title: RCW 41.05.400

text:
(1) The director 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 director, 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 director. Such eligibility may terminate pursuant to subsection (8) of this section.
(4) The director 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 director 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 director 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 director 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 director 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 director shall provide written notice to any person who is no longer eligible for coverage under the plan within thirty days of the director'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.
[ 2023 c 51 s 18; 2000 c 80 s 7; 2000 c 79 s 46.]
Notes:
Effective date—Severability—2000 c 79: See notes following RCW 48.04.010.

catchline: Plan of health care coverage—Available funds—Components—Eligibility—Director's duties.


doc_type: statute

jurisdiction: wa

title: RCW 41.05.405

text:
(1) If a public option plan is not available in each county in the state during plan year 2022 or later, the following requirements apply for all subsequent plan years:
(a) Upon an offer from a public option plan, a hospital licensed under chapter 70.41 RCW that receives payment for services provided to enrollees in the public employees' benefits program or school employees' benefits program, or through a medical assistance program under chapter 74.09 RCW, must contract with at least one public option plan to provide in-network services to enrollees of that plan. This subsection (1)(a) does not apply to a hospital owned and operated by a health maintenance organization licensed under chapter 48.46 RCW; and
(b) The authority shall contract, under RCW 41.05.410, with one or more health carriers to offer at least one standardized bronze, one standardized silver, and one standardized gold qualified health plan in every county in the state or in each county within a region of the state.
(2) Health carriers and hospitals may not condition negotiations or participation of a hospital licensed under chapter 70.41 RCW in any health plan offered by the health carrier on the hospital's negotiations or participation in a public option plan.
(3) By December 1st of the plan year during which enrollment in public option plans statewide is greater than 10,000 covered lives:
(a) The health benefit exchange, in consultation with the insurance commissioner and the authority, shall analyze public option plan rates paid to hospitals for in-network services and whether they have impacted hospital financial sustainability. The analysis must include any impact on hospitals' operating margins during the years public option health plans have been offered in the state and the estimated impact on operating margins in future years if enrollment in public option plans increases. It must also examine the income levels of public option plan enrollees over time. The analysis may examine a sample of hospitals of various sizes and located in various counties. In conducting its analysis, the exchange must give substantial weight to any available reporting of health care provider and health system costs under RCW 70.390.050;
(b) The health care cost transparency board established under chapter 70.390 RCW shall analyze the effect that enrollment in public option plans has had on consumers, including an analysis of the benefits provided to, and premiums and cost-sharing amounts paid by, consumers enrolled in public option plans compared to other standardized and nonstandardized qualified health plans; and
(c) The health benefit exchange, in consultation with the insurance commissioner, the authority, and interested stakeholders, including, but not limited to, statewide associations representing hospitals, health insurers, and physicians, shall review the analyses completed under (a) and (b) of this subsection and develop recommendations to the legislature to address financial or other issues identified in the analyses.
(4) The authority may adopt program rules, in consultation with the office of the insurance commissioner, to ensure compliance with this section, including levying fines and taking other contract actions it deems necessary to enforce compliance with this section.
(5) For the purposes of this section, "public option plan" means a qualified health plan contracted by the authority under RCW 41.05.410.
[ 2021 c 246 s 5.]

license: public-domain-government-work

rule_set: Revised Code of Washington

catchline: Public option plans—Availability—Hospital contracts—Recommendations.

code: rcw

unit: section

court: Washington State Legislature


title: RCW 41.05.410

text:
(1) The authority, in consultation with the health benefit exchange, must contract with one or more health carriers to offer qualified health plans on the Washington health benefit exchange for plan years beginning in 2021. A health carrier contracting with the authority under this section must offer at least one bronze, one silver, and one gold qualified health plan in a single county or in multiple counties. The goal of the procurement conducted under this section is to have a choice of qualified health plans under this section offered in every county in the state. The authority may not execute a contract with an apparently successful bidder under this section until after the insurance commissioner has given final approval of the health carrier's rates and forms pertaining to the health plan to be offered under this section and certification of the health plan under RCW 43.71.065.
(2) A qualified health plan offered under this section must meet the following criteria:
(a) The qualified health plan must be a standardized health plan established under RCW 43.71.095;
(b) The qualified health plan must meet all requirements for qualified health plan certification under RCW 43.71.065 including, but not limited to, requirements relating to rate review and network adequacy;
(c) The qualified health plan must incorporate recommendations of the Robert Bree collaborative and the health technology assessment program;
(d) The qualified health plan may use an integrated delivery system or a managed care model that includes care coordination or care management to enrollees as appropriate;
(e) The qualified health plan must meet additional participation requirements to reduce barriers to maintaining and improving health and align to state agency value-based purchasing. These requirements may include, but are not limited to, standards for population health management; high-value, proven care; health equity; primary care; care coordination and chronic disease management; wellness and prevention; prevention of wasteful and harmful care; and patient engagement;
(f) To reduce administrative burden and increase transparency, the qualified health plan's utilization review processes must:
(i) Be focused on care that has high variation, high cost, or low evidence of clinical effectiveness; and
(ii) Meet national accreditation standards;
(g) The total amount the qualified health plan reimburses providers and facilities for all covered benefits in the statewide aggregate, excluding pharmacy benefits, may not exceed one hundred sixty percent of the total amount medicare would have reimbursed providers and facilities for the same or similar services in the statewide aggregate;
(h) For services provided by rural hospitals certified by the centers for medicare and medicaid services as critical access hospitals or sole community hospitals, the rates may not be less than one hundred one percent of allowable costs as defined by the United States centers for medicare and medicaid services for purposes of medicare cost reporting;
(i) Reimbursement for primary care services, as defined by the authority, provided by a physician with a primary specialty designation of family medicine, general internal medicine, or pediatric medicine, may not be less than one hundred thirty-five percent of the amount that would have been reimbursed under the medicare program for the same or similar services; and
(j) The qualified health plan must comply with any requirements established by the authority to address amounts expended on pharmacy benefits including, but not limited to, increasing generic utilization and use of evidence-based formularies.
(3)(a) At the request of the authority for monitoring, enforcement, or program and quality improvement activities, a qualified health plan offered under this section must provide cost and quality of care information and data to the authority, and may not enter into an agreement with a provider or third party that would restrict the qualified health plan from providing this information or data.
(b) Pursuant to RCW 42.56.650, any cost or quality information or data submitted to the authority is exempt from public disclosure.
(4) Nothing in this section prohibits a health carrier offering qualified health plans under this section from offering other health plans in the individual market.
[ 2021 c 246 s 6; 2019 c 364 s 3.]

catchline: Qualified health plans—Contract for—Requirements—Cost and quality data.


title: RCW 41.05.413

text:
The director may, in his or her sole discretion, waive the requirements of RCW 41.05.410(2)(g) if he or she finds that:
(1) A health carrier offering a qualified health plan under RCW 41.05.410 is unable to form a provider network that meets the network access standards adopted by the insurance commissioner due to the requirements of RCW 41.05.410(2)(g); and
(2) The health carrier is able to achieve actuarially sound premiums that are ten percent lower than the previous plan year through other means.
[ 2023 c 51 s 19; 2019 c 364 s 4.]
Notes:

catchline: Qualified health plans—Reimbursement limit—Waiver.


title: RCW 41.05.430

text:
(1) For births taking place in a licensed hospital or birthing center, a health plan offered to employees and their covered dependents must allow a provider to separately bill for devices, implants, professional services, or a combination thereof, associated with immediate postpartum contraception and may not consider such devices, implants, services, or combinations thereof to be part of any payments for general obstetric procedures.
(2) For purposes of this section, "immediate postpartum contraception" means the postpartum insertion of intrauterine devices or contraceptive implants performed before the patient is discharged from the hospital or birthing center and includes the devices or implants themselves.
(3) This section does not apply to facility services associated with immediate postpartum contraception.
(4) Nothing in this section affects an enrollee's right to directly access women's health care services, including contraceptive services.
(5) This section applies to health plans issued or renewed on or after January 1, 2023.
[ 2022 c 122 s 2.]
Notes:
Findings—Intent—2022 c 122: "The legislature finds that healthy birth spacing helps reduce adverse health outcomes for both parents and babies. The legislature further finds that increasing immediate postpartum access to contraception, before a patient is discharged from the hospital or birthing center, is critical to maternal and newborn health and that immediate postpartum contraception is associated with longer contraceptive coverage, fewer unintended pregnancies, and cost savings for payers and health care systems. To help achieve these outcomes, it is the intent of the legislature to increase access to immediate postpartum contraception by requiring commercial health insurers to pay for immediate postpartum contraception separately from the maternity bundle in a manner that mirrors the payment process for immediate postpartum contraception used by the state's medicaid program." [ 2022 c 122 s 1.]

catchline: Plan of health care coverage—Immediate postpartum contraception devices.


title: RCW 41.05.520

text:
(1) The director 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 director 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 director 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 director 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 director 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.
[ 2023 c 51 s 20; 2003 1st sp.s. c 29 s 7.]
Notes:
Finding—Intent—Severability—Conflict with federal requirements—Effective date—2003 1st sp.s. c 29: See notes following RCW 74.09.650.

catchline: Pharmacy connection program—Notice.


title: RCW 41.05.525

text:
A health plan offered to employees, school employees, and their covered dependents under this chapter issued or renewed on or after January 1, 2020, shall provide coverage without prior authorization of at least one federal food and drug administration approved product for the treatment of opioid use disorder in the drug classes opioid agonists, opioid antagonists, and opioid partial agonists.
[ 2019 c 314 s 36.]
Notes:
Declaration—2019 c 314: See note following RCW 18.22.810.

catchline: Treatment of opioid use disorder—Prior authorization.


title: RCW 41.05.526

text:
(1) Except as provided in subsection (2) of this section, a health plan offered to employees and their covered dependents under this chapter issued or renewed on or after January 1, 2021, may not require an enrollee to obtain prior authorization for withdrawal management services or inpatient or residential substance use disorder treatment services in a behavioral health agency licensed or certified under RCW 71.24.037.
(2)(a) A health plan offered to employees and their covered dependents under this chapter issued or renewed on or after January 1, 2021, must:
(i) Provide coverage for no less than two business days, excluding weekends and holidays, in a behavioral health agency that provides inpatient or residential substance use disorder treatment prior to conducting a utilization review; and
(ii) Provide coverage for no less than three days in a behavioral health agency that provides withdrawal management services prior to conducting a utilization review.
(b)(i) The health plan may not require an enrollee to obtain prior authorization for the services specified in (a) of this subsection as a condition for payment of services prior to the times specified in (a) of this subsection.
(ii) Once the times specified in (a) of this subsection have passed, the health plan may initiate utilization management review procedures if the behavioral health agency continues to provide services or is in the process of arranging for a seamless transfer to an appropriate facility or lower level of care under subsection (6) of this section. For a health plan issued or renewed on or after January 1, 2025, if a health plan authorizes inpatient or residential substance use disorder treatment services pursuant to (a)(i) of this subsection following the initial medical necessity review process under (c)(iii) of this subsection, the length of the initial authorization may not be less than 14 days from the date that the patient was admitted to the behavioral health agency. Any subsequent reauthorization that the health plan approves after the first 14 days must continue for no less than seven days prior to requiring further reauthorization. Nothing prohibits a health plan from requesting information to assist with a seamless transfer under this subsection.
(c)(i) The behavioral health agency under (a) of this subsection must notify an enrollee's health plan as soon as practicable after admitting the enrollee, but not later than twenty-four hours after admitting the enrollee. The time of notification does not reduce the requirements established in (a) of this subsection.
(ii) The behavioral health agency under (a) of this subsection must provide the health plan with its initial assessment and initial treatment plan for the enrollee within two business days of admission, excluding weekends and holidays, or within three days in the case of a behavioral health agency that provides withdrawal management services.
(iii) After the time period in (a) of this subsection and receipt of the material provided under (c)(ii) of this subsection, the plan may initiate a medical necessity review process. Medical necessity review must be based on the standard set of criteria established under RCW 41.05.528. In a review for inpatient or residential substance use disorder treatment services, a health plan may not make a determination that a patient does not meet medical necessity criteria based primarily on the patient's length of abstinence. If the patient's abstinence from substance use was due to incarceration, hospitalization, or inpatient treatment, a health plan may not consider the patient's length of abstinence in determining medical necessity. If the health plan determines within one business day from the start of the medical necessity review period and receipt of the material provided under (c)(ii) of this subsection that the admission to the facility was not medically necessary and advises the agency of the decision in writing, the health plan is not required to pay the facility for services delivered after the start of the medical necessity review period, subject to the conclusion of a filed appeal of the adverse benefit determination. If the health plan's medical necessity review is completed more than one business day after the start of the medical necessity review period and receipt of the material provided under (c)(ii) of this subsection, the health plan must pay for the services delivered from the time of admission until the time at which the medical necessity review is completed and the agency is advised of the decision in writing.
(3)(a) The behavioral health agency shall document to the health plan the patient's need for continuing care and justification for level of care placement following the current treatment period, based on the standard set of criteria established under RCW 41.05.528, with documentation recorded in the patient's medical record.
(b) For a health plan issued or renewed on or after January 1, 2025, for inpatient or residential substance use disorder treatment services, the health plan may not consider the patient's length of stay at the behavioral health agency when making decisions regarding the authorization to continue care at the behavioral health agency.
(4) Nothing in this section prevents a health carrier from denying coverage based on insurance fraud.
(5) If the behavioral health agency under subsection (2)(a) of this section is not in the enrollee's network:
(a) The health plan is not responsible for reimbursing the behavioral health agency at a greater rate than would be paid had the agency been in the enrollee's network; and
(b) The behavioral health agency may not balance bill, as defined in RCW 48.43.005.
(6) When the treatment plan approved by the health plan involves transfer of the enrollee to a different facility or to a lower level of care, the care coordination unit of the health plan shall work with the current agency to make arrangements for a seamless transfer as soon as possible to an appropriate and available facility or level of care. The health plan shall pay the agency for the cost of care at the current facility until the seamless transfer to the different facility or lower level of care is complete. A seamless transfer to a lower level of care may include same day or next day appointments for outpatient care, and does not include payment for nontreatment services, such as housing services. If placement with an agency in the health plan's network is not available, the health plan shall pay the current agency until a seamless transfer arrangement is made.
(7) The requirements of this section do not apply to treatment provided in out-of-state facilities.
(8) For the purposes of this section "withdrawal management services" means twenty-four hour medically managed or medically monitored detoxification and assessment and treatment referral for adults or adolescents withdrawing from alcohol or drugs, which may include induction on medications for addiction recovery.
[ 2024 c 366 s 6; 2020 c 345 s 2.]
Notes:
Findings—Intent—2024 c 366: See note following RCW 71.24.847.
Findings—Intent—2020 c 345: "(1) The legislature finds that:
(a) Substance use disorder is a treatable brain disease from which people recover;
(b) Electing to go to addiction treatment is an act of great courage; and
(c) When people with substance use disorder are provided rapid access to quality treatment within their window of willingness, recovery happens.
(2) The legislature therefore intends to ensure that there is no wrong door for individuals accessing substance use disorder treatment services by requiring coverage, and prohibiting barriers created by prior authorization and premature utilization management review when persons with substance use disorders are ready or urgently in need of treatment services." [ 2020 c 345 s 1.]

catchline: Withdrawal management services—Substance use disorder treatment services—Prior authorization—Utilization review—Medical necessity review.


title: RCW 41.05.527

text:
(1) A health plan offered to public employees and their covered dependents under this chapter that is issued or renewed on or after January 1, 2023, must participate in the bulk purchasing and distribution program for opioid overdose reversal medication established in RCW 70.14.170 once the program is operational.
(2) For health plans issued or renewed on or after January 1, 2025, a health carrier must reimburse a hospital or psychiatric hospital that bills for the following outpatient services:
(a) For opioid overdose reversal medication dispensed or distributed to a patient under RCW 70.41.485 as a separate reimbursable expense; and
(b) For the administration of long-acting injectable buprenorphine as a separate reimbursable expense.
(3) Reimbursements provided under subsection (2) of this section must be separate from any bundled payment for outpatient hospital or emergency department services.
[ 2024 c 366 s 16; 2021 c 273 s 10.]
Notes:
Findings—Intent—2024 c 366: See note following RCW 71.24.847.
Rules—2021 c 273 ss 7-12: See note following RCW 70.14.170.
Findings—Intent—2021 c 273: See note following RCW 70.41.480.

catchline: Opioid overdose reversal medication bulk purchasing and distribution program.


title: RCW 41.05.528

text:
For the purposes of promoting standardized training for behavioral health professionals and facilitating communications between behavioral health agencies, executive agencies, managed care organizations, private health plans, and plans offered through the public employees' benefits board, it is the policy of the state to adopt a single standard set of criteria to define medical necessity for substance use disorder treatment and to define substance use disorder levels of care in Washington. The criteria selected must be comprehensive, widely understood and accepted in the field, and based on continuously updated research and evidence. The health care authority and the office of the insurance commissioner must independently review their regulations and practices by January 1, 2021. The health care authority may make rules if necessary to promulgate the selected standard set of criteria.
[ 2020 c 345 s 6.]
Notes:
Findings—Intent—2020 c 345: See note following RCW 41.05.526.

catchline: Standard set of criteria—Medical necessity for substance use disorder treatment—Substance use disorder levels of care—Rules.


title: RCW 41.05.530

text:
The authority may adopt rules to implement chapter 29, Laws of 2003 1st sp. sess.
[ 2003 1st sp.s. c 29 s 10.]
Notes:
Finding—Intent—Severability—Conflict with federal requirements—Effective date—2003 1st sp.s. c 29: See notes following RCW 74.09.650.

catchline: Prescription drug assistance, education—Rules.


title: RCW 41.05.531

text:
When updated versions of the ASAM Criteria, treatment criteria for addictive, substance related, and co-occurring conditions, inclusive of adolescent and transition age youth versions, are published by the American society of addiction medicine, the health care authority and the office of the insurance commissioner shall jointly determine whether to use the updated version, and, if so, the date upon which the updated version must begin to be used by medicaid managed care organizations, carriers, and other relevant entities. Both agencies shall post notice of their decision on their websites. For purposes of the ASAM Criteria, 4th edition, medicaid managed care organizations and carriers shall begin to use the updated criteria no later than January 1, 2026, unless the health care authority and the office of the insurance commissioner jointly determine that it should not be used.
[ 2024 c 366 s 10.]
Notes:
Findings—Intent—2024 c 366: See note following RCW 71.24.847.

catchline: Standard set of criteria—Updated versions—Review and use.


title: RCW 41.05.533

text:
(1) A health benefit plan offered to public employees and their covered dependents under this chapter that is not subject to chapter 48.43 RCW, that is issued or renewed after December 31, 2015, and that provides coverage for prescription drugs must implement a medication synchronization policy for the dispensing of prescription drugs to the plan's enrollees.
(a) If an enrollee requests medication synchronization for a new prescription, the health [benefit] plan must permit filling the drug: (i) For less than a one-month supply of the drug if synchronization will require more than a fifteen-day supply of the drug; or (ii) for more than a one-month supply of the drug if synchronization will require a fifteen-day supply of the drug or less.
(b) The health benefit plan shall adjust the enrollee cost-sharing for a prescription drug subject to coinsurance that is dispensed for less than the standard refill amount for the purpose of synchronizing the medications.
(c) The health benefit plan shall adjust the enrollee cost-sharing for a prescription drug with a copayment that is dispensed for less than the standard refill amount for the purpose of synchronizing the medications by:
(i) Discounting the copayment rate by fifty percent;
(ii) Discounting the copayment rate based on fifteen-day increments; or
(iii) Any other method that meets the intent of this section and is approved by the office of the insurance commissioner.
(2) Upon request of an enrollee, the prescribing provider or pharmacist shall:
(a) Determine that filling or refilling the prescription is in the best interest of the enrollee, taking into account the appropriateness of synchronization for the drug being dispensed;
(b) Inform the enrollee that the prescription will be filled to less than the standard refill amount for the purpose of synchronizing his or her medications; and
(c) Deny synchronization on the grounds of threat to patient safety or suspected fraud or abuse.
(3) For purposes of this section, the following terms have the following meanings unless the context clearly requires otherwise:
(a) "Medication synchronization" means the coordination of medication refills for a patient taking two or more medications for a chronic condition such that the patient's medications are refilled on the same schedule for a given time period.
(b) "Prescription" has the same meaning as in RCW 18.64.011.
[ 2015 c 213 s 2.]

catchline: Medication synchronization policy required for health benefit plans covering prescription drugs—Requirements—Definitions.


title: RCW 41.05.540

text:
(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.
[ 2023 c 51 s 21; 2007 c 259 s 40; 2005 c 360 s 8.]
Notes:
Subheadings not law—2007 c 259: See note following RCW 7.70.060.
Findings—Intent—2005 c 360: See note following RCW 36.70A.070.

catchline: State employee health program—Requirements.


title: RCW 41.05.550

text:
(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, including a plan offered through the health benefit exchange under chapter 43.71 RCW, 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 or an underinsured person who is a resident of this state and whose income meets financial criteria established by the foundation.
(e) "Underinsured" means an individual who has health insurance coverage including prescription drugs, but for whom the prescription drug coverage is inadequate for their needs.
(f) "Uninsured" means an individual who lacks health insurance coverage including prescription drugs.
(2)(a) The director 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.
[ 2023 c 51 s 22; 2015 c 161 s 1; 2008 c 87 s 1; 2005 c 267 s 1.]
Notes:

catchline: Prescription drug assistance foundation—Nonprofit and tax-exempt corporation—Definitions—Liability.


title: RCW 41.05.600

text:
(1) For the purposes of this section, "mental health services" means:
(a) For health benefit plans issued or renewed before January 1, 2021, 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 June 11, 2020, or such subsequent date as may be provided by the director by rule, consistent with the purposes of chapter 6, Laws of 2005, with the exception of the following categories, codes, and services: (i) Substance related disorders; (ii) 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; (iii) skilled nursing facility services, home health care, residential treatment, and custodial care; and (iv) court ordered treatment unless the authority's or contracted insuring entity's medical director determines the treatment to be medically necessary; and
(b) For health benefit plans issued or renewed on or after January 1, 2021, medically necessary outpatient and inpatient services provided to treat mental health and substance use 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 June 11, 2020, or such subsequent date as may be provided by the director by rule, consistent with the purposes of chapter 6, Laws of 2005.
(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 coverage for:
(a) 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
(b) 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) This section does not prohibit a requirement that mental health services be medically necessary, if a comparable requirement is applicable to medical and surgical services.
(4) Nothing in this section shall be construed to prevent the management of mental health.
(5) The director will consider care management techniques for mental health services if a comparable benefit management requirement is applicable to medical and surgical 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.
[ 2020 c 228 s 1; 2005 c 6 s 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 s 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 s 13.]

catchline: Mental health services—Definition—Coverage required, when.


title: RCW 41.05.601

text:
The director may adopt rules to implement RCW 41.05.600.
[ 2023 c 51 s 23; 2005 c 6 s 12.]
Notes:
Findings—Intent—Severability—2005 c 6: See notes following RCW 41.05.600.

catchline: Mental health services—Rules.


title: RCW 41.05.620

text:
(1) The authority shall contract with one or more external entities to expand access to peer support services.
(2) Beginning December 31, 2025, the entity or entities shall:
(a) Provide technical assistance to support primary care clinics, urgent care clinics, and hospitals to integrate certified peer support specialists into their clinical care models and bill health insurance carriers for those services;
(b) Develop detailed and innovative proposals to create low barrier and cost-effective opportunities for:
(i) Community-based agencies, including peer-run agencies and organizations that are not currently licensed as behavioral health agencies under chapter 71.24 RCW, to bill health carriers for peer support services;
(ii) Service providers to bill health carriers for behavioral health services that are currently funded by the state general fund, including the law enforcement assisted diversion program established under RCW 71.24.589, the recovery navigator program established under RCW 71.24.115, the arrest and jail alternatives program established under RCW 36.28A.450, and the homeless outreach stabilization transition program established under RCW 71.24.145;
(iii) Community-based victim services agencies, including agencies that support domestic violence, sexual assault, and human trafficking victims, to bill health carriers for peer support services provided to victims of gender-based violence; and
(iv) Tribes, tribal health providers, and urban Indian health programs to bill for peer support services provided by tribal elders;
(c) Develop a proposal to establish the concept of, and billing mechanisms for, substance use disorder peer-run respite centers that are modeled after the mental health peer-run respite centers established under RCW 71.24.649; and
(d) Explore options for health carriers to pay for peer support services through capitated payment arrangements rather than on a fee-for-service basis.
(3) By November 1, 2026, the contracted entity or entities shall submit reports to the authority to describe the type and quantity of technical assistance that have been provided, the proposals that have been developed, and the trends in health carriers providing payment for peer support services, and any policy or budget recommendations to encourage health carriers to reimburse providers for peer support services.
[ 2025 c 360 s 2.]

catchline: Peer support services—Access.


title: RCW 41.05.630

text:
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 s 1.]

catchline: Annual report of customer service complaints and appeals.


title: RCW 41.05.650

text:
(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 director 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 director 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.
[ 2023 c 51 s 24; 2009 c 299 s 1.]
Notes:

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


title: RCW 41.05.651

text:
The health care authority may adopt rules to implement chapter 299, Laws of 2009.
[ 2009 c 299 s 4.]


title: RCW 41.05.660

text:
(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;
(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 director 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 director. 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.
[ 2023 c 51 s 25; 2009 c 299 s 2.]
Notes:

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


title: RCW 41.05.670

text:
(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.
(6) The school employees' benefits board, under RCW 41.05.740, shall implement the provisions of this section, effective January 1, 2020.
[ 2017 3rd sp.s. c 13 s 812; 2011 c 316 s 6.]
Notes:
Intent—2017 3rd sp.s. c 13: See note following RCW 28A.150.410.
Collective bargaining agreements not impaired—2017 3rd sp.s. c 13: See note following RCW 41.56.139.

catchline: Chronic care management incentives—Provider reimbursement methods.


title: RCW 41.05.690

text:
(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 71.24.435;
(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.
[ 2019 c 325 s 5009; 2014 c 223 s 6.]
Notes:
Effective date—2019 c 325: See note following RCW 71.24.011.
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 s 1.]

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


title: RCW 41.05.700

text:
(1)(a) A health plan offered to employees, school employees, and their covered dependents under this chapter issued or renewed on or after January 1, 2017, shall reimburse a provider for a health care service provided to a covered person through telemedicine or store and forward technology if:
(i) The plan provides coverage of the health care service when provided in person by the provider;
(ii) The health care service is medically necessary;
(iii) The health care service is a service recognized as an essential health benefit under section 1302(b) of the federal patient protection and affordable care act in effect on January 1, 2015;
(iv) The health care service is determined to be safely and effectively provided through telemedicine or store and forward technology according to generally accepted health care practices and standards, and the technology used to provide the health care service meets the standards required by state and federal laws governing the privacy and security of protected health information; and
(v) Beginning January 1, 2023, for audio-only telemedicine, the covered person has an established relationship with the provider.
(b)(i) Except as provided in (b)(ii) of this subsection, a health plan offered to employees, school employees, and their covered dependents under this chapter issued or renewed on or after January 1, 2021, shall reimburse a provider for a health care service provided to a covered person through telemedicine the same amount of compensation the carrier would pay the provider if the health care service was provided in person by the provider.
(ii) Hospitals, hospital systems, telemedicine companies, and provider groups consisting of eleven or more providers may elect to negotiate an amount of compensation for telemedicine services that differs from the amount of compensation for in-person services.
(iii) For purposes of this subsection (1)(b), the number of providers in a provider group refers to all providers within the group, regardless of a provider's location.
(2) For purposes of this section, reimbursement of store and forward technology is available only for those covered services specified in the negotiated agreement between the health plan and health care provider.
(3) An originating site for a telemedicine health care service subject to subsection (1) of this section includes a:
(a) Hospital;
(b) Rural health clinic;
(c) Federally qualified health center;
(d) Physician's or other health care provider's office;
(e) Licensed or certified behavioral health agency;
(f) Skilled nursing facility;
(g) Home or any location determined by the individual receiving the service; or
(h) Renal dialysis center, except an independent renal dialysis center.
(4) Except for subsection (3)(g) of this section, any originating site under subsection (3) of this section may charge a facility fee for infrastructure and preparation of the patient. Reimbursement for a facility fee must be subject to a negotiated agreement between the originating site and the health plan. A distant site, a hospital that is an originating site for audio-only telemedicine, or any other site not identified in subsection (3) of this section may not charge a facility fee.
(5) The plan may not distinguish between originating sites that are rural and urban in providing the coverage required in subsection (1) of this section.
(6) The plan may subject coverage of a telemedicine or store and forward technology health service under subsection (1) of this section to all terms and conditions of the plan including, but not limited to, utilization review, prior authorization, deductible, copayment, or coinsurance requirements that are applicable to coverage of a comparable health care service provided in person.
(7) This section does not require the plan to reimburse:
(a) An originating site for professional fees;
(b) A provider for a health care service that is not a covered benefit under the plan; or
(c) An originating site or health care provider when the site or provider is not a contracted provider under the plan.
(8)(a) If a provider intends to bill a patient or the patient's health plan for an audio-only telemedicine service, the provider must obtain patient consent for the billing in advance of the service being delivered.
(b) If the health care authority has cause to believe that a provider has engaged in a pattern of unresolved violations of this subsection (8), the health care authority may submit information to the appropriate disciplining authority, as defined in RCW 18.130.020, for action. Prior to submitting information to the appropriate disciplining authority, the health care authority may provide the provider with an opportunity to cure the alleged violations or explain why the actions in question did not violate this subsection (8).
(c) If the provider has engaged in a pattern of unresolved violations of this subsection (8), the appropriate disciplining authority may levy a fine or cost recovery upon the provider in an amount not to exceed the applicable statutory amount per violation and take other action as permitted under the authority of the disciplining authority. Upon completion of its review of any potential violation submitted by the health care authority or initiated directly by an enrollee, the disciplining authority shall notify the health care authority of the results of the review, including whether the violation was substantiated and any enforcement action taken as a result of a finding of a substantiated violation.
(9) For purposes of this section:
(a)(i) "Audio-only telemedicine" means the delivery of health care services through the use of audio-only technology, permitting real-time communication between the patient at the originating site and the provider, for the purpose of diagnosis, consultation, or treatment.
(ii) For purposes of this section only, "audio-only telemedicine" does not include:
(A) The use of facsimile or email; or
(B) The delivery of health care services that are customarily delivered by audio-only technology and customarily not billed as separate services by the provider, such as the sharing of laboratory results;
(b) "Disciplining authority" has the same meaning as in RCW 18.130.020;
(c) "Distant site" means the site at which a physician or other licensed provider, delivering a professional service, is physically located at the time the service is provided through telemedicine;
(d) "Established relationship" means the provider providing audio-only telemedicine has access to sufficient health records to ensure safe, effective, and appropriate care services and:
(i) The covered person has had, within the past three years, at least one in-person appointment, or at least one real-time interactive appointment using both audio and video technology, with the provider providing audio-only telemedicine or with a provider employed at the same medical group, at the same clinic, or by the same integrated delivery system operated by a carrier licensed under chapter 48.44 or 48.46 RCW as the provider providing audio-only telemedicine; or
(ii) The covered person was referred to the provider providing audio-only telemedicine by another provider who has had, within the past three years, at least one in-person appointment, or at least one real-time interactive appointment using both audio and video technology, with the covered person and has provided relevant medical information to the provider providing audio-only telemedicine;
(e) "Health care service" has the same meaning as in RCW 48.43.005;
(f) "Hospital" means a facility licensed under chapter 70.41, 71.12, or 72.23 RCW;
(g) "Originating site" means the physical location of a patient receiving health care services through telemedicine;
(h) "Provider" has the same meaning as in RCW 48.43.005;
(i) "Store and forward technology" means use of an asynchronous transmission of a covered person's medical information from an originating site to the health care provider at a distant site which results in medical diagnosis and management of the covered person, and does not include the use of audio-only telephone, facsimile, or email; and
(j) "Telemedicine" means the delivery of health care services through the use of interactive audio and video technology, permitting real-time communication between the patient at the originating site and the provider, for the purpose of diagnosis, consultation, or treatment. For purposes of this section only, "telemedicine" includes audio-only telemedicine, but does not include facsimile or email.
[ 2024 c 215 s 1; 2023 c 8 s 1; 2022 c 213 s 1; 2021 c 157 s 1; 2020 c 92 s 2; 2018 c 260 s 30; 2017 c 219 s 2; 2016 c 68 s 4; 2015 c 23 s 2.]
Notes:
Conflict with federal requirements—2022 c 213: "If any part of this act is found to be in conflict with federal requirements that are a prescribed condition to the allocation of federal funds to the state, the conflicting part of this act is inoperative solely to the extent of the conflict and with respect to the agencies directly affected, and this finding does not affect the operation of the remainder of this act in its application to the agencies concerned. Rules adopted under this act must meet federal requirements that are a necessary condition to the receipt of federal funds by the state." [ 2022 c 213 s 6.]
Conflict with federal requirements—2021 c 157: See note following RCW 74.09.327.
Effective date—2020 c 92: See note following RCW 48.43.735.
Effective date—2017 c 219: See note following RCW 48.43.735.
Effective date—Intent—2016 c 68: See notes following RCW 48.43.735.
Effective date—2015 c 23 ss 2-4: "Sections 2 through 4 of this act take effect January 1, 2017." [ 2015 c 23 s 7.]
Adoption of sections—2015 c 23 ss 2-4: "The legislature encourages health plans to adopt the requirements of sections 2 through 4 of this act prior to January 1, 2017. Therefore, nothing in this act prohibits a plan from adopting the requirements of sections 2 through 4 of this act prior to January 1, 2017." [ 2015 c 23 s 8.]
Intent—2015 c 23: "It is the intent of the legislature to recognize the application of telemedicine as a reimbursable service by which an individual receives medical services from a health care provider without in-person contact with the provider. It is also the intent of the legislature to reduce the compliance requirements on hospitals when granting privileges or associations to telemedicine physicians." [ 2015 c 23 s 1.]

catchline: Reimbursement of health care services provided through telemedicine or store and forward technology—Audio-only telemedicine.


title: RCW 41.05.730

text:
(1) An eligible provider, as described in subsection (2) of this section, must, in addition to the rate of payment that the provider would otherwise receive for medicaid ground emergency medical transportation services, receive supplemental medicaid reimbursement to the extent provided by law.
(2) A provider is eligible for supplemental reimbursement only if the provider has all of the following characteristics continuously during a state fiscal year:
(a) Provides ground emergency medical transportation services to medicaid beneficiaries:
(b) Is a provider that is enrolled as a medicaid provider for the period being claimed;
(c) Is owned or operated by the state, a city, county, fire protection district, community services district, health care district, federally recognized Indian tribe or any unit of government as defined in 42 C.F.R. Sec. 433.50;
(3) An eligible provider's supplemental reimbursement pursuant to this section must be calculated and paid as follows:
(a) The supplemental reimbursement to an eligible provider, as described in subsection (2) of this section, must be equal to the amount of federal financial participation received as a result of the claims submitted pursuant to subsection (6)(b) of this section;
(b) In no instance may the amount certified pursuant to subsection (5)(a) of this section, when combined with the amount received from all other sources of reimbursement from the medicaid program, exceed one hundred percent of actual costs, as determined pursuant to the medicaid state plan, for ground emergency medical transportation services;
(c) The supplemental medicaid reimbursement provided by this section must be distributed exclusively to eligible providers under a payment methodology based on ground emergency medical transportation services provided to medicaid beneficiaries by eligible providers on a per-transport basis or other federally permissible basis. The authority shall obtain approval from the federal centers for medicare and medicaid services for the payment methodology to be utilized, and may not make any payment pursuant to this section prior to obtaining that approval.
(4)(a) It is the legislature's intent in enacting this section to provide the supplemental reimbursement described in this section without any expenditure from the general fund. An eligible provider, as a condition of receiving supplemental reimbursement pursuant to this section, shall enter into, and maintain, an agreement with the authority for the purposes of implementing this section and reimbursing the department for the costs of administering this section.
(b) The nonfederal share of the supplemental reimbursement submitted to the federal centers for medicare and medicaid services for purposes of claiming federal financial participation shall be paid only with funds from the governmental entities described in subsection (2)(c) of this section and certified to the state as provided in subsection (5) of this section.
(5) Participation in the program by an eligible provider described in this section is voluntary. If an applicable governmental entity elects to seek supplemental reimbursement pursuant to this section on behalf of an eligible provider owned or operated by the entity, as described in subsection (2)(c) of this section, the governmental entity shall do all of the following:
(a) Certify, in conformity with the requirements of 42 C.F.R. Sec. 433.51, that the claimed expenditures for the ground emergency medical transportation services are eligible for federal financial participation;
(b) Provide evidence supporting the certification as specified by the department;
(c) Submit data as specified by the department to determine the appropriate amounts to claim as expenditures qualifying for federal financial participation;
(d) Keep, maintain, and have readily retrievable, any records specified by the department to fully disclose reimbursement amounts to which the eligible provider is entitled, and any other records required by the federal centers for medicare and medicaid services.
(6) The department shall promptly seek any necessary federal approvals for the implementation of this section. The department may limit the program to those costs that are allowable expenditures under Title XIX of the federal social security act (42 U.S.C. Sec. 1396 et seq.). If federal approval is not obtained for implementation of this section, this section may not be implemented.
(a) The department shall submit claims for federal financial participation for the expenditures for the services described in subsection (5) of this section that are allowable expenditures under federal law.
(b) The department shall, on an annual basis, submit any necessary materials to the federal government to provide assurances that claims for federal financial participation will include only those expenditures that are allowable under federal law.
(7) If either a final judicial determination is made by any court of appellate jurisdiction or a final determination is made by the administrator of the federal centers for medicare and medicaid services that the supplemental reimbursement provided for in this section must be made to any provider not described in this section, the director shall execute a declaration stating that the determination has been made and on that date this section becomes inoperative.
[ 2015 c 147 s 1.]

catchline: Ground emergency medical transportation services—Medicaid reimbursement—Calculation—Federal approval—Department's duties.


title: RCW 41.05.735

text:
(1) The authority shall design and implement, in consultation with eligible providers as described in subsection (2) of this section, an intergovernmental transfer program relating to medicaid managed care, ground emergency medical transport services including those services provided by emergency medical technicians at the basic, advanced, and paramedic levels in the prestabilization and preparation for transport in order to increase capitation payments for the purpose of increasing reimbursement to eligible providers.
(2) A provider is eligible for increased reimbursement pursuant to this section only if the provider meets both of the following conditions in an applicable state fiscal year:
(a) Provides ground emergency medical transport services to medicaid managed care enrollees pursuant to a contract or other arrangement with a medicaid managed care plan.
(b) Is owned or operated by the state, a city, county, fire protection district, special district, community services district, health care district, federally recognized Indian tribe or unit of government as defined in 42 C.F.R. Sec. 433.50.
(3) To the extent intergovernmental transfers are voluntarily made by, and accepted from, an eligible provider described in subsection (2) of this section, or a governmental entity affiliated with an eligible provider, the department shall make increased capitation payments to applicable medicaid managed care plans for covered ground emergency medical transportation services.
(a) The increased capitation payments made pursuant to this section must be in amounts at least actuarially equivalent to the supplemental fee-for-service payments available for eligible providers to the extent permissible under federal law.
(b) Except as provided in subsection (6) of this section, all funds associated with intergovernmental transfers made and accepted pursuant to this section must be used to fund additional payments to eligible providers.
(c) Medicaid managed care plans shall pay one hundred percent of any amount of increased capitation payments made pursuant to this section to eligible providers for providing and making available ground emergency medical transportation and paramedical services pursuant to a contract or other arrangement with a medicaid managed care plan.
(4) The intergovernmental transfer program developed pursuant to this section must be implemented on the date federal approval was obtained, and only to the extent intergovernmental transfers from the eligible provider, or the governmental entity with which it is affiliated, are provided for this purpose. To the extent permitted by federal law, the department may implement the intergovernmental transfer program and increased capitation payments pursuant to this section on a retroactive basis as needed.
(5) Participation in the intergovernmental transfers under this section is voluntary on the part of the transferring entities for purposes of all applicable federal laws.
(6) This section must be implemented without any additional expenditure from the state general fund. As a condition of participation under this section, each eligible provider as described in subsection (2) of this section, or the governmental entity affiliated with an eligible provider, shall agree to reimburse the department for any costs associated with implementing this section. Intergovernmental transfers described in this section are subject to a twenty percent administration fee of the nonfederal share paid to the department and is allowed to count as a cost of providing the services.
(7) As a condition of participation under this section, medicaid managed care plans, eligible providers as described in subsection (2) of this section, and governmental entities affiliated with eligible providers shall agree to comply with any requests for information or similar data requirements imposed by the department for purposes of obtaining supporting documentation necessary to claim federal funds or to obtain federal approvals.
(8) This section must be implemented only if and to the extent federal financial participation is available and is not otherwise jeopardized, and any necessary federal approvals have been obtained.
(9) To the extent that the director determines that the payments made pursuant to this section do not comply with federal medicaid requirements, the director retains the discretion to return or not accept an intergovernmental transfer, and may adjust payments pursuant to this section as necessary to comply with federal medicaid requirements.
(10) To the extent federal approval is obtained, the increased capitation payments under this section may commence for dates of service on or after January 1, 2015.
[ 2015 c 147 s 2.]

catchline: Ground emergency medical transportation services—Medicaid reimbursement—Intergovernmental transfer program—Federal approval—Authority's duties.


title: RCW 41.05.740

text:
(1) The school employees' benefits board is created within the authority. The function of the school employees' benefits board is to design and approve insurance benefit plans for school employees and to establish eligibility criteria for participation in insurance benefit plans.
(2) By September 30, 2017, the governor shall appoint the following voting members to the school employees' benefits board as follows:
(a) Two members from associations representing certificated employees;
(b) Two members from associations representing classified employees;
(c) Four members with expertise in employee health benefits policy and administration, one of which is nominated by an association representing school business officials; and
(d) The director of the authority or his or her designee.
(3) Initial members of the school employees' benefits board shall serve staggered terms not to exceed four years. Members appointed thereafter shall serve two-year terms.
(4) Compensation and reimbursement related to school employees' benefits board member service are as follows:
(a) Members of the school employees' benefits board must be compensated in accordance with RCW 43.03.250 and must be reimbursed for their travel expenses while on official business in accordance with RCW 43.03.050 and 43.03.060.
(b) While school employees' benefits board members are carrying out their powers and duties under this chapter, if the service of any certificated or classified employee results in a need for a school employees' benefits board organization to employ a substitute for such certificated or classified employee during such service, payment for such a substitute may be made by the authority from funds appropriated by the legislature for the school employees' benefits board program. If such substitute is paid by the authority, no deduction shall be made from the salary of the certificated or classified employee. In no event shall a school employees' benefits board organization deduct from the salary of a certificated or classified employee serving on the school employees' benefits board more than the amount paid the substitute employed by the school employees' benefits board organization.
(5) The director of the authority or his or her designee shall be the chair and another member shall be selected by the school employees' benefits board as vice chair. The chair shall conduct meetings of the school employees' benefits board. The vice chair shall preside over meetings in the absence of the chair. The school employees' benefits board shall develop bylaws for the conduct of its business.
(6) The school employees' benefits board shall:
(a) Study all matters connected with the provision of health care coverage, life insurance, liability insurance, accidental death and dismemberment, and disability insurance, or any of, or combination of, the enumerated types of insurance for eligible school employees and their dependents on the best basis possible with relation both to the welfare of the school employees and the state. However, liability insurance should not be made available to dependents;
(b) Develop school employee benefit plans that include comprehensive, evidence-based health care benefits for school employees. In developing these plans, the school employees' benefits board shall consider the following elements:
(i) Methods of maximizing cost containment while ensuring access to quality health care;
(ii) 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;
(iii)(A) Wellness, preventive care, chronic disease management, and other initiatives that focus on proven strategies.
(B)(I) As of January 1, 2028, the school employees' benefits board shall no longer offer the smart health program, which includes the wellness incentive and the smart health online portal.
(II) Employees who have met the eligibility requirements to receive a wellness incentive by December 31, 2027, will still receive the wellness incentive in plan year 2028.
(III) Employees are not eligible to earn a wellness incentive as of January 1, 2028;
(iv) Utilization review procedures to support cost-effective benefits delivery;
(v) Ways to leverage efficient purchasing by coordinating with the public employees' benefits board;
(vi) Effective coordination of benefits; and
(vii) Minimum standards for insuring entities;
(c) Authorize premium contributions for a school employee and the employee's dependents in a manner that encourages the use of cost-efficient health care systems. For participating school employees, the required school employee share of the cost for family coverage premiums may not exceed three times the premiums for a school employee purchasing single coverage for the same coverage plan;
(d) Determine the terms and conditions of school employee and dependent eligibility criteria, enrollment policies, and scope of coverage. Employer groups obtaining benefits through contractual agreement with the authority for school employees defined in RCW 41.05.011(6)(b)(iv) may contractually agree with the authority to benefits eligibility criteria which differs from that determined by the school employees' benefits board. At a minimum, the eligibility criteria established by the school employees' benefits board shall address the following:
(i) The effective date of coverage following hire;
(ii) The benefits eligibility criteria, but the school employees' benefits board's criteria shall be no more restrictive than requiring that a school employee be anticipated to work at least six hundred thirty hours per school year to be benefits eligible; and
(iii) Coverage for dependents, including criteria for legal spouses; children up to age twenty-six; children of any age with disabilities, mental illness, or intellectual or other developmental disabilities; and state registered domestic partners, as defined in RCW 26.60.020, and others authorized by the legislature;
(e) Establish terms and conditions for a school employees' benefits board organization to have the ability to locally negotiate eligibility criteria for a school employee who is anticipated to work less than six hundred thirty hours in a school year. A school employees' benefits board organization that elects to use a lower threshold of hours for benefits eligibility must use benefits authorized by the school employees' benefits board and shall do so as an enrichment to the state's definition of basic education;
(f) Establish penalties to be imposed when a school employees' benefits board organization fails to comply with established participation criteria; and
(g) Participate with the authority in the preparation of specifications and selection of carriers contracted for school employee benefit plan coverage of eligible school employees in accordance with the criteria set forth in rules. To the extent possible, the school employees' benefits board shall leverage efficient purchasing by coordinating with the public employees' benefits board.
(7) School employees shall choose participation in one of the health care benefit plans developed by the school employees' benefits board. Individual school employees eligible for benefits under subsection (6)(d) of this section may be permitted to waive coverage under terms and conditions established by the school employees' benefits board.
(8) By November 30, 2021, the authority shall review the benefit plans provided through the school employees' benefits board, complete an analysis of the benefits provided and the administration of the benefits plans, and determine whether provisions in chapter 13, Laws of 2017 3rd sp. sess. have resulted in cost savings to the state. The authority shall submit a report to the relevant legislative policy and fiscal committees summarizing the results of the review and analysis.
[ 2025 c 396 s 2; 2023 c 13 s 7; 2018 c 260 s 1; 2017 3rd sp.s. c 13 s 801.]
Notes:
Finding—Intent—2023 c 13: See note following RCW 41.05.011.
Effective date—2017 3rd sp.s. c 13 ss 102, 505, and 801: See note following RCW 28A.400.205.
Intent—2017 3rd sp.s. c 13: See note following RCW 28A.150.410.
Collective bargaining agreements not impaired—2017 3rd sp.s. c 13: See note following RCW 41.56.139.

catchline: School employees' benefits board.


title: RCW 41.05.742

text:
Beginning with the 2022 plan year, individuals are limited to a single enrollment in medical, dental, and vision plans in either the school employees' benefits board or the public employees' benefits board. The school employees' benefits board and the public employees' benefits board shall adopt policies to reflect this single enrollment requirement.
[ 2021 c 18 s 1; 2020 c 8 s 4.]
Notes:
Effective date—2020 c 8: See note following RCW 41.05.744.

catchline: Single enrollment requirement.


title: RCW 41.05.743

text:
(1) For purposes of this section, "school board member" means the board of directors of a school district as governed by chapter 28A.343 RCW or the board of directors of an educational service district as governed by chapter 28A.310 RCW.
(2) As of January 1, 2024, a school board member may participate in the benefit plans offered by and subject to the terms and conditions determined by the school employees' benefits board. A school board member may enroll in medical, dental, and vision benefits and shall be responsible for premium rates developed by the authority. A school board member shall be responsible for submitting the full self-pay premium amount for the benefits the member elects to enroll in for each month the member is covered.
(3) A school board member may participate in the school employees' benefits board program for the duration of the member's elected term as a school board member and may renew the member's participation at the start of each subsequent term as a school board member.
(4) If a school board member voluntarily ends the member's enrollment in the school employees' benefits board program prior to the end of their elected term, the member is no longer eligible under this section to participate in the school employees' benefits board program for the remainder of the member's elected term.
(5) This section does not create any eligibility for school board members to participate in retiree benefits provided by the public employees' benefits board program.
[ 2023 c 13 s 8.]
Notes:
Finding—Intent—2023 c 13: See note following RCW 41.05.011.

catchline: School board members—Eligibility for health benefits.


title: RCW 41.05.744

text:
(1) A school employee eligible as of February 29, 2020, for the employer contribution towards benefits offered by the school employees' benefits board shall maintain their eligibility for the employer contribution under the following circumstances directly related or in response to the governor's February 29, 2020, proclamation of a state of emergency existing in all counties in the state of Washington related to the novel coronavirus (COVID-19):
(a) During any school closures or changes in school operations for the school employee;
(b) While the school employee is quarantined or required to care for a family member, as defined by RCW 49.46.210(2), who is quarantined; and
(c) In order to take care of a child as defined by RCW 49.46.210(2), when the child's:
(i) School is closed;
(ii) Regular day care facility is closed; or
(iii) Regular child care provider is unable to provide services.
(2) Requirements in subsection (1) of this section expires when the governor's state of emergency related to the novel coronavirus (COVID-19) ends.
(3) When regular school operations resume, school employees shall continue to maintain their eligibility for the employer contribution for the remainder of the school year so long as their work schedule returns to the schedule in place before February 29, 2020, or, if there is a change in schedule, so long as the new schedule, had it been in effect at the start of the school year, would have resulted in the employee being anticipated to work the minimum hours to meet benefits eligibility.
(4) Quarantine, as used in subsection (1)(b) [of this section] includes only periods of isolation required by the federal government, a foreign national government, a state or local public health official, a health care provider, or an employer.
[ 2020 c 8 s 5.]
Notes:
Effective date—2020 c 8: "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 [March 17, 2020]." [ 2020 c 8 s 6.]

catchline: School employee eligibility during COVID-19 state of emergency.


title: RCW 41.05.745

text:
(1) In addition to the benefits offering authority under this chapter, the school employees' benefits board may study and, subject to the availability of funding, offer the following employee-paid, voluntary benefits:
(a) Emergency transportation;
(b) Identity protection;
(c) Legal aid;
(d) Long-term care insurance;
(e) Noncommercial personal automobile insurance;
(f) Personal homeowner's or renter's insurance;
(g) Pet insurance;
(h) Specified disease or illness-triggered fixed payment insurance, hospital confinement fixed payment insurance, or other fixed payment insurance offered as an independent, noncoordinated benefit regulated by the office of the insurance commissioner;
(i) Travel insurance; and
(j) Voluntary employees' beneficiary association accounts.
(2) The health care authority, in consultation with the school employees' benefits board, shall review the optional benefits reported by school districts as required in RCW 28A.400.280 and determine if the optional benefits are in competition with benefits currently offered under either the authority's or the board's authorities. If a school district benefit offering is determined to be in competition with the benefits offered under either the authority's or the board's authorities, the health care authority must inform the school district of the benefits conflict and work with the school district, and the applicable carrier, to either modify and remove competing components of the district-based benefit or end the district-based offering. If a carrier is in the process of modifying benefits, including seeking any required regulatory approval, a school district may continue to offer the original benefit.
(3) Specified disease or illness-triggered fixed payment insurance, hospital confinement fixed payment insurance, or other fixed payment insurance offered pursuant to this section as an independent, noncoordinated benefit is not a health plan as defined in RCW 48.43.005.
[ 2020 c 231 s 3.]

catchline: School employees' benefits board—Employee-paid, voluntary benefits—Optional benefits.