title: RCW 48.20.550

text:
The commissioner shall adopt rules setting forth the content of a standard disclosure form to be provided to all applicants for individual, illness-triggered fixed payment insurance, hospital confinement fixed payment insurance, or other fixed payment insurance. The standard disclosure shall provide information regarding the level, type, and amount of benefits provided and the limitations, exclusions, and exceptions under the policy, as well as additional information to enhance consumer understanding. The disclosure shall specifically disclose that the coverage is not comprehensive in nature and will not cover the cost of most hospital and other medical services. Such disclosure form must be filed for approval with the commissioner prior to use. The standard disclosure forms must be provided at the time of solicitation and completion of the application form. All advertising and marketing materials other than the standard disclosure form must be filed with the commissioner at least thirty days prior to use.
[ 2007 c 296 s 2.]

catchline: Fixed payment insurance—Standard disclosure form.


doc_type: statute

jurisdiction: wa

title: RCW 48.20.555

text:
Illness-triggered fixed payment insurance, hospital confinement fixed payment insurance, or other fixed payment insurance policies are not considered to provide coverage for hospital or medical expenses under this chapter, if the benefits provided are a fixed dollar amount that is paid regardless of the amount charged. The benefits may not be related to, or be a percentage of, the amount charged by the provider of service and must be offered as an independent and noncoordinated benefit with any other health plan as defined in RCW 48.43.005(33).
[ 2025 c 58 s 2030; 2007 c 296 s 3.]
Notes:
Explanatory note—2025 c 58: See note following RCW 1.16.050.

license: public-domain-government-work

rule_set: Revised Code of Washington

catchline: Fixed payment insurance—Benefit restrictions.

code: rcw

unit: section

court: Washington State Legislature


title: RCW 48.20.580

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 insurance commissioner 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 insurer's medical director or designee determines the treatment to be medically necessary; and
(b) For a health benefit plan or a plan deemed by the commissioner to have a short-term limited purpose or duration, or to be a student-only health plan that is guaranteed renewable while the covered person is enrolled as a regular, full-time undergraduate student at an accredited higher education institution, 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 insurance commissioner by rule, consistent with the purposes of chapter 6, Laws of 2005.
(2) Each disability insurance contract providing 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 disability insurance contract. 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 disability insurance contract 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 disability insurance contract 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 disability insurance contract.
(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 services if a comparable benefit management requirement is applicable to medical and surgical services.
[ 2020 c 228 s 2; 2007 c 8 s 1.]
Notes:
Effective date—2007 c 8: "This act takes effect January 1, 2008." [ 2007 c 8 s 8.]

catchline: Mental health services—Definition—Coverage required, when. (Effective until January 1, 2027.)


title: RCW 48.20.900

text:
For the purposes of this chapter, the terms spouse, marriage, marital, husband, wife, widow, widower, next of kin, and family shall be interpreted as applying equally to state registered domestic partnerships or individuals in state registered domestic partnerships as well as to marital relationships and married persons, and references to dissolution of marriage shall apply equally to state registered domestic partnerships that have been terminated, dissolved, or invalidated, to the extent that such interpretation does not conflict with federal law. Where necessary to implement chapter 521, Laws of 2009, gender-specific terms such as husband and wife used in any statute, rule, or other law shall be construed to be gender neutral, and applicable to individuals in state registered domestic partnerships.
[ 2009 c 521 s 115.]

catchline: Construction—Chapter applicable to state registered domestic partnerships—2009 c 521.


title: RCW 48.200.010

text:
(1) The legislature finds that growth in managed health care systems has shifted substantial authority over health care decisions from providers and patients to health carriers and health care benefit managers. Health care benefit managers acting as intermediaries between carriers, health care providers, and patients exercise broad discretion to affect health care services recommended and delivered by providers and the health care choices of patients. Regularly, these health care benefit managers are making health care decisions on behalf of carriers. However, unlike carriers, health care benefit managers are not currently regulated.
(2) Therefore, the legislature finds that it is in the best interest of the public to create a separate chapter in this title for health care benefit managers.
(3) The legislature intends to protect and promote the health, safety, and welfare of Washington residents by establishing standards for regulatory oversight of health care benefit managers.
[ 2020 c 240 s 1.]

catchline: Findings—Intent.


title: RCW 48.200.020

text:
The definitions in this section apply throughout this chapter unless the context clearly requires otherwise.
(1) "Affiliate" or "affiliated employer" means a person who directly or indirectly through one or more intermediaries, controls or is controlled by, or is under common control with, another specified person.
(2) "Certification" has the same meaning as in RCW 48.43.005.
(3) "Covered person" has the same meaning as in RCW 48.43.005.
(4) "Employee benefits programs" means programs under both the public employees' benefits board established in RCW 41.05.055 and the school employees' benefits board established in RCW 41.05.740.
(5)(a) "Health care benefit manager" means a person or entity providing services to, or acting on behalf of, a health carrier or employee benefits programs, that directly or indirectly impacts the determination or utilization of benefits for, or patient access to, health care services, drugs, and supplies including, but not limited to:
(i) Prior authorization or preauthorization of benefits or care;
(ii) Certification of benefits or care;
(iii) Medical necessity determinations;
(iv) Utilization review;
(v) Benefit determinations;
(vi) Claims processing and repricing for services and procedures;
(vii) Outcome management;
(viii) Payment or authorization of payment to providers and facilities for services or procedures;
(ix) Dispute resolution, grievances, or appeals relating to determinations or utilization of benefits;
(x) Provider network management; or
(xi) Disease management.
(b) "Health care benefit manager" includes, but is not limited to, health care benefit managers that specialize in specific types of health care benefit management such as pharmacy benefit managers, radiology benefit managers, laboratory benefit managers, and mental health benefit managers.
(c) "Health care benefit manager" does not include:
(i) Health care service contractors as defined in RCW 48.44.010;
(ii) Health maintenance organizations as defined in RCW 48.46.020;
(iii) Issuers as defined in RCW 48.01.053;
(iv) The public employees' benefits board established in RCW 41.05.055;
(v) The school employees' benefits board established in RCW 41.05.740;
(vi) Discount plans as defined in RCW 48.155.010;
(vii) Direct patient-provider primary care practices as defined in RCW 48.150.010;
(viii) An employer administering its employee benefit plan or the employee benefit plan of an affiliated employer under common management and control;
(ix) A union, either on its own or jointly with an employer, administering a benefit plan on behalf of its members;
(x) An insurance producer selling insurance or engaged in related activities within the scope of the producer's license;
(xi) A creditor acting on behalf of its debtors with respect to insurance, covering a debt between the creditor and its debtors;
(xii) A behavioral health administrative services organization or other county-managed entity that has been approved by the state health care authority to perform delegated functions on behalf of a carrier;
(xiii) A hospital licensed under chapter 70.41 RCW or ambulatory surgical facility licensed under chapter 70.230 RCW, to the extent that it performs provider credentialing or recredentialing, but no other functions of a health care benefit manager as described in subsection (5)(a) of this section [(a) of this subsection];
(xiv) The Robert Bree collaborative under chapter 70.250 RCW;
(xv) The health technology clinical committee established under RCW 70.14.090;
(xvi) The prescription drug purchasing consortium established under RCW 70.14.060; or
(xvii) Any other entity that performs provider credentialing or recredentialing, but no other functions of a health care benefit manager as described in subsection (5)(a) of this section [(a) of this subsection].
(6) "Health care provider" or "provider" has the same meaning as in RCW 48.43.005.
(7) "Health care service" has the same meaning as in RCW 48.43.005.
(8) "Health carrier" or "carrier" has the same meaning as in RCW 48.43.005.
(9) "Laboratory benefit manager" means a person or entity providing service to, or acting on behalf of, a health carrier, employee benefits programs, or another entity under contract with a carrier, that directly or indirectly impacts the determination or utilization of benefits for, or patient access to, health care services, drugs, and supplies relating to the use of clinical laboratory services and includes any requirement for a health care provider to submit a notification of an order for such services.
(10) "Mail order pharmacy" means a pharmacy that primarily dispenses prescription drugs to patients through the mail or common carrier.
(11) "Mental health benefit manager" means a person or entity providing service to, or acting on behalf of, a health carrier, employee benefits programs, or another entity under contract with a carrier, that directly or indirectly impacts the determination of utilization of benefits for, or patient access to, health care services, drugs, and supplies relating to the use of mental health services and includes any requirement for a health care provider to submit a notification of an order for such services.
(12) "Network" means the group of participating providers, pharmacies, and suppliers providing health care services, drugs, or supplies to beneficiaries of a particular carrier or plan.
(13) "Person" includes, as applicable, natural persons, licensed health care providers, carriers, corporations, companies, trusts, unincorporated associations, and partnerships.
(14)(a) "Pharmacy benefit manager" means a person that contracts with pharmacies on behalf of a health carrier, employee benefits program, or medicaid managed care program to:
(i) Process claims for prescription drugs or medical supplies or provide retail network management for pharmacies or pharmacists;
(ii) Pay pharmacies or pharmacists for prescription drugs or medical supplies;
(iii) Negotiate rebates, discounts, or other price concessions with manufacturers for drugs paid for or procured as described in this subsection;
(iv) Establish or manage pharmacy networks; or
(v) Make credentialing determinations.
(b) "Pharmacy benefit manager" does not include a health care service contractor as defined in RCW 48.44.010.
(15) "Pharmacy network" means the pharmacies located in the state or licensed under chapter 18.64 RCW and contracted by a pharmacy benefit manager to dispense prescription drugs to covered persons.
(16)(a) "Radiology benefit manager" means any person or entity providing service to, or acting on behalf of, a health carrier, employee benefits programs, or another entity under contract with a carrier, that directly or indirectly impacts the determination or utilization of benefits for, or patient access to, the services of a licensed radiologist or to advanced diagnostic imaging services including, but not limited to:
(i) Processing claims for services and procedures performed by a licensed radiologist or advanced diagnostic imaging service provider; or
(ii) Providing payment or payment authorization to radiology clinics, radiologists, or advanced diagnostic imaging service providers for services or procedures.
(b) "Radiology benefit manager" does not include a health care service contractor as defined in RCW 48.44.010, a health maintenance organization as defined in RCW 48.46.020, or an issuer as defined in RCW 48.01.053.
(17) "Utilization review" has the same meaning as in RCW 48.43.005.
[ 2024 c 242 s 1; 2020 c 240 s 2.]
Notes:
Reviser's note: The definitions in this section have been alphabetized pursuant to RCW 1.08.015(2)(k).

catchline: Definitions.


title: RCW 48.200.030

text:
(1) To conduct business in this state, a health care benefit manager must register with the commissioner and annually renew the registration.
(2) To apply for registration with the commissioner under this section, a health care benefit manager must:
(a) Submit an application on forms and in a manner prescribed by the commissioner and verified by the applicant by affidavit or declaration under chapter 5.50 RCW. Applications must contain at least the following information:
(i) The identity of the health care benefit manager and of persons with any ownership or controlling interest in the applicant including relevant business licenses and tax identification numbers, and the identity of any entity that the health care benefit manager has a controlling interest in;
(ii) The business name, address, phone number, and contact person for the health care benefit manager;
(iii) Any areas of specialty such as pharmacy benefit management, radiology benefit management, laboratory benefit management, mental health benefit management, or other specialty;
(iv) A copy of the health care benefit manager's certificate of registration with the Washington state secretary of state; and
(v) Any other information as the commissioner may reasonably require.
(b) Pay an initial registration fee and annual renewal registration fee as established in rule by the commissioner. The fees for each registration must be set by the commissioner in an amount that ensures the registration, renewal, and oversight activities are self-supporting. If one health care benefit manager has a contract with more than one carrier, the health care benefit manager must complete only one application providing the details necessary for each contract.
(3) All receipts from fees collected by the commissioner under this section must be deposited into the insurance commissioner's regulatory account created in RCW 48.02.190.
(4) Before approving an application for or renewal of a registration, the commissioner must find that the health care benefit manager:
(a) Has not committed any act that would result in denial, suspension, or revocation of a registration;
(b) Has paid the required fees; and
(c) Has the capacity to comply with, and has designated a person responsible for, compliance with state and federal laws.
(5) Any material change in the information provided to obtain or renew a registration must be filed with the commissioner within thirty days of the change.
(6) Every registered health care benefit manager must retain a record of all transactions completed for a period of not less than seven years from the date of their creation. All such records as to any particular transaction must be kept available and open to inspection by the commissioner during the seven years after the date of completion of such transaction.
[ 2024 c 242 s 2; 2020 c 240 s 3.]

catchline: Registration requirements—Application—Fees—Retention of transaction records.


title: RCW 48.200.040

text:
(1) A health care benefit manager may not provide health care benefit management services to a health carrier or employee benefits programs without a written agreement describing the rights and responsibilities of the parties conforming to the provisions of this chapter and any rules adopted by the commissioner to implement or enforce this chapter including rules governing contract content.
(2) A health care benefit manager must file with the commissioner in the form and manner prescribed by the commissioner, every benefit management contract and contract amendment between the health care benefit manager and a health carrier, provider, pharmacy, pharmacy services administration organization, or other health care benefit manager, entered into directly or indirectly in support of a contract with a carrier or employee benefits programs, within 30 days following the effective date of the contract or contract amendment. Contracts and contract amendments between health care benefit managers and health carriers that were executed prior to July 23, 2023, and remain in force must be filed with the commissioner no later than 60 days following July 23, 2023.
(3) Contracts filed under this section are confidential and not subject to public inspection under RCW 48.02.120(2), or public disclosure under chapter 42.56 RCW, if filed in accordance with the procedures for submitting confidential filings through the system for electronic rate and form filings and the general filing instructions as set forth by the commissioner. In the event the referenced filing fails to comply with the filing instructions setting forth the process to withhold the contract from public inspection, and the health care benefit manager indicates that the contract is to be withheld from public inspection, the commissioner must reject the filing and notify the health care benefit manager through the system for electronic rate and form filings to amend its filing to comply with the confidentiality filing instructions.
[ 2023 c 107 s 1; 2020 c 240 s 4.]

catchline: Contract requirements—Written agreement describing rights and responsibilities—Filing of contracts—Confidentiality.


title: RCW 48.200.050

text:
(1) Upon notifying a carrier or health care benefit manager of an inquiry or complaint filed with the commissioner pertaining to the conduct of a health care benefit manager identified in the inquiry or complaint, the commissioner must provide notice of the inquiry or complaint to the health care benefit manager. Notice must also be sent to any carrier to which the inquiry or complaint pertains. The commissioner shall respond to and investigate complaints related to the conduct of a health care benefit manager subject to this chapter directly, without requiring that the complaint be pursued exclusively through a contracting carrier.
(2) Upon receipt of an inquiry from the commissioner, a health care benefit manager must provide to the commissioner within fifteen business days, in the form and manner required by the commissioner, a complete response to that inquiry including, but not limited to, providing a statement or testimony, producing its accounts, records, and files, responding to complaints, or responding to surveys and general requests. Failure to make a complete or timely response constitutes a violation of this chapter.
(3) Subject to chapter 48.04 RCW, if the commissioner finds that a health care benefit manager or any person responsible for the conduct of the health care benefit manager's affairs has:
(a) Violated any provision of this chapter or insurance law, or violated any rule, subpoena, or order of the commissioner or of another state's insurance commissioner;
(b) Failed to renew the health care benefit manager's registration;
(c) Failed to pay the registration or renewal fees;
(d) Provided incorrect, misleading, incomplete, or materially untrue information to the commissioner, to a carrier, or to a beneficiary;
(e) Used fraudulent, coercive, or dishonest practices, or demonstrated incompetence, or financial irresponsibility in this state or elsewhere; or
(f) Had a health care benefit manager registration, or its equivalent, denied, suspended, or revoked in any other state, province, district, or territory;
the commissioner may take any combination of the following actions against a health care benefit manager or any person responsible for the conduct of the health care benefit manager's affairs, other than an employee benefits program:
(i) Place on probation, suspend, revoke, or refuse to issue or renew the health care benefit manager's registration;
(ii) Issue a cease and desist order against the health care benefit manager, contracting carrier, or both;
(iii) Fine the health care benefit manager up to five thousand dollars per violation, and the contracting carrier is subject to a fine for acts conducted under the contract;
(iv) Issue an order requiring corrective action against the health care benefit manager, the contracting carrier acting with the health care benefit manager, or both the health care benefit manager and the contracting carrier acting with the health care benefit manager; and
(v) Temporarily suspend the health care benefit manager's registration by an order served by mail or by personal service upon the health care benefit manager not less than three days prior to the suspension effective date. The order must contain a notice of revocation and include a finding that the public safety or welfare requires emergency action. A temporary suspension under this subsection (3)(f)(v) continues until proceedings for revocation are concluded.
(4) A stay of action is not available for actions the commissioner takes by cease and desist order, by order on hearing, or by temporary suspension.
(5)(a) Health carriers and employee benefits programs are responsible for the compliance of any person or organization acting directly or indirectly on behalf of or at the direction of the carrier or program, or acting pursuant to carrier or program standards or requirements concerning the coverage of, payment for, or provision of health care benefits, services, drugs, and supplies.
(b) A carrier or program contracting with a health care benefit manager is responsible for the health care benefit manager's violations of this chapter, including a health care benefit manager's failure to produce records requested or required by the commissioner.
(c) No carrier or program may offer as a defense to a violation of any provision of this chapter that the violation arose from the act or omission of a health care benefit manager, or other person acting on behalf of or at the direction of the carrier or program, rather than from the direct act or omission of the carrier or program.
[ 2024 c 242 s 3; 2020 c 240 s 5.]

catchline: Inquiries or complaints—Violations of chapter—Enforcement actions—Responsibility of carriers and programs for compliance.


title: RCW 48.200.210

text:
The definitions in this section apply throughout this section and RCW 48.200.220 through 48.200.290 unless the context clearly requires otherwise.
(1) "Audit" means an on-site or remote review of the records of a pharmacy by or on behalf of an entity.
(2) "Claim" means a request from a pharmacy or pharmacist to be reimbursed for the cost of filling or refilling a prescription for a drug or for providing a medical supply or service.
(3) "Clerical error" means a minor error:
(a) In the keeping, recording, or transcribing of records or documents or in the handling of electronic or hard copies of correspondence;
(b) That does not result in financial harm to an entity; and
(c) That does not involve dispensing an incorrect dose, amount, or type of medication, failing to dispense a medication, or dispensing a prescription drug to the wrong person.
(4) "Entity" includes:
(a) A pharmacy benefit manager;
(b) An insurer;
(c) A third-party payor;
(d) A state agency; or
(e) A person that represents or is employed by one of the entities described in this subsection.
(5) "Fraud" means knowingly and willfully executing or attempting to execute a scheme, in connection with the delivery of or payment for health care benefits, items, or services, that uses false or misleading pretenses, representations, or promises to obtain any money or property owned by or under the custody or control of any person.
(6) "Pharmacist" has the same meaning as in RCW 18.64.011.
(7) "Pharmacy" has the same meaning as in RCW 18.64.011.
(8) "Third-party payor" means a person licensed under RCW 48.39.005.
[ 2024 c 242 s 4; 2020 c 240 s 10; 2014 c 213 s 3. Formerly RCW 19.340.020.]

catchline: Definitions applicable to RCW 48.200.220 through 48.200.290.


title: RCW 48.200.220

text:
An entity that audits claims or an independent third party that contracts with an entity to audit claims:
(1) Must establish, in writing, a procedure for a pharmacy to appeal the entity's findings with respect to a claim and must provide a pharmacy with a notice regarding the procedure, in writing or electronically, prior to conducting an audit of the pharmacy's claims;
(2) May not conduct an audit of a claim more than twenty-four months after the date the claim was adjudicated by the entity;
(3) Must give at least fifteen days' advance written notice of an on-site audit to the pharmacy or corporate headquarters of the pharmacy;
(4) May not conduct an on-site audit during the first five days of any month without the pharmacy's consent;
(5) Must conduct the audit in consultation with a pharmacist who is licensed by this or another state if the audit involves clinical or professional judgment;
(6) May not conduct an on-site audit of more than two hundred fifty unique prescriptions of a pharmacy in any twelve-month period except in cases of alleged fraud;
(7) May not conduct more than one on-site audit of a pharmacy in any twelve-month period;
(8) Must audit each pharmacy under the same standards and parameters that the entity uses to audit other similarly situated pharmacies;
(9) Must pay any outstanding claims of a pharmacy no more than forty-five days after the earlier of the date all appeals are concluded or the date a final report is issued under RCW 48.200.260(3);
(10) May not include dispensing fees or interest in the amount of any overpayment assessed on a claim unless the overpaid claim was for a prescription that was not filled correctly;
(11) May not recoup costs associated with:
(a) Clerical errors; or
(b) Other errors that do not result in financial harm to the entity or a consumer; and
(12) May not charge a pharmacy for a denied or disputed claim until the audit and the appeals procedure established under subsection (1) of this section are final.
[ 2020 c 240 s 11; 2014 c 213 s 4. Formerly RCW 19.340.040.]

catchline: Auditing of claims—Requirements—Prohibited practices.


title: RCW 48.200.230

text:
An entity's finding that a claim was incorrectly presented or paid must be based on identified transactions and not based on probability sampling, extrapolation, or other means that project an error using the number of patients served who have a similar diagnosis or the number of similar prescriptions or refills for similar drugs.
[ 2014 c 213 s 5. Formerly RCW 19.340.050.]

catchline: Basis of finding of claim.


title: RCW 48.200.240

text:
An entity that contracts with an independent third party to conduct audits may not:
(1) Agree to compensate the independent third party based on a percentage of the amount of overpayments recovered; or
(2) Disclose information obtained during an audit except to the contracting entity, the pharmacy subject to the audit, or the holder of the policy or certificate of insurance that paid the claim.
[ 2014 c 213 s 6. Formerly RCW 19.340.060.]

catchline: Contract with third party—Prohibited practices.


title: RCW 48.200.250

text:
For purposes of RCW 48.200.210 through 48.200.270, an entity, or an independent third party that contracts with an entity to conduct audits, must allow as evidence of validation of a claim:
(1) An electronic or physical copy of a valid prescription if the prescribed drug was, within fourteen days of the dispensing date:
(a) Picked up by the patient or the patient's designee;
(b) Delivered by the pharmacy to the patient; or
(c) Sent by the pharmacy to the patient using the United States postal service or other common carrier;
(2) Point of sale electronic register data showing purchase of the prescribed drug, medical supply, or service by the patient or the patient's designee; or
(3) Electronic records, including electronic beneficiary signature logs, electronically scanned and stored patient records maintained at or accessible to the audited pharmacy's central operations, and any other reasonably clear and accurate electronic documentation that corresponds to a claim.
[ 2020 c 240 s 12; 2014 c 213 s 7. Formerly RCW 19.340.070.]

catchline: Evidence of validation of claim.


title: RCW 48.200.260

text:
(1)(a) After conducting an audit, an entity must provide the pharmacy that is the subject of the audit with a preliminary report of the audit. The preliminary report must be received by the pharmacy no later than forty-five days after the date on which the audit was completed and must be sent:
(i) By mail or common carrier with a return receipt requested; or
(ii) Electronically with electronic receipt confirmation.
(b) An entity shall provide a pharmacy receiving a preliminary report under this subsection no fewer than forty-five days after receiving the report to contest the report or any findings in the report in accordance with the appeals procedure established under RCW 48.200.220(1) and must allow the submission of additional documentation in support of the claim. The entity shall consider a reasonable request for an extension of time to submit documentation to contest the report or any findings in the report.
(2) If an audit results in the dispute or denial of a claim, the entity conducting the audit shall allow the pharmacy to resubmit the claim using any commercially reasonable method, including facsimile, mail, or email.
(3) An entity must provide a pharmacy that is the subject of an audit with a final report of the audit no later than sixty days after the later of the date the preliminary report was received or the date the pharmacy contested the report using the appeals procedure established under RCW 48.200.220(1). The final report must include a final accounting of all moneys to be recovered by the entity.
(4) Recoupment of disputed funds from a pharmacy by an entity or repayment of funds to an entity by a pharmacy, unless otherwise agreed to by the entity and the pharmacy, shall occur after the audit and the appeals procedure established under RCW 48.200.220(1) are final. If the identified discrepancy for an individual audit exceeds forty thousand dollars, any future payments to the pharmacy may be withheld by the entity until the audit and the appeals procedure established under RCW 48.200.220(1) are final.
[ 2020 c 240 s 13; 2014 c 213 s 8. Formerly RCW 19.340.080.]

catchline: Preliminary audit report—Dispute or denial of claim—Final audit report—Recoupment of disputed funds.


title: RCW 48.200.270

text:
RCW 48.200.210 through 48.200.270 do not:
(1) Preclude an entity from instituting an action for fraud against a pharmacy;
(2) Apply to an audit of pharmacy records when fraud or other intentional and willful misrepresentation is indicated by physical review, review of claims data or statements, or other investigative methods; or
(3) Apply to a state agency that is conducting audits or a person that has contracted with a state agency to conduct audits of pharmacy records for prescription drugs paid for by the state medical assistance program.
[ 2020 c 240 s 14; 2014 c 213 s 9. Formerly RCW 19.340.090.]

catchline: Application.


title: RCW 48.200.280

text:
(1) The definitions in this subsection apply throughout this section unless the context clearly requires otherwise.
(a) "List" means the list of drugs for which reimbursement costs have been established to determine reimbursement amounts.
(b) "Multiple source drug" means any covered outpatient prescription drug for which there is at least one other drug product that is rated as therapeutically equivalent under the food and drug administration's most recent publication of "Approved Drug Products with Therapeutic Equivalence Evaluations"; is pharmaceutically equivalent or bioequivalent, as determined by the food and drug administration; and is sold or marketed in the state.
(c) "Network pharmacy" means a retail drug outlet licensed as a pharmacy under RCW 18.64.043 that contracts with a pharmacy benefit manager.
(d) "Therapeutically equivalent" has the same meaning as in RCW 69.41.110.
(2) A pharmacy benefit manager:
(a) May not place a drug on a list unless there are at least two therapeutically equivalent multiple source drugs, or at least one generic drug available from only one manufacturer, generally available for purchase by network pharmacies from national or regional wholesalers;
(b) Shall ensure that all drugs on a list are readily available for purchase by pharmacies in this state from national or regional wholesalers that serve pharmacies in Washington;
(c) Shall ensure that all drugs on a list are not obsolete;
(d) Shall make available to each network pharmacy at the beginning of the term of a contract, and upon renewal of a contract, the sources utilized to determine the reimbursement costs for multiple source drugs of the pharmacy benefit manager;
(e) Shall make a list available to a network pharmacy upon request in a format that is readily accessible to and usable by the network pharmacy;
(f) Shall update each list maintained by the pharmacy benefit manager every seven business days and make the updated lists, including all changes in the price of drugs, available to network pharmacies in a readily accessible and usable format;
(g) Shall ensure that dispensing fees are not included in the calculation of the reimbursement costs for multiple source drugs;
(h) May not cause or knowingly permit the use of any advertisement, promotion, solicitation, representation, proposal, or offer that is untrue, deceptive, or misleading;
(i) May not charge a pharmacy a fee related to the adjudication of a claim, credentialing, participation, certification, accreditation, or enrollment in a network including, but not limited to, a fee for the receipt and processing of a pharmacy claim, for the development or management of claims processing services in a pharmacy benefit manager network, or for participating in a pharmacy benefit manager network, and may not condition or link restrictions on fees related to credentialing, participation, certification, or enrollment in a pharmacy benefit manager's pharmacy network with a pharmacy's inclusion in the pharmacy benefit manager's pharmacy network for other lines of business;
(j) May not require accreditation standards inconsistent with or more stringent than accreditation standards established by a national accreditation organization;
(k) May not reimburse a pharmacy in the state an amount less than the amount the pharmacy benefit manager reimburses an affiliate for providing the same pharmacy services;
(l) May not directly or indirectly retroactively deny or reduce a claim or aggregate of claims after the claim or aggregate of claims has been adjudicated, unless:
(i) The original claim was submitted fraudulently; or
(ii) The denial or reduction is the result of a pharmacy audit conducted in accordance with RCW 48.200.220; and
(m) May not exclude a pharmacy from their pharmacy network based solely on the pharmacy being newly opened or open less than a defined amount of time, or because a license or location transfer occurs, unless there is a pending investigation for fraud, waste, and abuse.
(3) A pharmacy benefit manager must establish a process by which a network pharmacy, or its representative, may appeal its reimbursement for a drug. A network pharmacy may appeal a reimbursement amount paid by a pharmacy benefit manager for a drug if the reimbursement for the drug is less than the net amount that the network pharmacy paid to the supplier of the drug. An appeal requested under this section must be completed within thirty calendar days of the pharmacy submitting the appeal. If after thirty days the network pharmacy has not received the decision on the appeal from the pharmacy benefit manager, then the appeal is considered denied.
The pharmacy benefit manager shall uphold the appeal of a pharmacy with fewer than fifteen retail outlets, within the state of Washington, under its corporate umbrella if the pharmacy or pharmacist can demonstrate that it is unable to purchase a therapeutically equivalent interchangeable product from a supplier doing business in Washington at the pharmacy benefit manager's list price.
(4) Before a pharmacy or pharmacist files an appeal pursuant to this section, upon request by a pharmacy or pharmacist, a pharmacy benefit manager must provide a current and accurate list of bank identification numbers, processor control numbers, and pharmacy group identifiers for health plans and self-funded group health plans that have opted in to this section and RCW 48.200.310 and 48.200.320 pursuant to RCW 48.200.330 with which the pharmacy benefit manager either has a current contract or had a contract that has been terminated within the past 12 months to provide pharmacy benefit management services.
(5) A pharmacy benefit manager must provide as part of the appeals process established under subsection (3) of this section:
(a) A telephone number at which a network pharmacy may contact the pharmacy benefit manager and speak with an individual who is responsible for processing appeals; and
(b) If the appeal is denied, the reason for the denial and the national drug code of a drug that has been purchased by other network pharmacies located in Washington at a price that is equal to or less than the reimbursement amount paid by the pharmacy benefit manager for the drug. A pharmacy with 15 or more retail outlets, within the state of Washington, under its corporate umbrella may submit information to the commissioner about an appeal under subsection (3) of this section for purposes of information collection and analysis.
(6)(a) If an appeal is upheld under this section, the pharmacy benefit manager shall make a reasonable adjustment on a date no later than one day after the date of determination.
(b) If the request for an adjustment has come from a critical access pharmacy, as defined by the state health care authority by rule for purposes related to the prescription drug purchasing consortium established under RCW 70.14.060, the adjustment approved under (a) of this subsection shall apply only to critical access pharmacies.
(7) Beginning July 1, 2017, if a network pharmacy appeal to the pharmacy benefit manager is denied, or if the network pharmacy is unsatisfied with the outcome of the appeal, the pharmacy or pharmacist may dispute the decision and request review by the commissioner within thirty calendar days of receiving the decision.
(a) All relevant information from the parties may be presented to the commissioner, and the commissioner may enter an order directing the pharmacy benefit manager to make an adjustment to the disputed claim, deny the pharmacy appeal, or take other actions deemed fair and equitable. An appeal requested under this section must be completed within thirty calendar days of the request.
(b) Upon resolution of the dispute, the commissioner shall provide a copy of the decision to both parties within seven calendar days.
(c) The commissioner may authorize the office of administrative hearings, as provided in chapter 34.12 RCW, to conduct appeals under this subsection (7).
(d) A pharmacy benefit manager may not retaliate against a pharmacy for pursuing an appeal under this subsection (7).
(e) This subsection (7) applies only to a pharmacy with fewer than fifteen retail outlets, within the state of Washington, under its corporate umbrella.
(8) This section does not apply to the state medical assistance program.
[ 2024 c 242 s 5; 2020 c 240 s 15; 2016 c 210 s 4; 2014 c 213 s 10. Formerly RCW 19.340.100.]
Notes:
Effective date—2024 c 242 ss 5 and 7-9: "Sections 5 and 7 through 9 of this act take effect January 1, 2026." [ 2024 c 242 s 12.]

catchline: Predetermination of reimbursement costs—Appeals—Review by commissioner.


title: RCW 48.200.290

text:
(1) The commissioner shall have enforcement authority over this chapter and shall have authority to render a binding decision in any dispute between a pharmacy benefit manager, or third-party administrator of prescription drug benefits, and a pharmacy arising out of an appeal under *RCW 48.200.280(6) regarding drug pricing and reimbursement.
(2) Any person, corporation, third-party administrator of prescription drug benefits, pharmacy benefit manager, or business entity which violates any provision of this chapter shall be subject to a civil penalty in the amount of one thousand dollars for each act in violation of this chapter or, if the violation was knowing and willful, a civil penalty of five thousand dollars for each violation of this chapter.
[ 2020 c 240 s 16; 2016 c 210 s 2. Formerly RCW 19.340.110.]
Notes:
*Reviser's note: RCW 48.200.280 was amended by 2024 c 242 s 5, changing subsection (6) to subsection (7), effective January 1, 2026.

catchline: Enforcement—Disputes—Civil penalties.


title: RCW 48.200.300

text:
(1) Each health care benefit manager must appoint the commissioner as its attorney to receive service of, and upon whom must be served, all legal process issued against it in this state for causes of action arising within this state. Service upon the commissioner as attorney constitutes service upon the health care benefit manager. Service of legal process against the health care benefit manager can be had only by service upon the commissioner, except actions upon contractor bonds pursuant to RCW 18.27.040, where service may be upon the department of labor and industries.
(2) With the appointment the health care benefit manager must designate by name, email address, and address the person to whom the commissioner must forward legal process so served upon them. The health care benefit manager may change the person by filing a new designation.
(3) The health care benefit manager must keep the designation, address, and email address filed with the commissioner current.
(4) The appointment of the commissioner as attorney is irrevocable, binds any successor in interest or to the assets or liabilities of the health care benefit manager, and remains in effect as long as there is in force in this state any contract made by the health care benefit manager or liabilities or duties arising therefrom.
(5) The service of process must be accomplished and processed in the manner prescribed under RCW 48.02.200.
[ 2024 c 242 s 6.]

catchline: Service of process.


title: RCW 48.200.310

text:
(1) A pharmacy benefit manager may not:
(a) Reimburse a network pharmacy an amount less than the contract price between the pharmacy benefit manager and the insurer, third-party payor, or the prescription drug purchasing consortium the pharmacy benefit manager has contracted with;
(b) Require a covered person to pay more at the point of sale for a covered prescription drug than is required under RCW 48.43.430; or
(c) Require or coerce a patient to use their owned or affiliated pharmacies.
(2) A pharmacy benefit manager shall:
(a) Apply the same utilization review, fees, days allowance, and other conditions upon a covered person when the covered person obtains a prescription drug from a pharmacy that is included in the pharmacy benefit manager's pharmacy network, including mail order pharmacies;
(b) Permit the covered person to receive delivery or mail order of a prescription drug through any network pharmacy that is not primarily engaged in dispensing prescription drugs to patients through the mail or common carrier; and
(c) For new prescriptions issued after January 1, 2026, receive affirmative authorization from a covered person before filling prescriptions through a mail order pharmacy.
(3) If a covered person is using a mail order pharmacy, the pharmacy benefit manager shall:
(a) Allow for dispensing at local network pharmacies under the following circumstances to ensure patient access to prescription drugs:
(i) If the prescription is delayed more than one day after the expected delivery date provided by the mail order pharmacy; or
(ii) If the prescription drug arrives in an unusable condition; and
(b) Ensure patients have easy and timely access to prescription counseling by a pharmacist.
[ 2024 c 242 s 7.]
Notes:
Effective date—2024 c 242 ss 5 and 7-9: See note following RCW 48.200.280.

catchline: Prohibitions and duties.


title: RCW 48.200.320

text:
(1) A pharmacy benefit manager may not retaliate against a pharmacist or pharmacy for disclosing information in a court, in an administrative hearing, or legislative hearing, if the pharmacist or pharmacy has a good faith belief that the disclosed information is evidence of a violation of a state or federal law, rule, or regulation.
(2) A pharmacy benefit manager may not retaliate against a pharmacist or pharmacy for disclosing information to a government or law enforcement agency, if the pharmacist or pharmacy has a good faith belief that the disclosed information is evidence of a violation of a state or federal law, rule, or regulation.
(3) A pharmacist or pharmacy shall make reasonable efforts to limit the disclosure of confidential and proprietary information.
(4) Retaliatory actions against a pharmacy or pharmacist include cancellation of, restriction of, or refusal to renew or offer a contract to a pharmacy solely because the pharmacy or pharmacist has:
(a) Made disclosures of information that the pharmacist or pharmacy believes is evidence of a violation of a state or federal law, rule, or regulation;
(b) Filed complaints with the plan or pharmacy benefit manager; or
(c) Filed complaints against the plan or pharmacy benefit manager with the commissioner.
[ 2024 c 242 s 8.]
Notes:
Effective date—2024 c 242 ss 5 and 7-9: See note following RCW 48.200.280.

catchline: Prohibitions on retaliation.


title: RCW 48.200.330

text:
(1) Nothing in chapter 242, Laws of 2024 expands or restricts the entities subject to this chapter. Therefore, except as provided in subsection (2) of this section, this chapter continues to be inapplicable to a person or entity providing services to, or acting on behalf of, a union or employer administering a self-funded group health plan governed by the provisions of the federal employee retirement income security act of 1974 (29 U.S.C. Sec. 1001 et seq.).
(2) RCW 48.200.280, 48.200.310, and 48.200.320 apply to a pharmacy benefit manager's conduct pursuant to a contract with a self-funded group health plan governed by the provisions of the federal employee retirement income security act of 1974 (29 U.S.C. Sec. 1001 et seq.) only if the self-funded group health plan elects to participate in RCW 48.200.280, 48.200.310, and 48.200.320. To elect to participate in these provisions, a self-funded group health plan or its administrator shall provide notice, on a periodic basis, to the commissioner in a manner and by a date prescribed by the commissioner, attesting to the plan's participation and agreeing to be bound by RCW 48.200.280, 48.200.310, and 48.200.320. A self-funded group health plan or its administrator that elects to participate under this section, and any pharmacy benefit manager it contracts with, shall comply with RCW 48.200.280, 48.200.310, and 48.200.320.
(3) The commissioner does not have enforcement authority related to a pharmacy benefit manager's conduct pursuant to a contract with a self-funded group health plan governed by the federal employee retirement income security act of 1974, 29 U.S.C. Sec. 1001 et seq., that elects to participate in RCW 48.200.280, 48.200.310, and 48.200.320.
[ 2024 c 242 s 9.]
Notes:
Effective date—2024 c 242 ss 5 and 7-9: See note following RCW 48.200.280.

catchline: Application—Plans governed by the federal employee retirement income security act.


title: RCW 48.200.900

text:
The insurance commissioner may adopt any rules necessary to implement this act.
[ 2020 c 240 s 20.]

catchline: Rule making—2020 c 240.


title: RCW 48.200.901

text:
Sections 1 through 19 of this act take effect January 1, 2022.
[ 2020 c 240 s 23.]

catchline: Effective date—2020 c 240.


title: RCW 48.201.010

text:
The legislature finds that creating a framework for Washington private entities and public institutions of higher education to manage their risks through captive insurers will facilitate the growth and safety of those entities and protect the public interest. The legislature further finds that captive insurance promotes prudent risk management and provides access to insurance and reinsurance markets that may not be available to these Washington entities otherwise. The legislature believes that encouraging the use of captive insurance will support those who rely upon the strength and stability of employers in this state.
The legislature does not intend by chapter 281, Laws of 2021 to make Washington a captive domicile state. Rather, the legislature is establishing a framework for registration by captive insurers that insure Washington-based entities and are licensed by the jurisdictions in which they are domiciled.
[ 2021 c 281 s 1.]
Notes:
Effective date—2021 c 281: "This act is necessary for the immediate preservation of the public peace, health, or safety, or support of the state government and its existing public institutions, and takes effect immediately [May 12, 2021]." [ 2021 c 281 s 15.]

catchline: Findings—Intent—2021 c 281.


title: RCW 48.201.020

text:
The definitions in this section apply throughout this chapter unless the context clearly requires otherwise.
(1) "Affiliate" means an entity directly or indirectly controlling, controlled by, or under common control with another entity, such as a parent or a subsidiary corporation. "Affiliate" also means any person that holds an insured interest because that person has or had an employment or sales contract with an insured person.
(2) "Captive owner" means one of the following:
(a) An entity that is organized under Title 23B, 24, or 25 RCW, or analogous provisions of the law of another state or territory;
(b) A public institution of higher education; or
(c) A municipal corporation organized under Title 54 RCW.
(3) "Casualty insurance" has the same meaning as "general casualty insurance" as defined in RCW 48.11.070.
(4) "Control" means possession of the power to direct the management and policies of an entity through ownership of voting securities, by contract, or otherwise.
(5) "Eligible captive insurer" means an insurance company with the following characteristics:
(a) It is wholly or partially owned by a captive owner or, by contract, the captive owner is a participant or member of the insurance company;
(b) It insures risks of the captive owner, the captive owner's other affiliates, or both;
(c) One or more of its insureds have their principal place of business in Washington;
(d) It has assets that exceed its liabilities by at least $1,000,000 and has the ability to pay its debts as they come due, both as verified by audited financial statements prepared by an independent certified accountant; and
(e) It is licensed as a captive insurer by the jurisdiction in which it is domiciled.
(6) "Property insurance" has the same meaning as in RCW 48.11.040.
(7) "Public institution of higher education" means an institution of higher education as defined in RCW 28B.10.016.
[ 2025 c 53 s 3; 2021 c 281 s 2.]
Notes:
Effective date—2021 c 281: See note following RCW 48.201.010.

catchline: Definitions.


title: RCW 48.201.030

text:
(1) Within 120 days after May 12, 2021, or, if later, within 120 days after first issuing a policy that covers Washington risks, an entity acting as an eligible captive insurer must register with the commissioner.
(2) The commissioner will approve an eligible captive insurer's registration if the commissioner determines that the eligible captive insurer has sufficiently demonstrated:
(a)(i) That its assets exceed its liabilities by at least $1,000,000 and it has the ability to pay its debts as they come due, both as verified by audited financial statements prepared by an independent certified accountant; and
(ii) That it is in good standing in its jurisdiction of domicile; and
(b) The eligible captive insurer has paid a fee of $2,500.
(3) The commissioner may request additional documentation and information if needed to show that these requirements have been met.
(4) The commissioner may deny registration for any eligible captive insurer that fails to meet the requirements in subsections (2) and (3) of this section.
(5) A registered captive insurer may renew its certificate of registration for successive periods of 12 months each by, for each period, meeting the requirements of subsections (2)(a) and (3) of this section and paying a renewal fee in an amount set by the commissioner not to exceed $2,500.
(6) A registered eligible captive insurer may provide only property and casualty insurance and may provide such insurance to a captive owner, to the captive owner's other affiliates, or both. A registered eligible captive insurer may assume risks from other insurers as a reinsurer without regard to the limitations in the preceding sentence.
(7) A registered eligible captive insurer may insure risks of its affiliates and obtain or provide reinsurance for ceded or assumed risks insured in this state or elsewhere.
[ 2021 c 281 s 3.]
Notes:
Effective date—2021 c 281: See note following RCW 48.201.010.

catchline: Eligible captive insurer—Registration.


title: RCW 48.201.040

text:
(1) On or before the first day of March of each year, a registered eligible captive insurer must remit to the state treasurer through the commissioner a tax in the amount of two percent of the premiums, exclusive of returned premiums and sums collected to cover federal and state taxes and examination fees, for insurance directly procured by and provided to its parent or another affiliate for Washington risks during the preceding calendar year. The tax when collected must be credited to the general fund.
(2) For the purposes of this section, "Washington risks" means the share of risk covered by the premiums that is allocable to this state, based on where the underlying risks are located or where the losses or injuries giving rise to covered claims arise. A registered eligible captive insurer may use any reasonable method of determining such an allocation, including actuarial analysis or use of a proxy such as sales, property value, or payroll. Whether paid directly or by reimbursement, neither the timing nor the nature of a captive insurer's payment may be deemed to reflect, create, or constitute Washington risks.
(3) The registered eligible captive insurer must share its methodology and relevant analysis in determining its allocation with the commissioner.
(4) A registered eligible captive insurer is not liable for premium tax on moneys received as a reinsurer or on insurance placed through a surplus lines [line] broker or other intermediary that collects and remits premium tax.
(5) If a registered eligible captive insurer fails to remit the tax provided by this section by the last day of the month in which the tax becomes due, the registered eligible captive insurer must pay the tax and the penalties and interest provided in RCW 48.14.060. The tax may be collected by distraint, or the tax and fine may be recovered by an action instituted by the commissioner in any court of competent jurisdiction. Any fine collected by the commissioner must be paid to the state treasurer and credited to the general fund.
(6) Taxes on premiums are due under this section from an eligible captive insurer for any period after January 1, 2011, if not previously remitted to the commissioner, and further provided that all such taxes must be limited to an eligible captive insurer's Washington risks. Taxes due under this subsection for periods before July 1, 2021, are not subject to the penalties or interest provided in RCW 48.14.060. For periods beginning July 1, 2021, a registered eligible captive insurer is subject to the sanctions in subsection (5) of this section.
(7) Taxes on premiums may not be imposed on or collected from an eligible captive insurer affiliated with a public institution of higher education.
[ 2021 c 281 s 4.]
Notes:
Effective date—2021 c 281: See note following RCW 48.201.010.

catchline: Tax on premiums—Remittance.


title: RCW 48.201.050

text:
(1) The commissioner is authorized to make use of any of the powers established under Title 48 RCW to enforce the laws of this state. This includes, but is not limited to, the commissioner's administrative authority to investigate, issue subpoenas, conduct depositions and hearings, issue orders, impose penalties, and seek injunctive relief. With regard to any investigation, administrative proceedings, or litigation, the commissioner can rely on the procedural law and regulations of the state. An eligible captive insurer that violates any provision of this chapter after its effective date will be subject to the fines and penalties applicable to authorized insurers generally, including revocation of its registration, suspension of registration, and refusal to renew registration.
(2) An eligible captive insurer that fails to register under chapter 281, Laws of 2021 is acting as an unlawful, unauthorized insurer and is subject to the fines and penalties applicable to unlawful, unauthorized insurers generally.
[ 2021 c 281 s 5.]
Notes:
Effective date—2021 c 281: See note following RCW 48.201.010.

catchline: Commissioner's enforcement authority.


title: RCW 48.201.060

text:
The commissioner may adopt rules as necessary to implement chapter 281, Laws of 2021.
[ 2021 c 281 s 6.]
Notes:
Effective date—2021 c 281: See note following RCW 48.201.010.

catchline: Commissioner's rule-making authority.


title: RCW 48.205.010

text:
(1) The requirements of this chapter shall apply to pet insurance policies that are issued to any resident of this state, are sold, solicited, negotiated, or offered in this state, and policies or certificates that are delivered or issued for delivery in this state.
(2) All other applicable provisions of this state's insurance laws continue to apply to pet insurance except that the specific provisions of this chapter shall supersede any general provisions of law that would otherwise be applicable to pet insurance.
[ 2023 c 42 s 1.]
Notes:
Effective date—2023 c 42: "This act takes effect January 1, 2024." [ 2023 c 42 s 10.]


title: RCW 48.205.020

text:
The definitions in this section apply throughout this chapter unless the context clearly requires otherwise.
(1) "Chronic condition" means a condition that can be treated or managed, but not cured.
(2) "Congenital anomaly" and "congenital disorder" mean a condition that is present from birth, whether inherited or caused by the environment, which may cause or contribute to illness or disease.
(3) "Hereditary disorder" means an abnormality that is genetically transmitted from parent to offspring and may cause illness or disease.
(4) "Orthopedic" refers to conditions affecting the bones, skeletal muscle, cartilage, tendons, ligaments, and joints. "Orthopedic" includes, but is not limited to, elbow dysplasia, hip dysplasia, intervertebral disc degeneration, patellar luxation, and ruptured cranial cruciate ligaments. It does not include cancers or metabolic, hemopoietic, or autoimmune diseases.
(5) "Pet insurance" means a property insurance policy that provides coverage for accidents and illnesses of pets.
(6)(a) "Preexisting condition" means any condition for which any of the following are true prior to the effective date of a pet insurance policy or during any waiting period:
(i) A veterinarian provided medical advice;
(ii) The pet received previous treatment; or
(iii) Based on information from verifiable sources, the pet had signs or symptoms directly related to the condition for which a claim is being made.
(b) A condition for which coverage is afforded on a policy cannot be considered a preexisting condition on any renewal of the policy.
(7) "Renewal" means to issue and deliver at the end of an insurance policy period a policy which supersedes a policy previously issued and delivered by the same pet insurer or affiliated pet insurer and which provides types and limits of coverage substantially similar to those contained in the policy being superseded.
(8) "Veterinarian" means an individual who holds a valid license to practice veterinary medicine from the appropriate licensing entity in the jurisdiction in which he or she practices.
(9) "Veterinary expenses" means the costs associated with medical advice, diagnosis, care, or treatment provided by a veterinarian including, but not limited to, the cost of drugs prescribed by a veterinarian.
(10) "Waiting period" means the period of time specified in a pet insurance policy that is required to transpire before some or all of the coverage in the policy can begin.
(11) "Wellness program" means a subscription or reimbursement-based program that is separate from an insurance policy that provides goods and services to promote the general health, safety, or well-being of the pet.
[ 2023 c 42 s 2.]
Notes:
Effective date—2023 c 42: See note following RCW 48.205.010.


title: RCW 48.205.030

text:
(1) If a pet insurer uses any of the terms in RCW 48.205.020 in a policy of pet insurance, the pet insurer shall use the definition of each of those terms as set forth in RCW 48.205.020 and include the definition of the terms in the policy. The pet insurer shall also make the definition available through a clear and conspicuous link on the main page of either the pet insurer's website or the pet insurer's program administrator's website, or both.
(2) Nothing in RCW 48.205.020 shall in any way prohibit or limit the types of exclusions pet insurers may use in their policies or require pet insurers to have any of the limitations or exclusions in this chapter.
[ 2023 c 42 s 3.]
Notes:
Effective date—2023 c 42: See note following RCW 48.205.010.

catchline: Definitions—Usage.


title: RCW 48.205.040

text:
(1) A pet insurer transacting pet insurance shall disclose the following to consumers:
(a) If the policy excludes coverage due to any of the following:
(i) A preexisting condition;
(ii) A hereditary disorder;
(iii) Either a congenital anomaly or a congenital disorder, or both; or
(iv) A chronic condition;
(b) If the policy includes any other exclusions, the following statement: "Other exclusions may apply. Please refer to the exclusions section of the policy for more information";
(c) Any policy provision that limits coverage through a waiting or affiliation period, a deductible, coinsurance, or an annual or lifetime policy limit;
(d) Whether the pet insurer reduces coverage or increases premiums based on the insured's claim history, the age of the covered pet, or a change in the geographic location of the insured; and
(e) If the underwriting company differs from the brand name used to market and sell the product.
(2)(a) Unless the insured has filed a claim under the pet insurance policy, pet insurance applicants shall have the right to examine and return the policy, certificate, or endorsement to the company or an insurance producer appointed by the company within 15 days of its receipt and to have the premium refunded if, after examination of the policy, certificate, or endorsement, the applicant is not satisfied for any reason.
(b) Pet insurance policies, certificates, and endorsements must have a notice prominently printed on the first page or attached thereto including specific instructions to accomplish a return. The following free look statement or language substantially similar must be included:
"You have 15 days from the day you receive this policy, certificate, or endorsement to review it and return it to the company if you decide not to keep it. You do not have to tell the company why you are returning it. If you decide not to keep it, simply return it to the company at its administrative office or you may return it to the insurance producer that you bought it from as long as you have not filed a claim. You must return it within 15 days of the day you first received it. The company will refund the full amount of any premium paid within 30 days after it receives the returned policy, certificate, or endorsement. The premium refund will be sent directly to the person who paid it. The policy, certificate, or endorsement will be void as if it had never been issued."
(3) A pet insurer shall clearly disclose a summary description of the basis or formula on which the pet insurer determines claim payments under a pet insurance policy within the policy prior to policy issuance and through a clear and conspicuous link on the main page of either the pet insurer's website or pet insurer's program administrator's website, or both.
(4) A pet insurer that uses a benefit schedule to determine claim payment under a pet insurance policy shall:
(a) Clearly disclose the applicable benefit schedule in the policy; and
(b) Disclose all benefit schedules used by the pet insurer under its pet insurance policies through a clear and conspicuous link on the main page of either the pet insurer's website or pet insurer's program administrator's website, or both.
(5) A pet insurer that determines claim payments under a pet insurance policy based on usual and customary fees or any other reimbursement limitation based on prevailing veterinary service provider charges shall:
(a) Include a usual and customary fee limitation provision in the policy that clearly describes the pet insurer's basis for determining usual and customary fees and how that basis is applied in calculating claim payments; and
(b) Disclose the pet insurer's basis for determining usual and customary fees through a clear and conspicuous link on the main page of either the pet insurer's website or the pet insurer's program administrator's website, or both.
(6) If any medical examination by a licensed veterinarian is required to effectuate coverage, the pet insurer shall clearly and conspicuously disclose the required aspects of the examination prior to purchase and disclose that examination documentation may result in a preexisting condition exclusion.
(7) The pet insurer shall disclose waiting periods and the requirements applicable to them clearly and prominently to consumers prior to the policy purchase.
(8) The pet insurer shall include a summary of all policy provisions required in this section in a separate document titled "insurer disclosure of important policy provisions."
(9) The pet insurer shall post the insurer disclosure of important policy provisions document required in subsection (8) of this section through a clear and conspicuous link on the main page of either the pet insurer's website or the pet insurer's program administrator's website, or both.
(10) In connection with the issuance of a new pet insurance policy, the pet insurer shall provide the consumer with a copy of the insurer disclosure of important policy provisions document required in subsection (8) of this section in at least 12-point type when it delivers the policy.
(11) At the time a pet insurance policy is issued or delivered to a policyholder, the pet insurer shall include a written disclosure with the following information, printed in 12-point boldface type:
(a) The address and customer service telephone number of either the pet insurer or the insurance producer of record, or both; and
(b) If the policy was issued or delivered by an insurance producer, a statement advising the policyholder to contact the insurance producer for assistance.
(12) The disclosures required in this section are in addition to any other disclosure requirements required by law or regulation.
[ 2023 c 42 s 4.]
Notes:
Effective date—2023 c 42: See note following RCW 48.205.010.

catchline: Policy disclosures—Returns.


title: RCW 48.205.050

text:
(1) A pet insurer may issue policies that exclude coverage on the basis of one or more preexisting conditions with appropriate disclosure to the consumer. The pet insurer has the burden of proving that the preexisting condition exclusion applies to the condition for which a claim is being made.
(2)(a) A pet insurer may issue policies that impose waiting periods upon effectuation of the policy that do not exceed 30 days for illnesses or orthopedic conditions not resulting from an accident. Waiting periods for accidents are prohibited. Waiting periods may not be applied to renewals of existing coverage.
(b) A pet insurer utilizing a waiting period permitted in (a) of this subsection shall include a provision in its policy that allows the waiting periods to be waived upon completion of a medical examination. Pet insurers may require the examination to be conducted by a licensed veterinarian after the purchase of the policy.
(c) A medical examination under (b) of this subsection must be paid for by the policyholder, unless the policy specifies that the pet insurer will pay for the examination.
(d) A pet insurer can specify elements to be included as part of the examination and require documentation thereof, provided the specifications do not unreasonably restrict a consumer's ability to waive the waiting periods listed in (a) of this subsection.
(3) A pet insurer may not require a veterinary examination of the covered pet for the insured to have their policy renewed.
(4) If a pet insurer includes any prescriptive, wellness, or noninsurance benefits in the policy form, then it is made part of the policy contract and must follow all applicable laws and regulations in the insurance code.
(5) An insured's eligibility to purchase a pet insurance policy must not be based on participation, or lack of participation, in a separate wellness program.
[ 2023 c 42 s 5.]
Notes:
Effective date—2023 c 42: See note following RCW 48.205.010.


title: RCW 48.205.060

text:
(1) A pet insurer and insurance producer may not:
(a) Market a wellness program as pet insurance; or
(b) Market a wellness program during the sale, solicitation, or negotiation of pet insurance.
(2) If a wellness program is sold by either a pet insurer or an insurance producer, or both:
(a) The purchase of the wellness program may not be a requirement to the purchase of pet insurance;
(b) The costs of the wellness program must be separate and identifiable from any pet insurance policy sold by either a pet insurer, an insurance producer, or both;
(c) The terms and conditions for the wellness program must be separate from any pet insurance policy sold by either a pet insurer, an insurance producer, or both;
(d) The products or coverages available through the wellness program may not duplicate products or coverages available through the pet insurance policy;
(e) The advertising of the wellness program may not be misleading and must be in accordance with this section;
(f) Either a pet insurer or an insurance producer, or both, must clearly disclose the following to consumers, printed in 12-point boldface type:
(i) That wellness programs are not insurance; and
(ii) The address and customer service telephone number of either the pet insurer or the insurance producer of record, or both.
(3) Coverages included in the pet insurance policy contract described as "wellness" benefits are insurance.
(4) If any wellness program undertakes to indemnify another or pay a specified amount upon determinable contingencies, it is transacting in the business of insurance and is subject to the insurance code. This definition is not intended to classify a contract directly between a service provider and a pet owner that only involves the two parties as being the business of insurance unless other indications of insurance also exist.
[ 2023 c 42 s 6.]
Notes:
Effective date—2023 c 42: See note following RCW 48.205.010.


title: RCW 48.205.070

text:
(1) An insurance producer may not sell, solicit, or negotiate a pet insurance product until after the producer is appropriately licensed and has completed the required training identified in subsection (3) of this section.
(2) An insurer shall ensure that its producers are trained under subsection (3) of this section and that its producers have been appropriately trained on the coverages and conditions of its pet insurance products.
(3) The training required under this subsection must include information on the following topics:
(a) Preexisting conditions and waiting periods;
(b) The differences between pet insurance and noninsurance wellness programs;
(c) Hereditary disorders, congenital anomalies, congenital disorders, chronic conditions, and how pet insurance policies interact with those conditions or disorders; and
(d) Rating, underwriting, renewal, and other related administrative topics.
(4) The satisfaction of the training requirements of another state that are substantially similar to the provisions of subsection (3) of this section shall satisfy the training requirements in this state.
[ 2023 c 42 s 7.]
Notes:
Effective date—2023 c 42: See note following RCW 48.205.010.

catchline: Insurance producers—Training.


title: RCW 48.205.080

text:
The insurance commissioner may adopt rules as necessary to implement and administer this chapter.
[ 2023 c 42 s 8.]
Notes:
Effective date—2023 c 42: See note following RCW 48.205.010.

catchline: Rules.


title: RCW 48.208.010

text:
(1) All health carriers and medicaid managed care organizations shall pay an annual covered lives assessment under RCW 74.76.030.
(2) The commissioner shall assess a per member per month assessment for health carriers pursuant to RCW 74.76.030.
(3) The commissioner shall annually notify, in writing, each health carrier of the estimated total assessment and its payment obligation for the upcoming year. The commissioner shall determine a payment schedule for receipt of assessments under this section in accordance with the medicaid access program rules established by the authority. Payment collections may be made no more frequently than quarterly.
(4) Payments from health carriers are due to the commissioner within 45 days of the payment schedule determined under subsection (3) of this section. The commissioner shall charge interest as defined by RCW 43.17.240, which begins to accrue on the 46th day, on amounts received after the 45-day period. The commissioner may allow each health carrier in arrears to submit a payment plan, subject to approval by the commissioner and initial payment under an approved payment plan.
(5) The commissioner shall deposit annual assessments and interest collected under this section with the state treasurer to the credit of the medicaid access program account created in RCW 74.76.040.
(6) Health carriers shall submit any annual statements or other reports deemed necessary by the commissioner for the health care authority to calculate the assessment in a manner consistent with the schedule and procedures in accordance with RCW 74.76.030.
[ 2025 c 359 s 4.]
Notes:
Effective date—2025 c 359 ss 1-12, 14-16, and 18-20: See note following RCW 74.76.010.
Contingent expiration date—2025 c 359: See note following RCW 74.76.010.

catchline: Covered lives assessment—Notification. (Contingent expiration date.)


title: RCW 48.208.020

text:
The commissioner may adopt rules and undertake actions necessary to carry out RCW 48.208.010 including, but not limited to, rules prescribing the medicaid access program plan of operations, measures to enforce reporting of covered lives, audits of covered lives reporting, and payment of applicable assessments.
[ 2025 c 359 s 9.]
Notes:
Effective date—2025 c 359 ss 1-12, 14-16, and 18-20: See note following RCW 74.76.010.
Contingent expiration date—2025 c 359: See note following RCW 74.76.010.

catchline: Rules. (Contingent expiration date.)


title: RCW 48.208.030

text:
The medicaid access program, health carriers and medicaid managed care organizations assessed by the program, the commissioner, the commissioner's representatives, and the commissioner's employees are not civilly or criminally liable and may not have any penalty or cause of action of any nature arise against them for any action or inaction, including any discretionary decision or failure to make a discretionary decision, when the action or inaction is done in good faith and in the performance of the powers and duties assigned to the program. This section does not prohibit legal actions against the program to enforce the program's statutory or contractual duties or obligations.
[ 2025 c 359 s 11.]
Notes:
Effective date—2025 c 359 ss 1-12, 14-16, and 18-20: See note following RCW 74.76.010.
Contingent expiration date—2025 c 359: See note following RCW 74.76.010.

catchline: Medicaid access program—Liability. (Contingent expiration date.)


title: RCW 48.21.010

text:
(1) Group disability insurance is that form of disability insurance, including stop loss insurance as defined in RCW 48.11.030, provided by a master policy issued to an employer, to a trustee appointed by an employer or employers, or to an association of employers formed for purposes other than obtaining such insurance, covering, with or without their dependents, the employees, or specified categories of the employees, of such employers or their subsidiaries or affiliates, or issued to a labor union, or to an association of employees formed for purposes other than obtaining such insurance, covering, with or without their dependents, the members, or specified categories of the members, of the labor union or association, or issued pursuant to RCW 48.21.030. Group disability insurance includes the following groups that qualify for group life insurance:
RCW 48.24.020, 48.24.035, 48.24.040, 48.24.045, 48.24.050, 48.24.060, 48.24.070, 48.24.080, 48.24.090, and 48.24.095. A group under RCW 48.24.027 does not qualify as a group for the purposes of this chapter.
(2) Group disability insurance for lines of coverage identified in *RCW 48.43.005(26) (e), (h), (k), and (m) offered to a resident of this state under a group disability insurance policy may be issued to a group other than the groups described in subsection (1) of this section subject to the requirements in this subsection.
(a) A group disability insurance policy offered under this subsection may not be delivered in this state unless the commissioner finds that:
(i) The issuance of the group policy is not contrary to the best interest of the public;
(ii) The issuance of the group policy would result in economies of acquisition or administration; and
(iii) The benefits are reasonable in relation to the premium charged.
(b) A group disability insurance coverage may not be offered under this subsection in this state by an insurer under a policy issued in another state unless the commissioner or the insurance commissioner of another state having requirements substantially similar to those contained in this subsection has made a determination that the requirements have been met.
[ 2016 c 65 s 1; 2011 c 81 s 1; 2010 c 13 s 3; 1992 c 226 s 2; 1949 c 190 s 27; 1947 c 79 s .21.01; Rem. Supp. 1949 s 45.21.01.]
Notes:
*Reviser's note: RCW 48.43.005 was alphabetized pursuant to RCW 1.08.015(2)(k), changing subsection (26) to subsection (27), and effective January 1, 2020, changing subsection (26) to subsection (29). RCW 48.43.005 was alphabetized pursuant to RCW 1.08.015(2)(k), changing subsection (29) to subsection (31). Subsequently, RCW 48.43.005 was amended by 2024 c 218 s 1, changing subsection (31) to subsection (33).
Application—1992 c 226: See note following RCW 48.11.030.

catchline: "Group disability insurance" defined—Issuance.


title: RCW 48.21.015

text:
Group stop loss insurance is exempt from all sections of this chapter and chapter 48.32A RCW except for RCW 48.21.010 and this section. For the purpose of this exemption, group stop loss is further defined as follows:
(1) The policy must be issued to and insure the employer, the trustee or other sponsor of the plan, or the plan itself, but not the employees, members, or participants;
(2) Payment by the insurer must be made to the employer, the trustee, or other sponsor of the plan or the plan itself, but not to the employees, members, participants, or health care providers;
(3) The policy must contain a provision that establishes an aggregate attaching point or retention that is at the minimum one hundred twenty percent of the expected claims; and
(4) The policy may provide for an individual attaching point or retention that is not less than five percent of the expected claims or one hundred thousand dollars, whichever is less.
[ 2000 c 80 s 8; 1992 c 226 s 3.]
Notes:
Application—1992 c 226: See note following RCW 48.11.030.

catchline: "Group stop loss insurance" defined for the purpose of exemption—Scope of application.


title: RCW 48.21.020

text:
The term "employees" as used in this chapter shall be deemed to include as employees of a single employer, the compensated officers, managers, and employees of the employer and of subsidiary or affiliated corporations of a corporation employer, and the individual proprietors, partners, and employees of individuals and firms of which the business is controlled by the insured employer through stock ownership, contract or otherwise. The term "employer" as used in this chapter shall be deemed to include any municipal corporation or governmental unit, agency or department thereof as well as private individuals, firms, corporations and other persons.
[1947 c 79 s .21.02; Rem. Supp. 1947 s 45.21.02.]

catchline: "Employees," "employer" defined.


title: RCW 48.21.030

text:
A policy of group disability insurance may be issued to a corporation, as policyholder, existing primarily for the purpose of assisting individuals who are its subscribers in securing medical, hospital, dental, and other health care services for themselves and their dependents, covering all and not less than five hundred such subscribers and dependents, with respect only to medical, hospital, dental, and other health care services.
[1947 c 79 s .21.03; Rem. Supp. 1947 s 45.21.03.]

catchline: Health care groups.


title: RCW 48.21.040

text:
(1) Any policy or contract of disability insurance which conforms with the description and complies with the requirements contained in one of the following six paragraphs shall be deemed a blanket disability insurance policy:
(a) A policy issued to any common carrier of passengers, which carrier shall be deemed the policyholder, covering a group defined as all persons who may become such passengers, and whereby such passengers shall be insured against loss or damage resulting from death or bodily injury either while, or as a result of, being such passengers.
(b) A policy issued in the name of any volunteer fire department, first aid or ambulance squad or volunteer police organization, which shall be deemed the policyholder, and covering all the members of any such organization against loss from accidents resulting from hazards incidental to duties in connection with such organizations.
(c) A policy issued in the name of any established organization whether incorporated or not, having community recognition and operated for the welfare of the community and its members and not for profit, which shall be deemed the policyholder, and covering all volunteer workers who serve without pecuniary compensation and the members of the organization, against loss from accidents occurring while engaged in the actual performance of duties on behalf of such organization or in the activities thereof.
(d) A policy issued to an employer, who shall be deemed the policyholder, covering any group of employees defined by reference to exceptional hazards incident to such employment, insuring such employees against death or bodily injury resulting while, or from, being exposed to such exceptional hazards.
(e) A policy covering students or employees issued to a college, school, or other institution of learning or to the head or principal thereof, who or which shall be deemed the policyholder.
(f) A policy or contract issued to any other substantially similar group, which, in the commissioner's discretion, may be subject to the insurance of a blanket disability policy or contract.
(2) Nothing contained in this section shall be deemed to affect the liability of policyholders for the death of, or injury to, any such members of such group.
(3) Individual applications shall not be required from individuals covered under a blanket disability insurance contract.
[ 1959 c 225 s 7; 1947 c 79 s .21.04; Rem. Supp. 1947 s 45.21.04.]

catchline: "Blanket disability insurance" defined.


title: RCW 48.21.045

text:
(1)(a) An insurer offering any health benefit plan to a small employer, either directly or through an association or member-governed group formed specifically for the purpose of purchasing health care, may offer and actively market to the small employer a health benefit plan featuring a limited schedule of covered health care services. Nothing in this subsection shall preclude an insurer from offering, or a small employer from purchasing, other health benefit plans that may have more comprehensive benefits than those included in the product offered under this subsection. An insurer offering a health benefit plan under this subsection shall clearly disclose all covered benefits to the small employer in a brochure filed with the commissioner.
(b) A health benefit plan offered under this subsection shall provide coverage for hospital expenses and services rendered by a physician licensed under chapter 18.57 or 18.71 RCW but is not subject to the requirements of RCW 48.21.130, 48.21.140, 48.21.141, 48.21.142, 48.21.144, 48.21.146, 48.21.160 through 48.21.197, 48.21.200, 48.21.220, 48.21.225, 48.21.230, 48.21.235, 48.21.244, 48.21.250, 48.21.300, 48.21.310, or 48.21.320.
(2) Nothing in this section shall prohibit an insurer from offering, or a purchaser from seeking, health benefit plans with benefits in excess of the health benefit plan offered under subsection (1) of this section. All forms, policies, and contracts shall be submitted for approval to the commissioner, and the rates of any plan offered under this section shall be reasonable in relation to the benefits thereto.
(3) Premium rates for health benefit plans for small employers as defined in this section shall be subject to the following provisions:
(a) The insurer shall develop its rates based on an adjusted community rate and may only vary the adjusted community rate for:
(i) Geographic area;
(ii) Family size;
(iii) Age; and
(iv) Wellness activities.
(b) The adjustment for age in (a)(iii) of this subsection may not use age brackets smaller than five-year increments, which shall begin with age twenty and end with age sixty-five. Employees under the age of twenty shall be treated as those age twenty.
(c) The insurer shall be permitted to develop separate rates for individuals age sixty-five or older for coverage for which medicare is the primary payer and coverage for which medicare is not the primary payer. Both rates shall be subject to the requirements of this subsection (3).
(d) The permitted rates for any age group shall be no more than four hundred twenty-five percent of the lowest rate for all age groups on January 1, 1996, four hundred percent on January 1, 1997, and three hundred seventy-five percent on January 1, 2000, and thereafter.
(e) A discount for wellness activities shall be permitted to reflect actuarially justified differences in utilization or cost attributed to such programs. Up to a twenty percent variance may be allowed for small employers that develop and implement a wellness program or activities that directly improve employee wellness. Employers shall document program activities with the carrier and may, after three years of implementation, request a reduction in premiums based on improved employee health and wellness. While carriers may review the employer's claim history when making a determination regarding whether the employer's wellness program has improved employee health, the carrier may not use maternity or prevention services claims to deny the employer's request. Carriers may consider issues such as improved productivity or a reduction in absenteeism due to illness if submitted by the employer for consideration. Interested employers may also work with the carrier to develop a wellness program and a means to track improved employee health.
(f) The rate charged for a health benefit plan offered under this section may not be adjusted more frequently than annually except that the premium may be changed to reflect:
(i) Changes to the enrollment of the small employer;
(ii) Changes to the family composition of the employee;
(iii) Changes to the health benefit plan requested by the small employer; or
(iv) Changes in government requirements affecting the health benefit plan.
(g) On the census date, as defined in RCW 48.21.047, rating factors shall produce premiums for identical groups that differ only by the amounts attributable to plan design, and differences in census date between new and renewal groups, with the exception of discounts for health improvement programs.
(h) For the purposes of this section, a health benefit plan that contains a restricted network provision shall not be considered similar coverage to a health benefit plan that does not contain such a provision, provided that the restrictions of benefits to network providers result in substantial differences in claims costs. A carrier may develop its rates based on claims costs due to network provider reimbursement schedules or type of network. This subsection does not restrict or enhance the portability of benefits as provided in *RCW 48.43.015.
(i) Adjusted community rates established under this section shall pool the medical experience of all small groups purchasing coverage, including the small group participants in the health insurance partnership established in **RCW 70.47A.030. However, annual rate adjustments for each small group health benefit plan may vary by up to plus or minus four percentage points from the overall adjustment of a carrier's entire small group pool, such overall adjustment to be approved by the commissioner, upon a showing by the carrier, certified by a member of the American academy of actuaries that: (i) The variation is a result of deductible leverage, benefit design, or provider network characteristics; and (ii) for a rate renewal period, the projected weighted average of all small group benefit plans will have a revenue neutral effect on the carrier's small group pool. Variations of greater than four percentage points are subject to review by the commissioner, and must be approved or denied within sixty days of submittal. A variation that is not denied within sixty days shall be deemed approved. The commissioner must provide to the carrier a detailed actuarial justification for any denial within thirty days of the denial.
(j) For health benefit plans purchased through the health insurance partnership established in **chapter 70.47A RCW:
(i) Any surcharge established pursuant to **RCW 70.47A.030(2)(e) shall be applied only to health benefit plans purchased through the health insurance partnership; and
(ii) Risk adjustment or reinsurance mechanisms may be used by the health insurance partnership program to redistribute funds to carriers participating in the health insurance partnership based on differences in risk attributable to individual choice of health plans or other factors unique to health insurance partnership participation. Use of such mechanisms shall be limited to the partnership program and will not affect small group health plans offered outside the partnership.
(k) If the rate developed under this section varies the adjusted community rate for the factors listed in (a) of this subsection, the date for determining those factors must be no more than ninety days prior to the effective date of the health benefit plan.
(4) Nothing in this section shall restrict the right of employees to collectively bargain for insurance providing benefits in excess of those provided herein.
(5)(a) Except as provided in this subsection and subsection (3)(g) of this section, requirements used by an insurer in determining whether to provide coverage to a small employer shall be applied uniformly among all small employers applying for coverage or receiving coverage from the carrier.
(b) An insurer shall not require a minimum participation level greater than:
(i) One hundred percent of eligible employees working for groups with three or less employees; and
(ii) Seventy-five percent of eligible employees working for groups with more than three employees.
(c) In applying minimum participation requirements with respect to a small employer, a small employer shall not consider employees or dependents who have similar existing coverage in determining whether the applicable percentage of participation is met.
(d) An insurer may not increase any requirement for minimum employee participation or modify any requirement for minimum employer contribution applicable to a small employer at any time after the small employer has been accepted for coverage.
(e) Minimum participation requirements and employer premium contribution requirements adopted by the health insurance partnership board under **RCW 70.47A.110 shall apply only to the employers and employees who purchase health benefit plans through the health insurance partnership.
(6) An insurer must offer coverage to all eligible employees of a small employer and their dependents. An insurer may not offer coverage to only certain individuals or dependents in a small employer group or to only part of the group. An insurer may not modify a health plan with respect to a small employer or any eligible employee or dependent, through riders, endorsements or otherwise, to restrict or exclude coverage or benefits for specific diseases, medical conditions, or services otherwise covered by the plan.
(7) As used in this section, "health benefit plan," "small employer," "adjusted community rate," and "wellness activities" mean the same as defined in RCW 48.43.005.
[ 2010 c 292 s 7; 2009 c 131 s 1; 2008 c 143 s 6; 2007 c 260 s 7; 2004 c 244 s 1; 1995 c 265 s 14; 1990 c 187 s 2.]
Notes:
Reviser's note: *(1) RCW 48.43.015 was repealed by 2019 c 33 s 7.
**(2) Chapter 70.47A RCW was repealed in its entirety by 2017 3rd sp.s. c 25 s 9.
Application—2010 c 292: See note following RCW 48.43.005.
Application—2004 c 244: "Sections 1 through 15 of this act apply to all small group health benefit plans issued or renewed on or after June 10, 2004." [ 2004 c 244 s 17.]
Captions not law—Effective dates—Savings—Severability—1995 c 265: See notes following RCW 70.47.015.
Finding—Intent—1990 c 187: "The legislature finds that the rising cost of comprehensive group health coverage is exceeding the affordability of many small businesses and their employees. The legislature further finds that certain public policies have an adverse impact on the cost of such coverage. It is therefore the intent of the legislature to reduce costs by authorizing the development of basic hospital and medical coverage for small groups." [ 1990 c 187 s 1.]
Severability—1990 c 187: "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." [ 1990 c 187 s 6.]

catchline: Health plan benefits for small employers—Coverage—Exemption from statutory requirements—Premium rates—Requirements for providing coverage for small employers—Definitions.