care within this region; (c) indicate the size of the grant being requested, and how the money will be spent; and (d) include sufficient information for an evaluation of the application based on the criteria established in RCW 41.05.660.

[2009 c 299 § 1.]




41.05.651
Rules — 2009 c 299.

The health care authority may adopt rules to implement chapter 299, Laws of 2009.

[2009 c 299 § 4.]




41.05.655
School district health benefits — Reports.

By June 1, 2015, the health care authority must report to the governor, legislature, and joint legislative audit and review committee the following duties and analyses, based on two years of reports on school district health benefits submitted to it by the office of the insurance commissioner:

     (1) The director shall establish a specific target to realize the goal of greater equity between premium costs for full family coverage and employee only coverage for the same health benefit plan. In developing this target, the director shall consider the appropriateness of the three-to-one ratio of employee premium costs between full family coverage and employee only coverage, and consider alternatives based on the data and information received from the office of the insurance commissioner.

     (2) The director shall also study and report the advantages and disadvantages to the state, local school districts, and district employees:

     (a) Whether better progress on the legislative goals could be achieved through consolidation of school district health insurance purchasing through a single consolidated school employee health benefits purchasing plan;

     (b) Whether better progress on the legislative goals could be achieved by consolidating K-12 health insurance purchasing through the public employees' benefits board program, and whether consolidation into the public employees' benefits board program would be preferable to the creation of a consolidated school employee health benefits purchasing plan;

     (c) Whether certificated or classified employees, as separate groups, would be better served by purchasing health insurance through a single consolidated school employee health benefits purchasing plan or through participation in the public employees' benefits board program; and

     (d) Analyses shall include implications of taking any of the actions described in (a) through (c) of this subsection to include, at a minimum, the following: The costs for the state and school employees, impacts for existing purchasing programs, a proposed timeline for the implementation of any recommended actions.

[2012 2nd sp.s. c 3 § 6.]

Notes:

     Findings -- Goals -- Intent -- 2012 2nd sp.s. c 3: See note following RCW 28A.400.275.




41.05.660
Community health care collaborative grant program — Award and disbursement of grants.

(1) The community health care collaborative grants shall be awarded on a competitive basis based on a determination of which applicant organization will best serve the purposes of the grant program established in RCW 41.05.650. In making this determination, priority for funding shall be given to the applicants that demonstrate:

     (a) The initiatives to be supported by the community health care collaborative grant are likely to address, in a measurable fashion, documented health care access and quality improvement goals aligned with state health policy priorities and needs within the region to be served;

     (b) The applicant organization must document formal, active collaboration among key community partners that includes local governments, school districts, large and small businesses, nonprofit organizations, tribal governments, carriers, private health care providers, public health agencies, and community public health and safety networks, as defined in *RCW 70.190.010;

     (c) The applicant organization will match the community health care collaborative grant with funds from other sources. The health care authority may award grants solely to organizations providing at least two dollars in matching funds for each community health care collaborative grant dollar awarded;

     (d) The community health care collaborative grant will enhance the long-term capacity of the applicant organization and its members to serve the region's documented health care access needs, including the sustainability of the programs to be supported by the community health care collaborative grant;

     (e) The initiatives to be supported by the community health care collaborative grant reflect creative, innovative approaches which complement and enhance existing efforts to address the needs of the uninsured and underinsured and, if successful, could be replicated in other areas of the state; and

     (f) The programs to be supported by the community health care collaborative grant make efficient and cost-effective use of available funds through administrative simplification and improvements in the structure and operation of the health care delivery system.

     (2) The administrator of the health care authority shall endeavor to disburse community health care collaborative grant funds throughout the state, supporting collaborative initiatives of differing sizes and scales, serving at-risk populations.

     (3) Grants shall be disbursed over a two-year cycle, provided the grant recipient consistently provides timely reports that demonstrate the program is satisfactorily meeting the purposes of the grant and the objectives identified in the organization's application. The requirements for the performance reports shall be determined by the health care authority administrator. The performance measures shall be aligned with the community health care collaborative grant program goals and, where possible, shall be consistent with statewide policy trends and outcome measures required by other public and private grant funders.

[2009 c 299 § 2.]

Notes:

     *Reviser's note: RCW 70.190.010 was repealed by 2011 1st sp.s. c 32 § 13, effective June 30, 2012.




41.05.670
Chronic care management incentives — Provider reimbursement methods.

(1) Effective January 1, 2013, the authority must contract with all of the public employees' benefits board managed care plans and the self-insured plan or plans to include provider reimbursement methods that incentivize chronic care management within health homes resulting in reduced emergency department and inpatient use.

     (2) Health home services contracted for under this section may be prioritized to enrollees with complex, high cost, or multiple chronic conditions.

     (3) For the purposes of this section, "chronic care management," and "health home" have the same meaning as in RCW
74.09.010.

     (4) Contracts with fully insured plans and with any third-party administrator for the self-funded plan that include the items in subsection (1) of this section must be funded within the resources provided by employer funding rates provided for employee health benefits in the omnibus appropriations act.

     (5) Nothing in this section shall require contracted third-party health plans administering the self-insured contract to expend resources to implement items in subsection (1) of this section beyond the resources provided by employer funding rates provided for employee health benefits in the omnibus appropriations act or from other sources in the absence of these provisions.

[2011 c 316 § 6.]




41.05.680
Report — Chronic care management.

The authority shall coordinate a discussion with carriers to learn from successful chronic care management models and develop principles for effective reimbursement methods to align incentives in support of patient centered chronic care health homes. The authority shall submit a report to the appropriate committees of the legislature by December 1, 2012, describing the principles developed from the discussion and any steps taken by the public employees' benefits board or carriers in Washington state to implement the principles through their payment methodologies.

[2011 c 316 § 7.]




41.05.690
Performance measures committee — Membership — Selection of performance measures — Benchmarks for purchasing decisions — Public process for evaluation of measures.

(1) There is created a performance measures committee, the purpose of which is to identify and recommend standard statewide measures of health performance to inform public and private health care purchasers and to propose benchmarks to track costs and improvements in health outcomes.

     (2) Members of the committee must include representation from state agencies, small and large employers, health plans, patient groups, federally recognized tribes, consumers, academic experts on health care measurement, hospitals, physicians, and other providers. The governor shall appoint the members of the committee, except that a statewide association representing hospitals may appoint a member representing hospitals, and a statewide association representing physicians may appoint a member representing physicians. The governor shall ensure that members represent diverse geographic locations and both rural and urban communities. The chief executive officer of the lead organization must also serve on the committee. The committee must be chaired by the director of the authority.

     (3) The committee shall develop a transparent process for selecting performance measures, and the process must include opportunities for public comment.

     (4) By January 1, 2015, the committee shall submit the performance measures to the authority. The measures must include dimensions of:

     (a) Prevention and screening;

     (b) Effective management of chronic conditions;

     (c) Key health outcomes;

     (d) Care coordination and patient safety; and

     (e) Use of the lowest cost, highest quality care for preventive care and acute and chronic conditions.

     (5) The committee shall develop a measure set that:

     (a) Is of manageable size;

     (b) Is based on readily available claims and clinical data;

     (c) Gives preference to nationally reported measures and, where nationally reported measures may not be appropriate, measures used by state agencies that purchase health care or commercial health plans;

     (d) Focuses on the overall performance of the system, including outcomes and total cost;

     (e) Is aligned with the governor's performance management system measures and common measure requirements specific to medicaid delivery systems under RCW
70.320.020 and 43.20A.895;

     (f) Considers the needs of different stakeholders and the populations served; and

     (g) Is usable by multiple payers, providers, hospitals, purchasers, public health, and communities as part of health improvement, care improvement, provider payment systems, benefit design, and administrative simplification for providers and hospitals.

     (6) State agencies shall use the measure set developed under this section to inform and set benchmarks for purchasing decisions.

     (7) The committee shall establish a public process to periodically evaluate the measure set and make additions or changes to the measure set as needed.

[2014 c 223 § 6.]

Notes:

     Finding -- 2014 c 223: See note following RCW 41.05.800.




41.05.800
Community of health pilot projects — Designation — Grants — Rules. (Expires July 1, 2020.)

(1) The authority shall, subject to the availability of amounts appropriated or grants received for this specific purpose, award grants to support the development of two pilot projects for a community of health. A community of health is a regionally based, voluntary collaborative. The purpose of the collaborative is to align actions to achieve healthy communities and populations, improve health care quality, and lower costs. Grants may only be used for start-up costs.

     (2) The authority shall develop a process for designating an entity as a community of health. An entity seeking designation is eligible if:

     (a) It is a nonprofit or public-private partnership, including those led by local public health agencies;

     (b) Its membership is broad and incorporates key stakeholders, such as the long-term care system, the health care delivery system, behavioral health, social supports and services, primary care and specialty providers, hospitals, consumers, small and large employers, health plans, and public health, with no single entity or organizational cohort serving in a majority capacity; and

     (c) It demonstrates an ongoing capacity to:

     (i) Lead health improvement activities within the region with other local systems to improve health outcomes and the overall health of the community, improve health care quality, and lower costs; and

     (ii) Distribute tools and resources from the health extension program created in RCW
43.70.725.

     (3) In awarding grants under this section, the authority shall consider the extent to which the applicant will:

     (a) Base decisions on public input and an active collaboration among key community partners, which can include, but are not limited to, local governments, housing providers, school districts, early learning regional coalitions, large and small businesses, labor organizations, health and human service organizations, tribal governments, health carriers, providers, hospitals, public health agencies, and consumers;

     (b) Match the grant funding with funds from other sources; and

     (c) Demonstrate capability for sustainability without reliance on state general fund appropriations.

     (4) The authority may prioritize applications that commit to providing at least one dollar in matching funds for each grant dollar awarded.

     (5) Before grant funds are disbursed, the authority and the applicant must agree on performance requirements.

     (6) The authority may adopt rules necessary to implement this section, but may not adopt rules, policies, or procedures beyond the scope of the authority granted in this section.

[2014 c 223 § 4.]

Notes:

     Expiration date -- 2014 c 223 § 4: "Section 4 of this act expires July 1, 2020." [2014 c 223 § 21.]

     Finding -- 2014 c 223: "(1) The legislature finds that the state of Washington has an opportunity to transform its health care delivery system.

     (2) The state health care innovation plan establishes the following primary drivers of health transformation, each with individual key actions that are necessary to achieve the objective:

     (a) Improve health overall by stressing prevention and early detection of disease and integration of behavioral health;

     (b) Developing linkages between the health care delivery system and community; and

     (c) Supporting regional collaboratives for communities and populations, improve health care quality, and lower costs." [2014 c 223 § 1.]




41.05.900
Short title.

This chapter shall be known as the Washington state health care reform act of 1988.

[1988 c 107 § 1.]




41.05.901
Implementation — Effective dates — 1988 c 107.

(1) The state health care authority shall be established and shall take such steps as are necessary to ensure that this act is fully implemented on October 1, 1988.

     There is hereby appropriated for the biennium ending June 30, 1989, the sum of one million three hundred thousand dollars, or as much thereof as is necessary, to the office of the governor from the state employees' insurance administrative account, for the purposes of implementing this subsection.

     (2) Subsection (1) of this section, RCW
48.14.027 and 82.04.4331, and sections 13 and 31, chapter 107, Laws of 1988 are necessary for the immediate preservation of the public peace, health, and safety, the support of the state government and its existing public institutions, and shall take effect March 16, 1988.

     (3) The remainder of this act shall take effect on October 1, 1988.

[1988 c 107 § 36.]