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Chapter 48.43 RCW

INSURANCE REFORM

Sections

HTMLPDF 48.43.001Intent.
HTMLPDF 48.43.005Definitions.
HTMLPDF 48.43.007Availability of price and quality information—Transparency tools for members—Requirements.
HTMLPDF 48.43.008Enrollment in employer-sponsored health plan—Person eligible for medical assistance.
HTMLPDF 48.43.009Health care sharing ministries.
HTMLPDF 48.43.012Health plans—Preexisting conditions—Rules.
HTMLPDF 48.43.01211Health plans—Eligibility—Health status-related factors—Rules.
HTMLPDF 48.43.0122Individual health benefit plans—Open enrollment and special enrollment periods—Rules—Enforcement.
HTMLPDF 48.43.0123Health plans—Rescission of coverage—Rules.
HTMLPDF 48.43.0124Health plans—Cost sharing for essential health benefits—Rules.
HTMLPDF 48.43.0125Essential health benefits—Annual or lifetime dollar limits.
HTMLPDF 48.43.0126Summary of benefits and explanation of coverage—Standards and requirements—Notice of modification—Fines—Standards for definitions of health insurance terms—Rules.
HTMLPDF 48.43.0127Group health plans—Waiting period—Rules.
HTMLPDF 48.43.0128Nongrandfathered health plans and plans issued or renewed on or after January 1, 2022—Prohibited discrimination—Rules.
HTMLPDF 48.43.016Utilization management standards and criteria—Health carrier requirements—Definitions.
HTMLPDF 48.43.0161Prior authorization practices—Carrier annual reporting requirements—Commissioner's standardized report.
HTMLPDF 48.43.021Personally identifiable health information—Restrictions on release.
HTMLPDF 48.43.022Enrollee identification card—Social security number restriction.
HTMLPDF 48.43.023Pharmacy identification cards—Rules.
HTMLPDF 48.43.028Eligibility to purchase certain health benefit plans—Small employers and small groups.
HTMLPDF 48.43.035Group health benefit plans—Guaranteed issue and continuity of coverage—Exceptions.
HTMLPDF 48.43.038Individual health plans—Guarantee of continuity of coverage—Exceptions.
HTMLPDF 48.43.039Grace period—Notification or information—Information concerning delinquencies or nonpayment of premiums—Defined.
HTMLPDF 48.43.041Individual health benefit plans—Mandatory benefits.
HTMLPDF 48.43.043Colorectal cancer examinations and laboratory tests—Required benefits or coverage.
HTMLPDF 48.43.045Health plan requirements—Annual reports—Exemptions.
HTMLPDF 48.43.047Health plans—Minimum coverage for preventive services—No cost-sharing requirements.
HTMLPDF 48.43.049Health carrier data—Information from annual statement—Format prescribed by commissioner—Public availability.
HTMLPDF 48.43.055Procedures for review and adjudication of health care provider complaints—Requirements.
HTMLPDF 48.43.059Payments made by a second-party payment process—Definition.
HTMLPDF 48.43.065Right of individuals to receive services—Right of providers, carriers, and facilities to refuse to participate in or pay for services for reason of conscience or religion—Requirements.
HTMLPDF 48.43.071Health care information—Requirement to provide free copy to covered person appealing denial of social security benefits—Exceptions.
HTMLPDF 48.43.072Required reproductive health care coverage—Restrictions on copayments, deductibles, and other form of cost sharing.
HTMLPDF 48.43.0725Reproductive health plan coverage—Immediate postpartum contraception devices.
HTMLPDF 48.43.073Required abortion coverage—Limitations.
HTMLPDF 48.43.074Qualified health plans—Single invoice billing—Certification of compliance required in the segregation plan for premium amounts attributable to coverage of abortion services.
HTMLPDF 48.43.076Digital breast examinations—Cost sharing.
HTMLPDF 48.43.078Digital breast tomosynthesis—Intent to ensure women with access—Commissioner's and health care authority's duty to clarify mandates.
HTMLPDF 48.43.081Anatomic pathology services—Payment for services—Definitions.
HTMLPDF 48.43.083Chiropractor services—Participating provider agreement—Health carrier reimbursement.
HTMLPDF 48.43.085Health carrier may not prohibit its enrollees from contracting for services outside the health care plan.
HTMLPDF 48.43.087Contracting for services at enrollee's expense—Mental health care practitioner—Conditions—Exception.
HTMLPDF 48.43.091Health carrier coverage of outpatient mental health services—Requirements.
HTMLPDF 48.43.093Health carrier coverage of emergency medical services—Requirements—Conditions.
HTMLPDF 48.43.094Pharmacist provided services—Health plan requirements.
HTMLPDF 48.43.096Medication synchronization policy required for health plans covering prescription drugs—Requirements—Definitions.
HTMLPDF 48.43.0961Continuity of coverage for health plans covering prescription drugs for behavioral health.
HTMLPDF 48.43.097Filing of financial statements—Every health carrier.
HTMLPDF 48.43.105Preparation of documents that compare health carriers—Immunity—Due diligence.
HTMLPDF 48.43.115Maternity services—Intent—Definitions—Patient preference—Clinical sovereignty of provider—Notice to policyholders—Application.
HTMLPDF 48.43.121Ground ambulance services organizations—Coverage.
HTMLPDF 48.43.125Coverage at a long-term care facility following hospitalization—Definition.
HTMLPDF 48.43.135Hearing instruments—Coverage.
HTMLPDF 48.43.176Eosinophilic gastrointestinal associated disorder—Elemental formula.
HTMLPDF 48.43.180Denturist services.
HTMLPDF 48.43.185General anesthesia services for dental procedures.
HTMLPDF 48.43.190Payment of chiropractic services—Parity.
HTMLPDF 48.43.195Contraceptive drugs—Twelve-month refill coverage.
DISCLOSURE OF MATERIAL TRANSACTIONS
HTMLPDF 48.43.200Disclosure of certain material transactions—Report—Information is confidential.
HTMLPDF 48.43.205Material acquisitions or dispositions.
HTMLPDF 48.43.210Asset acquisitions—Asset dispositions.
HTMLPDF 48.43.215Report of a material acquisition or disposition of assets—Information required.
HTMLPDF 48.43.220Material nonrenewals, cancellations, or revisions of ceded reinsurance agreements.
HTMLPDF 48.43.225Report of a material nonrenewal, cancellation, or revision of ceded reinsurance agreements—Information required.
MISCELLANEOUS
HTMLPDF 48.43.290Coverage for prescribed durable medical equipment and mobility enhancing equipment—Sales and use taxes—Definitions.
RISK-BASED CAPITAL STANDARDS FOR HEALTH CARRIERS
HTMLPDF 48.43.300Definitions.
HTMLPDF 48.43.305Report of RBC levels—Distribution of report—Formula for determination—Commissioner may make adjustments.
HTMLPDF 48.43.310Company action level event—Required RBC plan—Commissioner's review—Notification—Challenge by carrier.
HTMLPDF 48.43.315Regulatory action level event—Required RBC plan—Commissioner's review—Notification—Challenge by carrier.
HTMLPDF 48.43.320Authorized control level event—Commissioner's options.
HTMLPDF 48.43.325Mandatory control level event—Commissioner's duty—Regulatory control.
HTMLPDF 48.43.330Carrier's right to hearing—Request by carrier—Date set by commissioner.
HTMLPDF 48.43.335Confidentiality of RBC reports and plans—Use of certain comparisons prohibited—Certain information intended solely for use by commissioner.
HTMLPDF 48.43.340Powers or duties of commissioner not limited—Rules.
HTMLPDF 48.43.345Foreign or alien carriers—Required RBC report—Commissioner may require RBC plan—Mandatory control level event.
HTMLPDF 48.43.350No liability or cause of action against commissioner or department.
HTMLPDF 48.43.355Notice by commissioner to carrier—When effective.
HTMLPDF 48.43.360Initial RBC reports—Calculation of initial RBC levels—Subsequent reports.
HTMLPDF 48.43.366Self-funded multiple employer welfare arrangements.
HTMLPDF 48.43.370RBC standards not applicable to certain carriers.
PRESCRIPTION DRUG UTILIZATION MANAGEMENT
HTMLPDF 48.43.400Prescription drug utilization management—Definitions.
HTMLPDF 48.43.410Prescription drug utilization management—Clinical review criteria—Requirement to be evidence-based and updated regularly.
HTMLPDF 48.43.420Prescription drug utilization management—Exception request process—Conditions, requirements, and time frames for approval or denial of requests—Emergency fill coverage—Notice of new policies and procedures.
HTMLPDF 48.43.430Prescription medication—Maximum charge at point of sale—Requirements.
HTMLPDF 48.43.435Prescription medication—Cost-sharing calculation—Application—Rules.
HTMLPDF 48.43.440Human immunodeficiency virus postexposure prophylaxis drugs—Cost sharing and prior authorization.
HEALTH CARE PATIENT PROTECTION
HTMLPDF 48.43.500Intent—Purpose—2000 c 5.
HTMLPDF 48.43.505Enrollee's and protected individual's right to privacy and confidential services—Health carrier or insurer duties—Requests for confidential communications—Rules.
HTMLPDF 48.43.5051Requests for confidential communications—Monitoring and ensuring compliance—Standardized form for submission of requests—Rules.
HTMLPDF 48.43.510Carrier required to disclose health plan information—Marketing and advertising restrictions—Rules.
HTMLPDF 48.43.515Access to appropriate health services—Enrollee options—Rules.
HTMLPDF 48.43.517Enrollment of child participating in medical assistance program—Employer-sponsored health plan.
HTMLPDF 48.43.520Requirement to maintain a documented utilization review program description and written utilization review criteria—Rules.
HTMLPDF 48.43.525Prohibition against retrospective denial of health plan coverage—Rules.
HTMLPDF 48.43.530Requirement for carriers to have comprehensive grievance and appeal processes—Carrier's duties—Procedures—Appeals—Rules.
HTMLPDF 48.43.535Independent review of health care disputes—System for using certified independent review organizations—Rules.
HTMLPDF 48.43.537Health care disputes—Certifying independent review organizations—Application—Restrictions—Maximum fee schedule for conducting reviews—Rules.
HTMLPDF 48.43.540Requirement to designate a licensed medical director—Exemption.
HTMLPDF 48.43.545Standard of care—Liability—Causes of action—Defense—Exception.
HTMLPDF 48.43.550Delegation of duties—Carrier accountability.
MISCELLANEOUS
HTMLPDF 48.43.600Overpayment recovery—Carrier.
HTMLPDF 48.43.605Overpayment recovery—Health care provider.
HTMLPDF 48.43.650Fixed payment insurance products—Commissioner's annual report.
HTMLPDF 48.43.670Plan or contract renewal—Modification of wellness program.
HTMLPDF 48.43.680Lifetime limit on transplants—Definition.
HTMLPDF 48.43.690Assessments under RCW 70.290.040 considered medical expenses.
HTMLPDF 48.43.700Exchange—Plans that a carrier must offer—Review—Rules.
HTMLPDF 48.43.705Plans offered outside of exchange.
HTMLPDF 48.43.710Certification as qualified health plan not an exemption.
HTMLPDF 48.43.715Individual and small group market—Selection of benchmark plan—Minimum requirements—Criteria—List of state-mandated health benefits.
HTMLPDF 48.43.720Reinsurance and risk adjustment programs—Affordable care act—Rules.
HTMLPDF 48.43.725Exclusion of mandated benefits from health plan—Carrier requirements—Notice—Fees—Commissioner's duties.
HTMLPDF 48.43.730Carrier must file provider contracts and compensation agreements with commissioner—Approval or disapproval—Confidentiality—Hearings—Rules—Definitions.
HTMLPDF 48.43.731Health care benefit management contracts—Carrier filing requirements—Notice to enrollees—Confidentiality of filings.
HTMLPDF 48.43.733Rates and forms of group health benefit plans—Timing of filings—Exceptions—Rules.
HTMLPDF 48.43.734Health carrier rate filings—Review of surplus, capital, and profit levels.
HTMLPDF 48.43.735Reimbursement of health care services provided through telemedicine or store and forward technology—Audio-only telemedicine.
HTMLPDF 48.43.740Dental only plan—Emergency dental conditions—Definitions.
HTMLPDF 48.43.743Dental only plan—Annual data statement—Contents—Public use—Definition.
HTMLPDF 48.43.745Dental only plan—Denturist services.
HTMLPDF 48.43.750Health care provider credentialing applications—Use of electronic database by health carriers.
HTMLPDF 48.43.755Health care provider credentialing applications—Use of electronic database by providers.
HTMLPDF 48.43.757Health care provider credentialing applications—Reimbursement requirements.
HTMLPDF 48.43.760Opioid use disorder—Coverage without prior authorization.
HTMLPDF 48.43.761Withdrawal management services—Substance use disorder treatment services—Prior authorization—Utilization review—Medical necessity review.
HTMLPDF 48.43.762Opioid overdose reversal medication bulk purchasing and distribution program.
HTMLPDF 48.43.764Standard set of criteria—Authority review.
HTMLPDF 48.43.765Health carrier network adequacy—Mental health and substance abuse treatment.
HTMLPDF 48.43.767Behavioral health services—Network access.
HTMLPDF 48.43.770Individual market health plan availability—Annual report.
HTMLPDF 48.43.775Qualified health plan participation—Reimbursement rate for other health plans.
HTMLPDF 48.43.780Cap on enrollee's required payment amount for specific drugs and equipment—Cost-sharing requirements.
HTMLPDF 48.43.785COVID-19 personal protective equipment expenses—Health care provider reimbursement.
HTMLPDF 48.43.790Behavioral services—Next-day appointments.
HTMLPDF 48.43.795Qualified health plans—Acceptance of premium and cost-sharing assistance.
HTMLPDF 48.43.800Primary care expenditures assessment—Review.
HTMLPDF 48.43.805Prescription drug upper payment limit—Rules.
HTMLPDF 48.43.810Biomarker testing—Standards—Construction.
HTMLPDF 48.43.815Donor human milk—Standards.
HTMLPDF 48.43.820Consolidated appropriations act enforcement—Implementation of federal regulations.
HTMLPDF 48.43.825Certified peer specialist services—Network access standards.
HTMLPDF 48.43.830Prior authorization.
HTMLPDF 48.43.835Physician assistants—Coverage.
CONSTRUCTION
HTMLPDF 48.43.902Effective date—1996 c 312.
HTMLPDF 48.43.904Construction—Chapter applicable to state registered domestic partnerships—2009 c 521.