Chapter 48.43 RCW



HTMLPDF 48.43.001Intent.
HTMLPDF 48.43.005Definitions.
HTMLPDF 48.43.007Availability of price and quality informationTransparency tools for membersRequirements.
HTMLPDF 48.43.008Enrollment in employer-sponsored health planPerson eligible for medical assistance.
HTMLPDF 48.43.009Health care sharing ministries.
HTMLPDF 48.43.012Health plansPreexisting conditionsRules.
HTMLPDF 48.43.01211Health plansEligibilityHealth status-related factorsRules.
HTMLPDF 48.43.0122Individual health benefit plansOpen enrollment and special enrollment periodsRulesEnforcement.
HTMLPDF 48.43.0123Health plansRescission of coverageRules.
HTMLPDF 48.43.0124Health plansCost sharing for essential health benefitsRules.
HTMLPDF 48.43.0125Essential health benefitsAnnual or lifetime dollar limits.
HTMLPDF 48.43.0126Summary of benefits and explanation of coverageStandards and requirementsNotice of modificationFinesStandards for definitions of health insurance termsRules.
HTMLPDF 48.43.0127Group health plansWaiting periodRules.
HTMLPDF 48.43.0128Nongrandfathered health plans and plans issued or renewed on or after January 1, 2022Prohibited discriminationRules.
HTMLPDF 48.43.016Utilization management standards and criteriaHealth carrier requirementsDefinitions.
HTMLPDF 48.43.0161Prior authorization practicesCarrier annual reporting requirementsCommissioner's standardized report.
HTMLPDF 48.43.021Personally identifiable health informationRestrictions on release.
HTMLPDF 48.43.022Enrollee identification cardSocial security number restriction.
HTMLPDF 48.43.023Pharmacy identification cardsRules.
HTMLPDF 48.43.028Eligibility to purchase certain health benefit plansSmall employers and small groups.
HTMLPDF 48.43.035Group health benefit plansGuaranteed issue and continuity of coverageExceptions.
HTMLPDF 48.43.038Individual health plansGuarantee of continuity of coverageExceptions.
HTMLPDF 48.43.039Grace periodNotification or informationInformation concerning delinquencies or nonpayment of premiumsDefined.
HTMLPDF 48.43.041Individual health benefit plansMandatory benefits.
HTMLPDF 48.43.043Colorectal cancer examinations and laboratory testsRequired benefits or coverage.
HTMLPDF 48.43.045Health plan requirementsAnnual reportsExemptions.
HTMLPDF 48.43.047Health plansMinimum coverage for preventive servicesNo cost-sharing requirements.
HTMLPDF 48.43.049Health carrier dataInformation from annual statementFormat prescribed by commissionerPublic availability.
HTMLPDF 48.43.055Procedures for review and adjudication of health care provider complaintsRequirements.
HTMLPDF 48.43.059Payments made by a second-party payment processDefinition.
HTMLPDF 48.43.065Right of individuals to receive servicesRight of providers, carriers, and facilities to refuse to participate in or pay for services for reason of conscience or religionRequirements.
HTMLPDF 48.43.071Health care informationRequirement to provide free copy to covered person appealing denial of social security benefitsExceptions.
HTMLPDF 48.43.072Required reproductive health care coverageRestrictions on copayments, deductibles, and other form of cost sharing.
HTMLPDF 48.43.0725Reproductive health plan coverageImmediate postpartum contraception devices.
HTMLPDF 48.43.073Required abortion coverageLimitations.
HTMLPDF 48.43.074Qualified health plansSingle invoice billingCertification of compliance required in the segregation plan for premium amounts attributable to coverage of abortion services.
HTMLPDF 48.43.076Digital breast examinationsCost sharing.
HTMLPDF 48.43.078Digital breast tomosynthesisIntent to ensure women with accessCommissioner's and health care authority's duty to clarify mandates.
HTMLPDF 48.43.081Anatomic pathology servicesPayment for servicesDefinitions.
HTMLPDF 48.43.083Chiropractor servicesParticipating provider agreementHealth 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 expenseMental health care practitionerConditionsException.
HTMLPDF 48.43.091Health carrier coverage of outpatient mental health servicesRequirements.
HTMLPDF 48.43.093Health carrier coverage of emergency medical servicesRequirementsConditions.
HTMLPDF 48.43.094Pharmacist provided servicesHealth plan requirements.
HTMLPDF 48.43.096Medication synchronization policy required for health plans covering prescription drugsRequirementsDefinitions.
HTMLPDF 48.43.0961Continuity of coverage for health plans covering prescription drugs for behavioral health.
HTMLPDF 48.43.097Filing of financial statementsEvery health carrier.
HTMLPDF 48.43.105Preparation of documents that compare health carriersImmunityDue diligence.
HTMLPDF 48.43.115Maternity servicesIntentDefinitionsPatient preferenceClinical sovereignty of providerNotice to policyholdersApplication.
HTMLPDF 48.43.121Ground ambulance services organizationsCoverage.
HTMLPDF 48.43.125Coverage at a long-term care facility following hospitalizationDefinition.
HTMLPDF 48.43.135Hearing instrumentsCoverage.
HTMLPDF 48.43.176Eosinophilic gastrointestinal associated disorderElemental formula.
HTMLPDF 48.43.180Denturist services.
HTMLPDF 48.43.185General anesthesia services for dental procedures.
HTMLPDF 48.43.190Payment of chiropractic servicesParity.
HTMLPDF 48.43.195Contraceptive drugsTwelve-month refill coverage.
HTMLPDF 48.43.200Disclosure of certain material transactionsReportInformation is confidential.
HTMLPDF 48.43.205Material acquisitions or dispositions.
HTMLPDF 48.43.210Asset acquisitionsAsset dispositions.
HTMLPDF 48.43.215Report of a material acquisition or disposition of assetsInformation 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 agreementsInformation required.
HTMLPDF 48.43.290Coverage for prescribed durable medical equipment and mobility enhancing equipmentSales and use taxesDefinitions.
HTMLPDF 48.43.300Definitions.
HTMLPDF 48.43.305Report of RBC levelsDistribution of reportFormula for determinationCommissioner may make adjustments.
HTMLPDF 48.43.310Company action level eventRequired RBC planCommissioner's reviewNotificationChallenge by carrier.
HTMLPDF 48.43.315Regulatory action level eventRequired RBC planCommissioner's reviewNotificationChallenge by carrier.
HTMLPDF 48.43.320Authorized control level eventCommissioner's options.
HTMLPDF 48.43.325Mandatory control level eventCommissioner's dutyRegulatory control.
HTMLPDF 48.43.330Carrier's right to hearingRequest by carrierDate set by commissioner.
HTMLPDF 48.43.335Confidentiality of RBC reports and plansUse of certain comparisons prohibitedCertain information intended solely for use by commissioner.
HTMLPDF 48.43.340Powers or duties of commissioner not limitedRules.
HTMLPDF 48.43.345Foreign or alien carriersRequired RBC reportCommissioner may require RBC planMandatory control level event.
HTMLPDF 48.43.350No liability or cause of action against commissioner or department.
HTMLPDF 48.43.355Notice by commissioner to carrierWhen effective.
HTMLPDF 48.43.360Initial RBC reportsCalculation of initial RBC levelsSubsequent reports.
HTMLPDF 48.43.366Self-funded multiple employer welfare arrangements.
HTMLPDF 48.43.370RBC standards not applicable to certain carriers.
HTMLPDF 48.43.400Prescription drug utilization managementDefinitions.
HTMLPDF 48.43.410Prescription drug utilization managementClinical review criteriaRequirement to be evidence-based and updated regularly.
HTMLPDF 48.43.420Prescription drug utilization managementException request processConditions, requirements, and time frames for approval or denial of requestsEmergency fill coverageNotice of new policies and procedures.
HTMLPDF 48.43.430Prescription medicationMaximum charge at point of saleRequirements.
HTMLPDF 48.43.435Prescription medicationCost-sharing calculationApplicationRules.
HTMLPDF 48.43.440Human immunodeficiency virus postexposure prophylaxis drugsCost sharing and prior authorization.
HTMLPDF 48.43.500IntentPurpose2000 c 5.
HTMLPDF 48.43.505Enrollee's and protected individual's right to privacy and confidential servicesHealth carrier or insurer dutiesRequests for confidential communicationsRules.
HTMLPDF 48.43.5051Requests for confidential communicationsMonitoring and ensuring complianceStandardized form for submission of requestsRules.
HTMLPDF 48.43.510Carrier required to disclose health plan informationMarketing and advertising restrictionsRules.
HTMLPDF 48.43.515Access to appropriate health servicesEnrollee optionsRules.
HTMLPDF 48.43.517Enrollment of child participating in medical assistance programEmployer-sponsored health plan.
HTMLPDF 48.43.520Requirement to maintain a documented utilization review program description and written utilization review criteriaRules.
HTMLPDF 48.43.525Prohibition against retrospective denial of health plan coverageRules.
HTMLPDF 48.43.530Requirement for carriers to have comprehensive grievance and appeal processesCarrier's dutiesProceduresAppealsRules.
HTMLPDF 48.43.535Independent review of health care disputesSystem for using certified independent review organizationsRules.
HTMLPDF 48.43.537Health care disputesCertifying independent review organizationsApplicationRestrictionsMaximum fee schedule for conducting reviewsRules.
HTMLPDF 48.43.540Requirement to designate a licensed medical directorExemption.
HTMLPDF 48.43.545Standard of careLiabilityCauses of actionDefenseException.
HTMLPDF 48.43.550Delegation of dutiesCarrier accountability.
HTMLPDF 48.43.600Overpayment recoveryCarrier.
HTMLPDF 48.43.605Overpayment recoveryHealth care provider.
HTMLPDF 48.43.650Fixed payment insurance productsCommissioner's annual report.
HTMLPDF 48.43.670Plan or contract renewalModification of wellness program.
HTMLPDF 48.43.680Lifetime limit on transplantsDefinition.
HTMLPDF 48.43.690Assessments under RCW 70.290.040 considered medical expenses.
HTMLPDF 48.43.700ExchangePlans that a carrier must offerReviewRules.
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 marketSelection of benchmark planMinimum requirementsCriteriaList of state-mandated health benefits.
HTMLPDF 48.43.720Reinsurance and risk adjustment programsAffordable care actRules.
HTMLPDF 48.43.725Exclusion of mandated benefits from health planCarrier requirementsNoticeFeesCommissioner's duties.
HTMLPDF 48.43.730Carrier must file provider contracts and compensation agreements with commissionerApproval or disapprovalConfidentialityHearingsRulesDefinitions.
HTMLPDF 48.43.731Health care benefit management contractsCarrier filing requirementsNotice to enrolleesConfidentiality of filings.
HTMLPDF 48.43.733Rates and forms of group health benefit plansTiming of filingsExceptionsRules.
HTMLPDF 48.43.734Health carrier rate filingsReview of surplus, capital, and profit levels.
HTMLPDF 48.43.735Reimbursement of health care services provided through telemedicine or store and forward technologyAudio-only telemedicine.
HTMLPDF 48.43.740Dental only planEmergency dental conditionsDefinitions.
HTMLPDF 48.43.743Dental only planAnnual data statementContentsPublic useDefinition.
HTMLPDF 48.43.745Dental only planDenturist services.
HTMLPDF 48.43.750Health care provider credentialing applicationsUse of electronic database by health carriers.
HTMLPDF 48.43.755Health care provider credentialing applicationsUse of electronic database by providers.
HTMLPDF 48.43.757Health care provider credentialing applicationsReimbursement requirements.
HTMLPDF 48.43.760Opioid use disorderCoverage without prior authorization.
HTMLPDF 48.43.761Withdrawal management servicesSubstance use disorder treatment servicesPrior authorizationUtilization reviewMedical necessity review.
HTMLPDF 48.43.762Opioid overdose reversal medication bulk purchasing and distribution program.
HTMLPDF 48.43.764Standard set of criteriaAuthority review.
HTMLPDF 48.43.765Health carrier network adequacyMental health and substance abuse treatment.
HTMLPDF 48.43.767Behavioral health servicesNetwork access.
HTMLPDF 48.43.770Individual market health plan availabilityAnnual report.
HTMLPDF 48.43.775Qualified health plan participationReimbursement rate for other health plans.
HTMLPDF 48.43.780Cap on enrollee's required payment amount for specific drugs and equipmentCost-sharing requirements.
HTMLPDF 48.43.785COVID-19 personal protective equipment expensesHealth care provider reimbursement.
HTMLPDF 48.43.790Behavioral servicesNext-day appointments.
HTMLPDF 48.43.795Qualified health plansAcceptance of premium and cost-sharing assistance.
HTMLPDF 48.43.800Primary care expenditures assessmentReview.
HTMLPDF 48.43.805Prescription drug upper payment limitRules.
HTMLPDF 48.43.810Biomarker testingStandardsConstruction.
HTMLPDF 48.43.815Donor human milkStandards.
HTMLPDF 48.43.820Consolidated appropriations act enforcementImplementation of federal regulations.
HTMLPDF 48.43.825Certified peer specialist servicesNetwork access standards.
HTMLPDF 48.43.830Prior authorization.
HTMLPDF 48.43.835Physician assistantsCoverage.
HTMLPDF 48.43.902Effective date1996 c 312.
HTMLPDF 48.43.904ConstructionChapter applicable to state registered domestic partnerships2009 c 521.