title: RCW 48.43.039

text:
(1) For an enrollee who is in the second or third month of the grace period, an issuer of a qualified health plan shall:
(a) Upon request by a health care provider or health care facility, provide information regarding the enrollee's eligibility status in real time;
(b) Notify a health care provider or health care facility that an enrollee is in the grace period within three business days after submittal of a claim or status request for services provided; and
(c) If the health care provider or health care facility is providing care to an enrollee in the grace period, the provider or facility shall, wherever possible, encourage the enrollee to pay delinquent premiums to the issuer and provide information regarding the impact of nonpayment of premiums on access to services.
(2) The information or notification required under subsection (1) of this section must, at a minimum:
(a) Indicate "grace period" or use the appropriate national coding standard as the reason for pending the claim if a claim is pended due to the enrollee's grace period status; and
(b) Except for notifications provided electronically, indicate that enrollee is in the second or third month of the grace period.
(3) No earlier than January 1, 2016, and once the exchange has terminated premium aggregation functionality for qualified health plans offered in the individual exchange and issuers are accepting all payments from enrollees directly, an issuer of a qualified health plan shall:
(a) For an enrollee in the grace period, include a statement in a delinquency notice that concisely explains the impact of nonpayment of premiums on access to coverage and health care services and encourages the enrollee to contact the issuer regarding coverage options that may be available;
(b) For an enrollee who has exhausted the grace period, include a statement in a termination notice for nonpayment of premium informing the enrollee that other coverage options such as medicaid may be available and to contact the issuer or the exchange for additional information; and
(c) For a delinquency notice described in this subsection, include concise information on how a subsidized enrollee may report to the exchange a change in income or circumstances, including any deadline for doing so, and an explanation that it may result in a change in premium or cost-sharing amount or program eligibility.
(4) Upon the transfer of premium collection to the qualified health plan, each qualified health plan must provide detailed reports to the exchange to support the legislative reporting requirements.
(5) For purposes of this section, "grace period" means nonpayment of premiums by an enrollee receiving advance payments of the premium tax credit, as defined in section 1412 of the patient protection and affordable care act, P.L. 111-148, as amended by the health care and education reconciliation act, P.L. 111-152, and implementing regulations issued by the federal department of health and human services.
[ 2018 c 44 s 9; 2015 3rd sp.s. c 33 s 4; 2014 c 84 s 3; 2014 c 84 s 2.]
Notes:
Contingent effective date—2014 c 84 s 3: "Section 3 of this act takes effect January 1st following the issuance of a report under section 2(3) of this act indicating that coverage was terminated due to nonpayment of premium for ten thousand or more enrollees who were in the grace period in that calendar year. In no case may section 3 of this act take effect before January 1, 2015. The health benefit exchange must provide notice of the effective date of section 3 of this act to affected parties, the chief clerk of the house of representatives, the secretary of the senate, the office of the code reviser, and others as deemed appropriate by the health benefit exchange." [ 2014 c 84 s 4.] The health benefit exchange issued a report meeting the contingency requirements of this section on December 1, 2014; therefore, the effective date of section 3, chapter 84, Laws of 2014 is January 1, 2015.

catchline: Grace period—Notification or information—Information concerning delinquencies or nonpayment of premiums—Defined.


doc_type: statute

jurisdiction: wa

title: RCW 48.43.041

text:
(1) All individual health benefit plans, other than catastrophic health plans, offered or renewed on or after October 1, 2000, shall include benefits described in this section. Nothing in this section shall be construed to require a carrier to offer an individual health benefit plan.
(a) Maternity services that include, with no enrollee cost-sharing requirements beyond those generally applicable cost-sharing requirements: Diagnosis of pregnancy; prenatal care; delivery; care for complications of pregnancy; physician services; hospital services; operating or other special procedure rooms; radiology and laboratory services; appropriate medications; anesthesia; and services required under RCW 48.43.115; and
(b) Prescription drug benefits with at least a two thousand dollar benefit payable by the carrier annually.
(2) If a carrier offers a health benefit plan that is not a catastrophic health plan to groups, and it chooses to offer a health benefit plan to individuals, it must offer at least one health benefit plan to individuals that is not a catastrophic health plan.
[ 2000 c 79 s 26.]
Notes:
Effective dates—2000 c 79 ss 26, 38, and 39: "(1) Section 38 of this act takes effect July 1, 2000.
(2) Section 39 of this act takes effect September 1, 2000.
(3) *Section 26 of this act takes effect on the first day of the month following the expiration of a one hundred eighty-day period beginning on the effective date of section 25 of this act." [ 2000 c 79 s 50.]
*Reviser's note: Section 26 of this act takes effect October 1, 2000.
Severability—2000 c 79: See note following RCW 48.04.010.

license: public-domain-government-work

rule_set: Revised Code of Washington

catchline: Individual health benefit plans—Mandatory benefits.

code: rcw

unit: section

court: Washington State Legislature


title: RCW 48.43.043

text:
(1) Health plans issued or renewed on or after July 1, 2008, must provide benefits or coverage for colorectal cancer examinations and laboratory tests consistent with the guidelines or recommendations of the United States preventive services task force or the federal centers for disease control and prevention. Benefits or coverage must be provided:
(a) For any of the colorectal screening examinations and tests in the selected guidelines or recommendations, at a frequency identified in such guidelines or recommendations, as deemed appropriate by the patient's physician after consultation with the patient; and
(b) To a covered individual who is:
(i) At least fifty years old; or
(ii) Less than fifty years old and at high risk or very high risk for colorectal cancer according to such guidelines or recommendations.
(2) To encourage colorectal cancer screenings, patients and health care providers must not be required to meet burdensome criteria or overcome significant obstacles to secure such coverage. An individual may not be required to pay an additional deductible or coinsurance for testing that is greater than an annual deductible or coinsurance established for similar benefits. If the health plan does not cover a similar benefit, a deductible or coinsurance may not be set at a level that materially diminishes the value of the colorectal cancer benefit required.
(3)(a) A health carrier is not required under this section to provide for a referral to a nonparticipating health care provider, unless the carrier does not have an appropriate health care provider that is available and accessible to administer the screening exam and that is a participating health care provider with respect to such treatment.
(b) If a health carrier refers an individual to a nonparticipating health care provider pursuant to this section, screening exam services or resulting treatment, if any, must be provided at no additional cost to the individual beyond what the individual would otherwise pay for services provided by a participating health care provider.
[ 2007 c 23 s 1.]

catchline: Colorectal cancer examinations and laboratory tests—Required benefits or coverage.


title: RCW 48.43.045

text:
(1) Every health plan delivered, issued for delivery, or renewed by a health carrier on and after January 1, 1996, shall:
(a) Permit every category of health care provider to provide health services or care included in the basic essential health benefits benchmark plan established by the commissioner consistent with RCW 48.43.715, to the extent that:
(i) The provision of such health services or care is within the health care providers' permitted scope of practice;
(ii) The providers agree to abide by standards related to:
(A) Provision, utilization review, and cost containment of health services;
(B) Management and administrative procedures; and
(C) Provision of cost-effective and clinically efficacious health services; and
(iii) The plan covers such services or care in the essential health benefits benchmark plan. The reference to the essential health benefits does not create a mandate to cover a service that is otherwise not a covered benefit.
(b) Annually report the names and addresses of all officers, directors, or trustees of the health carrier during the preceding year, and the amount of wages, expense reimbursements, or other payments to such individuals, unless substantially similar information is filed with the commissioner or the national association of insurance commissioners. This requirement does not apply to a foreign or alien insurer regulated under chapter 48.20 or 48.21 RCW that files a supplemental compensation exhibit in its annual statement as required by law.
(2) The requirements of subsection (1)(a) of this section do not apply to a licensed health care profession regulated under Title 18 RCW when the licensing statute for the profession states that such requirements do not apply.
[ 2015 c 237 s 2; 2007 c 253 s 12; 2007 c 98 s 18; 2006 c 25 s 7; 1997 c 231 s 205; 1995 c 265 s 8.]
Notes:
Effective date—Implementation—2007 c 253: See RCW 18.250.901 and 18.250.902.
Effective dates—2007 c 98: See RCW 18.74.912.
Short title—Part headings and captions not law—Severability—Effective dates—1997 c 231: See notes following RCW 48.43.005.
Captions not law—Effective dates—Savings—Severability—1995 c 265: See notes following RCW 70.47.015.

catchline: Health plan requirements—Annual reports—Exemptions.


title: RCW 48.43.047

text:
(1) A nongrandfathered health plan issued on or after April 1, 2026, must, at a minimum, provide coverage for the following preventive services:
(a) Evidence-based items or services that have a rating of A or B in the recommendations of the United States preventive services task force in effect on June 30, 2025, and items and services included in rules adopted by the insurance commissioner under this section with respect to the enrollee;
(b) With respect to infants, children, and adolescents, evidence-informed preventive care and screenings provided for in comprehensive guidelines supported by the health resources and services administration in effect on June 30, 2025, and preventive care and screenings included in rules adopted by the insurance commissioner under this section;
(c) With respect to women, additional preventive care and screenings that are not listed with a rating of A or B by the United States preventive services task force but that are provided for in comprehensive guidelines supported by the health resources and services administration in effect on June 30, 2025, and preventive care and screenings included in rules adopted by the insurance commissioner under this section; and
(d) Immunizations that have in effect a recommendation from the department of health under RCW 43.70.527.
(2) A nongrandfathered health plan must provide coverage for:
(a) The preventive services required to be covered under subsection (1)(a) through (c) of this section consistent with federal rules and guidance related to coverage of such preventive services in effect on June 30, 2025, and rules adopted by the insurance commissioner under this section; and
(b) Immunizations required to be covered under subsection (1)(d) of this section consistent with department of health guidance issued under RCW 43.70.527.
(3) A nongrandfathered health plan must provide coverage for the preventive services required to be covered under subsections (1) and (2) of this section for plan years that begin on or after the date that is one year after the date the recommendation or guideline is issued.
(4)(a) Except as provided in (b) of this subsection, the health plan may not impose cost-sharing requirements for the preventive services required to be covered under subsections (1) and (2) of this section when the services are provided by an in-network provider. If a plan does not have in its network a provider who can provide an item or service described in subsections (1) and (2) of this section, the plan must cover the item or service when performed by an out-of-network provider and may not impose cost sharing with respect to the item or service.
(b) For a health plan offered as a qualifying health plan for a health savings account, the carrier may apply cost sharing to coverage of the services required to be covered under subsections (1) and (2) of this section only at the minimum level necessary to preserve the enrollee's ability to claim tax exempt contributions and withdrawals from the enrollee's health savings account under internal revenue service laws and regulations.
(5) A carrier may use reasonable medical management techniques to determine the frequency, method, treatment, or setting for an item or service described in subsections (1) and (2) of this section to the extent not specified in the relevant recommendation or guideline, federal rules and guidance related to the coverage of preventive services in effect on June 30, 2025, department of health guidance issued under RCW 43.70.527, and any rules adopted by the insurance commissioner.
(6) The insurance commissioner may adopt rules necessary to implement the requirements of this section, including rules modifying coverage requirements for preventive services under subsection (1)(a) through (c) of this section based on the addition of preventive services or other changes to the recommendations and guidelines referenced in subsection (1)(a) through (c) of this section that are made after June 30, 2025. Any rules adopted by the insurance commissioner must be as or more favorable to enrollees with respect to coverage of preventive services than the recommendations and guidelines in effect on June 30, 2025. In adopting any rules under this subsection, the insurance commissioner must:
(a) Consult with the health care authority and department of health; and
(b) Consider the recommendations of the department of health issued under RCW 43.70.527 and recommendations issued by the United States preventive services task force, the health resources and services administration, and experts and expert organizations that the commissioner in their discretion deems relevant and based on reasonable scientific evidence and judgment.
[ 2026 c 13 s 3; 2024 c 314 s 1; 2018 c 14 s 1.]
Notes:
Intent—Effective date—2026 c 13: See notes following RCW 43.70.527.

catchline: Health plans—Minimum coverage for preventive services—No cost-sharing requirements.


title: RCW 48.43.055

text:
(1) Except as provided by subsection (2) of this section, each health carrier as defined under RCW 48.43.005 shall file with the commissioner its procedures for review and adjudication of complaints initiated by health care providers. Procedures filed under this section shall provide a fair review for consideration of complaints. Every health carrier shall provide reasonable means allowing any health care provider aggrieved by actions of the health carrier to be heard after submitting a written request for review. If the health carrier fails to grant or reject a request within thirty days after it is made, the complaining health care provider may proceed as if the complaint had been rejected. A complaint that has been rejected by the health carrier may be submitted to nonbinding mediation. Mediation shall be conducted under chapter 7.07 RCW, or any other rules of mediation agreed to by the parties. This section is solely for resolution of provider complaints. Complaints by, or on behalf of, a covered person are subject to the grievance processes in RCW 48.43.530.
(2) For purposes of out-of-network payment disputes between a health carrier and health care provider covered under the provisions of chapter 48.49 RCW, the arbitration provisions of chapter 48.49 RCW apply.
[ 2019 c 427 s 28; 2005 c 172 s 19; 2002 c 300 s 6; 1995 c 265 s 20.]
Notes:
Findings—Intent—Effective date—2019 c 427: See RCW 48.49.003 and 48.49.900.
Short title—Effective date—2005 c 172: See RCW 7.07.900 and 7.07.904.
Captions not law—Effective dates—Savings—Severability—1995 c 265: See notes following RCW 70.47.015.

catchline: Procedures for review and adjudication of health care provider complaints—Requirements.


title: RCW 48.43.059

text:
(1) For the purposes of this section, "second-party payment process" means a process in which: (a) An individual has an account under his or her name maintained with a financial institution and is either managed by the financial institution or an entity that, with the express agreement with the individual, has established the account on behalf of the individual with a financial institution; (b) the account is funded with funds from the individual or his or her family members or in a manner otherwise consistent with federal law including, but not limited to, federal guidance implementing the federal patient protection and affordable care act; and (c) the account is under the control of the covered person, such that the covered person may authorize payments from the account.
(2) All issuers must accept any payments made by a second-party payment process; however, no issuer need accept payment by a second-party payment process if the second-party payer is controlled by or receives funding from any entity where such entity may be reimbursed by an issuer for providing health care services or if the account under the control of the covered person is funded by any such entity, except those third-party entities from whom federal law requires such issuer to accept payment.
(3) Payments made under subsection (2) of this section may be made with any legal tender denominated in United States dollars.
[ 2015 c 284 s 2.]
Notes:
Recognition—Intent—2015 c 284: "(1) The legislature recognizes that under regulations implementing the federal patient protection and affordable care act, issuers offering individual market qualified health plans are required to accept third-party premium and cost-sharing payments from the Ryan White HIV/AIDS program under Title XXVI of the public health service act, Indian tribes, tribal organizations or urban Indian organizations, and state and federal government programs. However, federal regulators have stated that they have serious concerns about payments made on a third-party basis by hospitals, health care providers, and other commercial entities using their own funds because of the potential that such payments could cause distortions in the insurance market.
(2) The legislature intends to clarify that an entity that makes premium payments from accounts that are owned and controlled by the covered person do not constitute a third party for the purposes of acceptance of premium payments by an issuer. The legislature does not intend to impact third-party payment programs required under federal law , including, but not limited to, federal guidance implementing the federal patient protection and affordable care act." [ 2015 c 284 s 1.]

catchline: Payments made by a second-party payment process—Definition.


title: RCW 48.43.065

text:
(1) The legislature recognizes that every individual possesses a fundamental right to exercise their religious beliefs and conscience. The legislature further recognizes that in developing public policy, conflicting religious and moral beliefs must be respected. Therefore, while recognizing the right of conscientious objection to participating in specific health services, the state shall also recognize the right of individuals enrolled with plans containing the basic health plan services to receive the full range of services covered under the plan.
(2)(a) No individual health care provider, religiously sponsored health carrier, or health care facility may be required by law or contract in any circumstances to participate in the provision of or payment for a specific service if they object to so doing for reason of conscience or religion. No person may be discriminated against in employment or professional privileges because of such objection.
(b) The provisions of this section are not intended to result in an enrollee being denied timely access to any service included in the basic health plan services. Each health carrier shall:
(i) Provide written notice to enrollees, upon enrollment with the plan, listing services that the carrier refuses to cover for reason of conscience or religion;
(ii) Provide written information describing how an enrollee may directly access services in an expeditious manner; and
(iii) Ensure that enrollees refused services under this section have prompt access to the information developed pursuant to (b)(ii) of this subsection.
(c) The insurance commissioner shall establish by rule a mechanism or mechanisms to recognize the right to exercise conscience while ensuring enrollees timely access to services and to assure prompt payment to service providers.
(3)(a) No individual or organization with a religious or moral tenet opposed to a specific service may be required to purchase coverage for that service or services if they object to doing so for reason of conscience or religion.
(b) The provisions of this section shall not result in an enrollee being denied coverage of, and timely access to, any service or services excluded from their benefits package as a result of their employer's or another individual's exercise of the conscience clause in (a) of this subsection.
(c) The insurance commissioner shall define by rule the process through which health carriers may offer the basic health plan services to individuals and organizations identified in (a) and (b) of this subsection in accordance with the provisions of subsection (2)(c) of this section.
(4) Nothing in this section requires a health carrier, health care facility, or health care provider to provide any health care services without appropriate payment of premium or fee.
[ 1995 c 265 s 25.]
Notes:
Captions not law—Effective dates—Savings—Severability—1995 c 265: See notes following RCW 70.47.015.

catchline: Right of individuals to receive services—Right of providers, carriers, and facilities to refuse to participate in or pay for services for reason of conscience or religion—Requirements.


title: RCW 48.43.071

text:
Upon request of a covered person or a covered person's personal representative, an issuer shall provide the covered person or representative with one copy of the covered person's health care information free of charge if the covered person is appealing the denial of federal supplemental security income or social security disability benefits. The issuer may provide the health care information in either paper or electronic format. An issuer is not required to provide a covered person or a covered person's personal representative with a free copy of health care information that has previously been provided free of charge pursuant to a request within the preceding two years. For purposes of this section, "health care information" has the same meaning as in RCW 70.02.010.
[ 2018 c 87 s 4.]

catchline: Health care information—Requirement to provide free copy to covered person appealing denial of social security benefits—Exceptions.


title: RCW 48.43.072

text:
(1) A health plan or student health plan, including student health plans deemed by the insurance commissioner to have a short-term limited purpose or duration or to be guaranteed renewable while the covered person is enrolled as a regular full-time undergraduate or graduate student at an accredited higher education institution, shall provide coverage for:
(a) All contraceptive drugs, devices, and other products, approved by the federal food and drug administration, including over-the-counter contraceptive drugs, devices, and products, approved by the federal food and drug administration. This includes condoms, regardless of the gender or sexual orientation of the covered person, and regardless of whether they are to be used for contraception or exclusively for the prevention of sexually transmitted infections;
(b) Voluntary sterilization procedures;
(c) The consultations, examinations, procedures, and medical services that are necessary to prescribe, dispense, insert, deliver, distribute, administer, or remove the drugs, devices, and other products or services in (a) and (b) of this subsection;
(d) The following preventive services:
(i) Screening for physical, mental, sexual, and reproductive health care needs that arise from a sexual assault; and
(ii) Well-person preventive visits;
(e) Medically necessary services and prescription medications for the treatment of physical, mental, sexual, and reproductive health care needs that arise from a sexual assault; and
(f) The following reproductive health-related over-the-counter drugs and products approved by the federal food and drug administration: Prenatal vitamins for pregnant persons; and breast pumps for covered persons expecting the birth or adoption of a child.
(2) The coverage required by subsection (1) of this section:
(a) May not require copayments, deductibles, or other forms of cost sharing:
(i) Except for:
(A) The medically necessary services and prescription medications required by subsection (1)(e) of this section; and
(B) The drugs and products in subsection (1)(f) of this section; or
(ii) Unless the health plan is offered as a qualifying health plan for a health savings account. For such a qualifying health plan, the carrier must establish the plan's cost sharing for the coverage required by subsection (1) of this section at the minimum level necessary to preserve the enrollee's ability to claim tax exempt contributions and withdrawals from the enrollee's health savings account under internal revenue service laws and regulations; and
(b) May not require a prescription to trigger coverage of over-the-counter contraceptive drugs, devices, and products, approved by the federal food and drug administration, except those reproductive health-related drugs and products as set forth in subsection (1)(f) of this section.
(3) A health carrier may not deny the coverage required in subsection (1) of this section because an enrollee changed the enrollee's contraceptive method within a twelve-month period.
(4) Except as otherwise authorized under this section, a health benefit plan may not impose any restrictions or delays on the coverage required under this section, such as medical management techniques that limit enrollee choice in accessing the full range of contraceptive drugs, devices, or other products, approved by the federal food and drug administration.
(5) Benefits provided under this section must be extended to all enrollees, enrolled spouses, and enrolled dependents.
(6) This section may not be construed to allow for denial of care on the basis of race, color, national origin, sex, sexual orientation, gender expression or identity, marital status, age, citizenship, immigration status, or disability.
(7) A health plan or student health plan, including student health plans deemed by the insurance commissioner to have a short-term limited purpose or duration or to be guaranteed renewable while the covered person is enrolled as a regular full-time undergraduate or graduate student at an accredited higher education institution, issued or renewed on or after January 1, 2021, may not issue automatic initial denials of coverage for reproductive health care services that are ordinarily or exclusively available to individuals of one gender, based on the fact that the individual's gender assigned at birth, gender identity, or gender otherwise recorded in one or more government-issued documents, is different from the one to which such health services are ordinarily or exclusively available.
(8) The definitions in this subsection apply throughout this section unless the context clearly requires otherwise.
(a) "Gender expression" means a person's gender-related appearance and behavior, whether or not stereotypically associated with the person's gender assigned at birth.
(b) "Gender identity" means a person's internal sense of the person's own gender, regardless of the person's gender assigned at birth.
(c) "Reproductive health care services" means any medical services or treatments, including pharmaceutical and preventive care service or treatments, directly involved in the reproductive system and its processes, functions, and organs involved in reproduction, in all stages of life. Reproductive health care services does not include infertility treatment.
(d) "Reproductive system" includes, but is not limited to: Genitals, gonads, the uterus, ovaries, fallopian tubes, and breasts.
(e) "Well-person preventive visits" means the preventive annual visits recommended by the federal health resources and services administration women's preventive services guidelines, with the understanding that those visits must be covered for women, and when medically appropriate, for transgender, nonbinary, and intersex individuals.
(9) This section may not be construed to authorize discrimination on the basis of gender identity or expression, or perceived gender identity or expression, in the provision of nonreproductive health care services.
(10) The commissioner, under RCW 48.30.300, and the human rights commission, under chapter 49.60 RCW[,] shall share enforcement authority over complaints of discrimination under this section as set forth in RCW 49.60.178.
(11) The commissioner may adopt rules to implement this section.
[ 2019 c 399 s 3; 2018 c 119 s 2.]
Notes:
Recommendations—Preexposure and postexposure prophylaxis financial support awareness—2019 c 399: "The department of health shall develop recommendations for increasing awareness about financial support that is available for preexposure and postexposure prophylaxis. The department of health shall consult with the state board of health, the health care authority, and the health benefit exchange in developing its recommendation related to outreach and education to affected populations. By December 1, 2019, the department of health shall provide its recommendations to the appropriate committees of the legislature." [ 2019 c 399 s 7.]
Effective dates—2019 c 399 ss 2 and 3: See note following RCW 74.09.875.
Findings—Short title—2019 c 399: See notes following RCW 74.09.875.
Findings—Declarations—2018 c 119: "The legislature finds and declares that:
(1) Washington has a long history of protecting gender equity and women's reproductive health;
(2) Access to the full range of health benefits and preventive services, as guaranteed under the laws of this state, provides all Washingtonians with the opportunity to lead healthier and more productive lives;
(3) Reproductive health care is the care necessary to support the reproductive system, the capability to reproduce, and the freedom and services necessary to decide if, when, and how often to do so, which can include contraception, cancer and disease screenings, abortion, preconception, maternity, prenatal, and postpartum care. This care is an essential part of primary care for women and teens, and often reproductive health issues are the primary reason they seek routine medical care;
(4) Neither a woman's income level nor her type of insurance should prevent her from having access to a full range of reproductive health care, including contraception and abortion services;
(5) Restrictions and barriers to health coverage for reproductive health care have a disproportionate impact on low-income women, women of color, immigrant women, and young women, and these women are often already disadvantaged in their access to the resources, information, and services necessary to prevent an unintended pregnancy or to carry a healthy pregnancy to term;
(6) This state has a history of supporting and expanding timely access to comprehensive contraceptive access to prevent unintended pregnancy;
(7) Existing state and federal law should be enhanced to ensure greater contraceptive coverage and timely access for all individuals covered by health plans in Washington to all methods of contraception approved by the federal food and drug administration;
(8) Nearly half of pregnancies in both the United States and Washington are unintended. Unintended pregnancy is associated with negative outcomes, such as delayed prenatal care, maternal depression, increased risk of physical violence during pregnancy, low birth weight, decreased mental and physical health during childhood, and lower education attainment for the child;
(9) Access to contraception has been directly connected to the economic success of women and the ability of women to participate in society equally;
(10) Cost-sharing requirements and other barriers can dramatically reduce the use of preventive health care measures, particularly for women in lower income households, and eliminating cost sharing and other barriers for contraceptives leads to sizable increases in the use of preventive health care measures;
(11) It is vital that the full range of contraceptives are available to women because contraindications may restrict the use of certain types of contraceptives and because women need access to the contraceptive method most effective for their health;
(12) Medical management techniques such as denials, step therapy, or prior authorization in public and private health care coverage can impede access to the most effective contraceptive methods;
(13) Many insurance companies do not typically cover male methods of contraception, or they require high cost sharing despite the critical role men play in the prevention of unintended pregnancy; and
(14) Restrictions on abortion coverage interfere with a woman's personal, private pregnancy decision making, with his or her health and well-being, and with his or her constitutionally protected right to safe and legal medical abortion care." [ 2018 c 119 s 1.]

catchline: Required reproductive health care coverage—Restrictions on copayments, deductibles, and other form of cost sharing.


title: RCW 48.43.0725

text:
(1) For births taking place in a licensed hospital or birthing center, a health plan must allow a provider to separately bill for devices, implants, professional services, or a combination thereof, associated with immediate postpartum contraception and may not consider such devices, implants, services, or combinations thereof to be part of any payments for general obstetric procedures.
(2) For purposes of this section, "immediate postpartum contraception" means the postpartum insertion of intrauterine devices or contraceptive implants performed before the patient is discharged from the hospital or birthing center and includes the devices or implants themselves.
(3) This section does not apply to facility services associated with immediate postpartum contraception.
(4) Nothing in this section affects an enrollee's right to directly access women's health care services, including contraceptive services.
(5) This section applies to health plans issued or renewed on or after January 1, 2023.
[ 2022 c 122 s 3.]
Notes:
Findings—Intent—2022 c 122: See note following RCW 41.05.430.

catchline: Reproductive health plan coverage—Immediate postpartum contraception devices.


title: RCW 48.43.073

text:
(1)(a) Except as provided in subsection (5) of this section, if a health plan issued or renewed on or after January 1, 2019, provides coverage for maternity care or services, the health plan must also provide a covered person with substantially equivalent coverage to permit the abortion of a pregnancy. Except as provided in subsection (5) of this section, if a student health plan, including student health plans deemed by the insurance commissioner to have a short-term limited purpose or duration or to be guaranteed renewable while the covered person is enrolled as a regular full-time undergraduate or graduate student at an accredited higher education institution, issued or renewed on or after January 1, 2022, provides coverage for maternity care or services, the health plan must also provide a covered person with substantially equivalent coverage to permit the abortion of a pregnancy.
(b) Except as provided in (c) of this subsection, for health plans issued or renewed on or after January 1, 2024, a health carrier may not impose cost sharing for abortion of a pregnancy.
(c) For a health plan that provides coverage for abortion of a pregnancy and is offered as a qualifying health plan for a health savings account, the health carrier shall establish the plan's cost sharing for the coverage required by this section at the minimum level necessary to preserve the enrollee's ability to claim tax exempt contributions and withdrawals from the enrollee's health savings account under internal revenue service laws and regulations.
(2)(a) Except as provided in (b) of this subsection, a health plan or student health plan subject to subsection (1) of this section may not limit in any way a person's access to services related to the abortion of a pregnancy.
(b)(i) Coverage for the abortion of a pregnancy may be subject to terms and conditions generally applicable to the health plan or student health plan's coverage of maternity care or services.
(ii) A health plan or student health plan is not required to cover abortions that would be unlawful under RCW 9.02.120.
(3) Nothing in this section may be interpreted to limit in any way an individual's constitutionally or statutorily protected right to voluntarily terminate a pregnancy.
(4) This section does not, pursuant to 42 U.S.C. Sec. 18054(a)(6), apply to a multistate plan that does not provide coverage for the abortion of a pregnancy.
(5) If the application of this section to a health plan or student health plan results in noncompliance with federal requirements that are a prescribed condition to the allocation of federal funds to the state, this section is inapplicable to the plan to the minimum extent necessary for the state to be in compliance. The inapplicability of this section to a specific health plan or student health plan under this subsection does not affect the operation of this section in other circumstances.
[ 2023 c 194 s 1; 2021 c 53 s 1; 2018 c 119 s 3.]
Notes:
Findings—Declarations—2018 c 119: See note following RCW 48.43.072.

catchline: Required abortion coverage—Limitations.


title: RCW 48.43.074

text:
(1) The legislature intends to codify the state's current practice of requiring health carriers to bill enrollees with a single invoice and to segregate into a separate account the premium attributable to abortion services for which federal funding is prohibited. Washington has achieved full compliance with section 1303 of the federal patient protection and affordable care act by requiring health carriers to submit a single invoice to enrollees and to segregate into a separate account the premium amounts attributable to coverage of abortion services for which federal funding is prohibited. Further, section 1303 states that the act does not preempt or otherwise have any effect on state laws regarding the prohibition of, or requirement of, coverage, funding, or procedural requirements on abortions.
(2) In accordance with RCW 48.43.073 related to requirements for coverage and funding of abortion services, an issuer offering a qualified health plan must:
(a) Bill enrollees and collect payment through a single invoice that includes all benefits and services covered by the qualified health plan; and
(b) Include in the segregation plan required under applicable federal and state law a certification that the issuer's billing and payment processes meet the requirements of this section.
[ 2019 c 399 s 5.]
Notes:
Effective date—2019 c 399 s 5: "Section 5 of 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 13, 2019]." [ 2019 c 399 s 10.]
Findings—Short title—2019 c 399: See notes following RCW 74.09.875.
Recommendations—Preexposure and postexposure prophylaxis financial support awareness—2019 c 399: See note following RCW 48.43.072.

catchline: Qualified health plans—Single invoice billing—Certification of compliance required in the segregation plan for premium amounts attributable to coverage of abortion services.


title: RCW 48.43.076

text:
(1) Except as provided in subsection (2) of this section, for nongrandfathered health plans issued or renewed on or after January 1, 2024, that include coverage of supplemental breast examinations and diagnostic breast examinations, health carriers may not impose cost sharing for such examinations.
(2) For a health plan that provides coverage of supplemental breast examinations and diagnostic breast examinations and is offered as a qualifying health plan for a health savings account, the health carrier shall establish the plan's cost sharing for the coverage of the services described in this section at the minimum level necessary to preserve the enrollee's ability to claim tax exempt contributions from their health savings account under internal revenue service laws and regulations.
(3) For purposes of this section:
(a) "Diagnostic breast examination" means a medically necessary and appropriate examination of the breast, including an examination using diagnostic mammography, digital breast tomosynthesis, also called three dimensional mammography, breast magnetic resonance imaging, or breast ultrasound, that is used to evaluate an abnormality:
(i) Seen or suspected from a screening examination for breast cancer; or
(ii) Detected by another means of examination.
(b) "Supplemental breast examination" means a medically necessary and appropriate examination of the breast, including an examination using breast magnetic resonance imaging or breast ultrasound, that is:
(i) Used to screen for breast cancer when there is no abnormality seen or suspected; and
(ii) Based on personal or family medical history, or additional factors that may increase the individual's risk of breast cancer.
[ 2023 c 366 s 2.]
Notes:
Intent—2023 c 366: "(1) In 1989 the legislature enacted Substitute House Bill No. 1074 requiring disability insurers, group disability insurers, health care service contractors, health maintenance organizations, and plans offered to public employees that provide benefits for hospital or medical care to provide benefits for screening and diagnostic mammography services.
(2) In 2010 the United States congress enacted the patient protection and affordable care act, which required coverage of certain preventative care services including screening mammograms with no cost sharing.
(3) In 2013 the Washington state office of the insurance commissioner adopted rules establishing the essential health benefits benchmark plan, which listed diagnostic and screening mammogram services as state benefit requirements under preventative and wellness services.
(4) In 2018 the legislature enacted Senate Bill No. 5912 which directed the office of the insurance commissioner to clarify that the existing mandates for mammography included coverage for tomosynthesis, also known as three-dimensional mammography, under the same terms and conditions allowed for mammography.
(5) The legislature intends to establish that the requirements for coverage of mammography services predated the affordable care act and are already included in the state's essential health benefits benchmark plan. Furthermore, the legislature intends to prohibit cost sharing for certain types of breast examinations." [ 2023 c 366 s 1.]

catchline: Digital breast examinations—Cost sharing.


title: RCW 48.43.078

text:
(1) Digital breast tomosynthesis, also called three-dimensional mammography, is the latest advancement in breast imaging. Studies indicate that digital breast tomosynthesis can result in a forty-one percent increase in invasive cancer detection, a fifteen percent decrease in the recall rate from screening mammography, and a twenty-nine percent increase in the detection of all breast cancers. In addition, the American college of radiology has indicated that tomosynthesis is no longer investigational. Therefore, it is the intent of the legislature to ensure women have access to the most effective breast imaging and to clarify that the existing mandate for mammography must include tomosynthesis.
(2) The legislature directs the office of the insurance commissioner to clarify that the existing mandates for mammography in RCW 48.20.393, 48.21.225, 48.44.325, and 48.46.275 include coverage for tomosynthesis under the same terms and conditions currently allowed for mammography. The application of a deductible and cost sharing is prohibited, consistent with 42 U.S.C. Sec. 300-gg-13.
(3) The legislature also directs the health care authority to clarify that the existing mandate for mammography in RCW 41.05.180 includes coverage for tomosynthesis under the same terms and conditions currently allowed for mammography. The application of a deductible and cost sharing is prohibited, consistent with 42 U.S.C. Sec. 300-gg-13.
[ 2018 c 115 s 1.]

catchline: Digital breast tomosynthesis—Intent to ensure women with access—Commissioner's and health care authority's duty to clarify mandates.


title: RCW 48.43.081

text:
(1) A clinical laboratory or physician, located in this state, or in another state, providing anatomic pathology services for patients in this state, shall present or cause to be presented a claim, bill, or demand for payment for these services only to the following:
(a) The patient;
(b) The responsible insurer or other third-party payer;
(c) The hospital, public health clinic, or nonprofit health clinic ordering such services;
(d) A direct patient-provider primary care practice regulated by chapter 48.150 RCW, provided the practice:
(i) Is in compliance with all applicable provisions of law to regulate that practice;
(ii) Has furnished a written confirmation to the physician or laboratory providing the anatomic pathology service that the patient is not covered for anatomic pathology services under any health insurance plan or program;
(iii) Furnishes the patient with an itemized bill that does not, directly or indirectly, mark up or increase the actual amount billed by the physician or clinical laboratory that performed the service; and
(iv) Discloses to the patient, through printed material or through a website, that all anatomic pathology services are billed at exactly the amount charged for the service by the physician or laboratory that provided the service, and the identity of the provider;
(e) The referring laboratory, excluding a laboratory of a physician's office or group practice that does not perform the professional component of the anatomic pathology service for which such claim, bill, or demand is presented; or
(f) Governmental agencies or their specified public or private agent, agency, or organization on behalf of the recipient of the services.
(2) Except for a physician at a referring laboratory that has been billed pursuant to subsection (1)(d) or (6) of this section, no licensed practitioner in the state may, directly or indirectly, charge, bill, or otherwise solicit payment for anatomic pathology services unless such services were rendered personally by the licensed practitioner or under the licensed practitioner's direct supervision in accordance with section 353 of the public health service act (42 U.S.C. Sec. 263a).
(3) No patient, insurer, third-party payer, hospital, public health clinic, or nonprofit health clinic may be required to reimburse any licensed practitioner for charges or claims submitted in violation of this section.
(4) Nothing in this section may be construed to mandate the assignment of benefits for anatomic pathology services as defined in this section.
(5) For purposes of this section, "anatomic pathology services" means:
(a) Histopathology or surgical pathology, meaning the gross and microscopic examination performed by a physician or under the supervision of a physician, including histologic processing;
(b) Cytopathology, meaning the microscopic examination of cells from the following: (i) Fluids, (ii) aspirates, (iii) washings, (iv) brushings, or (v) smears, including the pap test examination performed by a physician or under the supervision of a physician;
(c) Hematology, meaning the microscopic evaluation of bone marrow aspirates and biopsies performed by a physician, or under the supervision of a physician, and peripheral blood smears when the attending or treating physician, or technologist requests that a blood smear be reviewed by a pathologist;
(d) Subcellular pathology or molecular pathology, meaning the assessment of a patient specimen for the detection, localization, measurement, or analysis of one or more protein or nucleic acid targets; and
(e) Blood-banking services performed by pathologists.
(6) The provisions of this section do not prohibit billing of a referring laboratory for anatomic pathology services in instances where a sample or samples must be sent to another physician or laboratory for consultation or histologic processing, except that for purposes of this subsection the term "referring laboratory" does not include a laboratory of a physician's office or group practice that does not perform the professional component of the anatomic pathology service involved.
(7) The uniform disciplinary act, chapter 18.130 RCW, governs the discipline of any practitioner who violates the provisions of this section.
[ 2012 c 100 s 1; 2011 c 128 s 1.]
Notes:
Retroactive application—2012 c 100: "Section 1 of this act applies retroactively to July 22, 2011, so that no entity is liable for having presented or caused to be presented a claim, bill, or demand for payment to a direct patient-provider primary care practice in accordance with section 1(1)(d) of this act." [ 2012 c 100 s 2.]

catchline: Anatomic pathology services—Payment for services—Definitions.


title: RCW 48.43.083

text:
(1) A health carrier must reimburse a chiropractor who has signed a participating provider agreement for services determined by the carrier to be medically necessary if:
(a) The service is:
(i) Covered chiropractic health care, as defined in RCW 48.43.515, by the health plan under which the enrollee received the services; and
(ii) Provided by the chiropractor, or the chiropractor's employee specified in RCW 18.25.190 (2) or (3) who works in the same location as the chiropractor and to whom the chiropractor, pursuant to rules adopted by the Washington state chiropractic quality assurance commission, has delegated the service. The employee must meet the health carrier's reasonable qualifications for all such providers in the relevant class, including but not limited to standards for education and background checks, as applicable; and
(b) The chiropractor complies with the terms and conditions of the participating provider agreement. Violations of the participating provider agreement by an employee of the chiropractor to whom he or she has delegated a service may be deemed by the carrier to have been committed by the chiropractor.
(2) If a health carrier offers a participating provider agreement to a chiropractor within a single practice organized as a sole proprietorship, partnership, or corporation, the carrier must offer the same participating provider agreement to any other chiropractor within that practice providing services at the same location. The agreement may allow either party to terminate it without cause.
[ 2007 c 502 s 1.]
Notes:
Savings—2007 c 502: "This act does not affect any existing right acquired or liability or obligation incurred prior to January 1, 2008." [ 2007 c 502 s 3.]
Severability—2007 c 502: "If any provision of this act or its application to any person or circumstance is held invalid, the remainder of the act or the application of the provision to other persons or circumstances is not affected." [ 2007 c 502 s 4.]
Effective date—2007 c 502: "This act takes effect January 1, 2008." [ 2007 c 502 s 5.]

catchline: Chiropractor services—Participating provider agreement—Health carrier reimbursement.


title: RCW 48.43.085

text:
Notwithstanding any other provision of law, no health carrier subject to the jurisdiction of the state of Washington may prohibit directly or indirectly its enrollees from freely contracting at any time to obtain any health care services outside the health care plan on any terms or conditions the enrollees choose. Nothing in this section shall be construed to bind a carrier for any services delivered outside the health plan. The provisions of this section shall be disclosed pursuant to *RCW 48.43.095(2). The insurance commissioner is prohibited from adopting rules regarding this section.
[ 1996 c 312 s 3.]
Notes:
*Reviser's note: RCW 48.43.095 was repealed by 2000 c 5 s 29, effective July 1, 2001.

catchline: Health carrier may not prohibit its enrollees from contracting for services outside the health care plan.


title: RCW 48.43.087

text:
(1) For purposes of this section:
(a) "Health carrier" includes disability insurers regulated under chapter 48.20 or 48.21 RCW, health care services contractors regulated under chapter 48.44 RCW, plans operating under the health care authority under chapter 41.05 RCW, the basic health plan operating under chapter 70.47 RCW, the state health insurance pool operating under chapter 48.41 RCW, insuring entities regulated under this chapter, and health maintenance organizations regulated under chapter 48.46 RCW.
(b) "Intermediary" means a person duly authorized to negotiate and execute provider contracts with health carriers on behalf of mental health care practitioners.
(c) Consistent with their lawful scopes of practice, "mental health care practitioners" includes only the following: Any generally recognized medical specialty of practitioners licensed under chapter 18.57 or 18.71 RCW who provide mental health services, advanced practice psychiatric nurses as authorized by the state board of nursing under chapter 18.79 RCW, psychologists licensed under chapter 18.83 RCW, and mental health counselors, marriage and family therapists, and social workers licensed under chapter 18.225 RCW.
(d) "Mental health services" means outpatient services.
(2) Consistent with federal and state law and rule, no contract between a mental health care practitioner and an intermediary or between a mental health care practitioner and a health carrier that is written, amended, or renewed after June 6, 1996, may contain a provision prohibiting a practitioner and an enrollee from agreeing to contract for services solely at the expense of the enrollee as follows:
(a) On the exhaustion of the enrollee's mental health care coverage;
(b) During an appeal or an adverse certification process;
(c) When an enrollee's condition is excluded from coverage; or
(d) For any other clinically appropriate reason at any time.
(3) If a mental health care practitioner provides services to an enrollee during an appeal or adverse certification process, the practitioner must provide to the enrollee written notification that the enrollee is responsible for payment of these services, unless the health carrier elects to pay for services provided.
(4) This section does not apply to a mental health care practitioner who is employed full time on the staff of a health carrier.
[ 2025 c 58 s 5050; 2001 c 251 s 33; 1996 c 304 s 1.]
Notes:
Explanatory note—2025 c 58: See note following RCW 1.16.050.
Severability—2001 c 251: See RCW 18.225.900.

catchline: Contracting for services at enrollee's expense—Mental health care practitioner—Conditions—Exception.


title: RCW 48.43.091

text:
Every health carrier that provides coverage for any outpatient mental health service shall comply with the following requirements:
(1) In performing a utilization review of mental health services for a specific enrollee, the utilization review is limited to accessing only the specific health care information contained in the enrollee's record.
(2) In performing an audit of a provider that has furnished mental health services to a carrier's enrollees, the audit is limited to accessing only the records of enrollees covered by the specific health carrier for which the audit is being performed, except as otherwise permitted by RCW 70.02.050 and * 71.05.630.
[ 1999 c 87 s 1.]
Notes:
*Reviser's note: RCW 71.05.630 was repealed by 2013 c 200 s 34, effective July 1, 2014.

catchline: Health carrier coverage of outpatient mental health services—Requirements.


title: RCW 48.43.093

text:
(1)(a) A health carrier shall cover emergency services provided to a covered person if a prudent layperson acting reasonably would have believed that an emergency medical condition existed. In addition, a health carrier shall not require prior authorization of emergency services if a prudent layperson acting reasonably would have believed that an emergency medical condition existed. With respect to care obtained from a nonparticipating hospital emergency department or behavioral health emergency services provider, a health carrier shall cover emergency services. In addition, a health carrier shall not require prior authorization of emergency services.
(b) A health carrier shall cover emergency services without limiting what constitutes an emergency medical condition solely on the basis of diagnosis codes. Any determination of whether the prudent layperson standard has been met must be based on all pertinent documentation and be focused on the presenting symptoms and not solely on the final diagnosis.
(2) Coverage of emergency services may be subject to applicable in-network copayments, coinsurance, and deductibles, as provided in chapter 48.49 RCW.
(3) Nothing in this section is to be construed as prohibiting a health carrier from:
(a) Requiring notification of stabilization or inpatient admission within the time frame specified in its contract with the hospital or behavioral health emergency services provider or as soon thereafter as medically possible but no less than twenty-four hours; or
(b) Requiring a hospital or emergency behavioral health emergency services provider to make a documented good faith effort to notify the covered person's health carrier within 48 hours of stabilization, or by the end of the business day following the day the stabilization occurs, whichever is later, if the covered person needs to be stabilized. If a health carrier requires such notification, the health carrier shall provide access to an authorized representative seven days a week to receive notifications.
(4) Except to the extent provided otherwise in this section, follow-up care that is a direct result of the emergency must be obtained in accordance with the health plan's usual terms and conditions of coverage. All other terms and conditions of coverage may be applied to emergency services.
[ 2022 c 263 s 3; 2019 c 427 s 3; 1997 c 231 s 301.]
Notes:
Effective date—2022 c 263: See note following RCW 43.371.100.
Findings—Intent—Effective date—2019 c 427: See RCW 48.49.003 and 48.49.900.
Short title—Part headings and captions not law—Severability—Effective dates—1997 c 231: See notes following RCW 48.43.005.

catchline: Health carrier coverage of emergency medical services—Requirements—Conditions.


title: RCW 48.43.094

text:
(1) For health plans issued or renewed on or after January 1, 2017:
(a) Benefits shall not be denied for any health care service performed by a pharmacist licensed under chapter 18.64 RCW if:
(i) The service performed was within the lawful scope of such person's license;
(ii) The plan would have provided benefits if the service had been performed by a physician licensed under chapter 18.71 or 18.57 RCW, an *advanced registered nurse practitioner licensed under chapter 18.79 RCW, or a physician's assistant licensed under chapter 18.71A RCW; and
(iii) The pharmacist is included in the plan's network of participating providers; and
(b) The health plan must include an adequate number of pharmacists in its network of participating medical providers.
(2) The participation of pharmacies in the plan network's drug benefit does not satisfy the requirement that plans include pharmacists in their networks of participating medical providers.
(3) For health benefit plans issued or renewed on or after January 1, 2016, but before January 1, 2017, health plans that delegate credentialing agreements to contracted health care facilities must accept credentialing for pharmacists employed or contracted by those facilities. Health plans must reimburse facilities for covered services provided by network pharmacists within the pharmacists' scope of practice per negotiations with the facility.
(4) This section does not supersede the requirements of RCW 48.43.045.
[ 2020 c 80 s 36; 2015 c 237 s 1.]
Notes:
*Reviser's note: The term "advanced registered nurse practitioner" was changed to "advanced practice registered nurse" by 2024 c 239 s 1, effective June 30, 2027.
Effective date—2020 c 80 ss 12-59: See note following RCW 7.68.030.
Intent—2020 c 80: See note following RCW 18.71A.010.
Lead organization and advisory committee—2015 c 237: "(1) The insurance commissioner shall designate a lead organization to establish and facilitate an advisory committee to implement the provisions of section 1 of this act. The lead organization and advisory committee shall develop best practice recommendations on standards for credentialing, privileging, billing, and payment processes to ensure pharmacists are adequately included and appropriately utilized in participating provider networks of health plans. In developing these standards, the committee shall also discuss topics as they relate to implementation including current credentialing requirements for health care providers consistent with chapter 18.64 RCW, existing processes of similarly situated health care providers, pharmacist training, care coordination, and the role of pharmacist prescriptive authority agreements pursuant to WAC 246-863-100.
(2) The lead organization shall create an advisory committee including, but not limited to, representatives of the following stakeholders:
(a) The insurance commissioner or designee;
(b) The secretary of health or designee;
(c) An organization representing pharmacists;
(d) An organization representing physicians;
(e) An organization representing hospitals;
(f) A hospital conducting internal credentialing of pharmacists;
(g) A clinic with pharmacists providing medical services;
(h) A community pharmacy with pharmacists providing medical services;
(i) The two largest health carriers in Washington based upon enrollment;
(j) A health care system that coordinates care and coverage;
(k) A school or college of pharmacy in Washington;
(l) A representative from a pharmacy benefit manager or organization that represents pharmacy benefit managers; and
(m) Other representatives appointed by the insurance commissioner.
(3) No later than December 1, 2015, the advisory committee shall present initial best practice recommendations to the insurance commissioner and the department of health. If necessary, the insurance commissioner or department of health may adopt rules to implement the standards developed by the lead organization and advisory committee. The advisory committee will remain intact to assist the insurance commissioner or department of health in rule making. The rules adopted by the insurance commissioner or the department of health must be consistent with the recommendations developed by the advisory committee.
(4) For purposes of this section, "lead organization" means a private sector organization or organizations designated by the insurance commissioner to lead development of processes, guidelines, and standards to streamline health care administration to be adopted by payors and providers of health care services operating in the state." [ 2015 c 237 s 3.]
PDF
RCW 48.43.094
Pharmacist provided services—Health plan requirements. (Effective June 30, 2027.)
(1) For health plans issued or renewed on or after January 1, 2017:
(a) Benefits shall not be denied for any health care service performed by a pharmacist licensed under chapter 18.64 RCW if:
(i) The service performed was within the lawful scope of such person's license;
(ii) The plan would have provided benefits if the service had been performed by a physician licensed under chapter 18.71 or 18.57 RCW, an advanced practice registered nurse licensed under chapter 18.79 RCW, or a physician's assistant licensed under chapter 18.71A RCW; and
(iii) The pharmacist is included in the plan's network of participating providers; and
(b) The health plan must include an adequate number of pharmacists in its network of participating medical providers.
(2) The participation of pharmacies in the plan network's drug benefit does not satisfy the requirement that plans include pharmacists in their networks of participating medical providers.
(3) For health benefit plans issued or renewed on or after January 1, 2016, but before January 1, 2017, health plans that delegate credentialing agreements to contracted health care facilities must accept credentialing for pharmacists employed or contracted by those facilities. Health plans must reimburse facilities for covered services provided by network pharmacists within the pharmacists' scope of practice per negotiations with the facility.
(4) This section does not supersede the requirements of RCW 48.43.045.
[ 2025 c 58 s 5104; 2020 c 80 s 36; 2015 c 237 s 1.]
Notes:
Effective date—2025 c 58 ss 5058-5170: See note following RCW 7.68.030.
Explanatory note—2025 c 58: See note following RCW 1.16.050.
Effective date—2020 c 80 ss 12-59: See note following RCW 7.68.030.
Intent—2020 c 80: See note following RCW 18.71A.010.
Lead organization and advisory committee—2015 c 237: "(1) The insurance commissioner shall designate a lead organization to establish and facilitate an advisory committee to implement the provisions of section 1 of this act. The lead organization and advisory committee shall develop best practice recommendations on standards for credentialing, privileging, billing, and payment processes to ensure pharmacists are adequately included and appropriately utilized in participating provider networks of health plans. In developing these standards, the committee shall also discuss topics as they relate to implementation including current credentialing requirements for health care providers consistent with chapter 18.64 RCW, existing processes of similarly situated health care providers, pharmacist training, care coordination, and the role of pharmacist prescriptive authority agreements pursuant to WAC 246-863-100.
(2) The lead organization shall create an advisory committee including, but not limited to, representatives of the following stakeholders:
(a) The insurance commissioner or designee;
(b) The secretary of health or designee;
(c) An organization representing pharmacists;
(d) An organization representing physicians;
(e) An organization representing hospitals;
(f) A hospital conducting internal credentialing of pharmacists;
(g) A clinic with pharmacists providing medical services;
(h) A community pharmacy with pharmacists providing medical services;
(i) The two largest health carriers in Washington based upon enrollment;
(j) A health care system that coordinates care and coverage;
(k) A school or college of pharmacy in Washington;
(l) A representative from a pharmacy benefit manager or organization that represents pharmacy benefit managers; and
(m) Other representatives appointed by the insurance commissioner.
(3) No later than December 1, 2015, the advisory committee shall present initial best practice recommendations to the insurance commissioner and the department of health. If necessary, the insurance commissioner or department of health may adopt rules to implement the standards developed by the lead organization and advisory committee. The advisory committee will remain intact to assist the insurance commissioner or department of health in rule making. The rules adopted by the insurance commissioner or the department of health must be consistent with the recommendations developed by the advisory committee.
(4) For purposes of this section, "lead organization" means a private sector organization or organizations designated by the insurance commissioner to lead development of processes, guidelines, and standards to streamline health care administration to be adopted by payors and providers of health care services operating in the state." [ 2015 c 237 s 3.]

catchline: Pharmacist provided services—Health plan requirements. (Effective until June 30, 2027.)


title: RCW 48.43.096

text:
(1) A health benefit plan issued or renewed after December 31, 2015, that provides coverage for prescription drugs must implement a medication synchronization policy for the dispensing of prescription drugs to the plan's enrollees.
(a) If an enrollee requests medication synchronization for a new prescription, the health plan must permit filling the drug: (i) For less than a one-month supply of the drug if synchronization will require more than a fifteen-day supply of the drug; or (ii) for more than a one-month supply of the drug if synchronization will require a fifteen-day supply of the drug or less.
(b) The health benefit plan shall adjust the enrollee cost-sharing for a prescription drug subject to coinsurance that is dispensed for less than the standard refill amount for the purpose of synchronizing the medications.
(c) The health benefit plan shall adjust the enrollee cost-sharing for a prescription drug with a copayment that is dispensed for less than the standard refill amount for the purpose of synchronizing the medications by:
(i) Discounting the copayment rate by fifty percent;
(ii) Discounting the copayment rate based on fifteen-day increments; or
(iii) Any other method that meets the intent of this section and is approved by the office of the insurance commissioner.
(2) Upon request of an enrollee, the prescribing provider or pharmacist shall:
(a) Determine that filling or refilling the prescription is in the best interest of the enrollee, taking into account the appropriateness of synchronization for the drug being dispensed;
(b) Inform the enrollee that the prescription will be filled to less than the standard refill amount for the purpose of synchronizing his or her medications; and
(c) Deny synchronization on the grounds of threat to patient safety or suspected fraud or abuse.
(3) For purposes of this section, the following terms have the following meanings unless the context clearly requires otherwise:
(a) "Medication synchronization" means the coordination of medication refills for a patient taking two or more medications for a chronic condition such that the patient's medications are refilled on the same schedule for a given time period.
(b) "Prescription" has the same meaning as in RCW 18.64.011.
[ 2015 c 213 s 1.]

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


title: RCW 48.43.0961

text:
(1) Except as provided in subsection (2) of this section, for health plans that include prescription drug coverage issued or renewed on or after January 1, 2025, a health carrier or its health care benefit manager may not require the substitution of a nonpreferred drug with a preferred drug in a given therapeutic class, or increase an enrollee's cost-sharing obligation mid-plan year for the drug, if the prescription is for a refill of an antipsychotic, antidepressant, antiepileptic, or other drug prescribed to the enrollee to treat a serious mental illness, the enrollee is medically stable on the drug, and a participating provider continues to prescribe the drug.
(2) Nothing in this section prohibits:
(a) The carrier from requiring generic substitution during the current plan year;
(b) The carrier from adding new drugs to its formulary during the current plan year;
(c) The carrier from removing a drug from its formulary for reasons of patient safety concerns, drug recall or removal from the market, or medical evidence indicating no therapeutic effect of the drug; or
(d) A participating provider from prescribing a different drug that is covered by the plan and medically appropriate for the enrollee.
(3) For the purposes of this section:
(a) "Refill" means a second or subsequent filling of a previously issued prescription.
(b) "Serious mental illness" means a mental disorder, as defined in the most recent edition of the diagnostic and statistical manual of mental disorders published by the American psychiatric association, that results in serious functional impairment that substantially interferes with or limits one or more major life activities.
[ 2023 c 325 s 1.]

catchline: Continuity of coverage for health plans covering prescription drugs for behavioral health.


title: RCW 48.43.097

text:
Every health carrier holding a registration from the commissioner shall file its financial statements as required by this code and by the commissioner in accordance with the accounting practices and procedures manuals as adopted by the national association of insurance commissioners, unless otherwise provided by law.
[ 1999 c 33 s 3.]

catchline: Filing of financial statements—Every health carrier.


title: RCW 48.43.105

text:
(1) A public or private entity who exercises due diligence in preparing a document of any kind that compares health carriers of any kind is immune from civil liability from claims based on the document and the contents of the document.
(2)(a) There is absolute immunity to civil liability from claims based on such a comparison document and its contents if the information was provided by the carrier, was substantially accurately presented, and contained the effective date of the information that the carrier supplied, if any.
(b) Where due diligence efforts to obtain accurate information have been taken, there is immunity from claims based on such a comparison document and its contents if the publisher of the comparison document asked for such information from the carrier, was refused, and relied on any usually reliable source for the information including, but not limited to, carrier enrollees, customers, insurance producers, or providers. The carrier enrollees, customers, insurance producers, or providers are likewise immune from civil liability on claims based on information they provided if they believed the information to be accurate and had exercised due diligence in their efforts to confirm the accuracy of the information provided.
(3) The immunity from liability contained in this section applies only if the comparison document contains the following in a conspicuous place and in easy to read typeface:
This comparison is based on information believed to be reliable by its publisher, but the accuracy of the information cannot be guaranteed. Caution is suggested to all readers who are encouraged to confirm data of importance to the reader before any purchasing or other decisions are made.
(4) The insurance commissioner is prohibited from adopting rules regarding this section.
[ 2008 c 217 s 48; 1996 c 312 s 5.]
Notes:
Severability—Effective date—2008 c 217: See notes following RCW 48.03.020.

catchline: Preparation of documents that compare health carriers—Immunity—Due diligence.


title: RCW 48.43.115

text:
(1) The legislature recognizes the role of health care providers as the appropriate authority to determine and establish the delivery of quality health care services to maternity patients and their newly born children. It is the intent of the legislature to recognize patient preference and the clinical sovereignty of providers as they make determinations regarding services provided and the length of time individual patients may need to remain in a health care facility after giving birth. It is not the intent of the legislature to diminish a carrier's ability to utilize managed care strategies but to ensure the clinical judgment of the provider is not undermined by restrictive carrier contracts or utilization review criteria that fail to recognize individual postpartum needs.
(2) Unless otherwise specifically provided, the following definitions apply throughout this section:
(a) "Attending provider" means a provider who: Has clinical hospital privileges consistent with RCW 70.43.020; is included in a provider network of the carrier that is providing coverage; and is a physician licensed under chapter 18.57 or 18.71 RCW, a certified nurse midwife licensed under chapter 18.79 RCW, a midwife licensed under chapter 18.50 RCW, a physician's assistant licensed under chapter 18.71A RCW, or an *advanced registered nurse practitioner licensed under chapter 18.79 RCW.
(b) "Health carrier" or "carrier" means disability insurers regulated under chapter 48.20 or 48.21 RCW, health care services contractors regulated under chapter 48.44 RCW, health maintenance organizations regulated under chapter 48.46 RCW, plans operating under the health care authority under chapter 41.05 RCW, the state health insurance pool operating under chapter 48.41 RCW, and insuring entities regulated under this chapter.
(3)(a) Every health carrier that provides coverage for maternity services must permit the attending provider, in consultation with the mother, to make decisions on the length of inpatient stay, rather than making such decisions through contracts or agreements between providers, hospitals, and insurers. These decisions must be based on accepted medical practice.
(b) Covered eligible services may not be denied for inpatient, postdelivery care to a mother and her newly born child after a vaginal delivery or a cesarean section delivery for such care as ordered by the attending provider in consultation with the mother.
(c) At the time of discharge, determination of the type and location of follow-up care must be made by the attending provider in consultation with the mother rather than by contract or agreement between the hospital and the insurer. These decisions must be based on accepted medical practice.
(d) Covered eligible services may not be denied for follow-up care, including in-person care, as ordered by the attending provider in consultation with the mother. Coverage for providers of follow-up services must include, but need not be limited to, attending providers as defined in this section, home health agencies licensed under chapter 70.127 RCW, and registered nurses licensed under chapter 18.79 RCW.
(e) This section does not require attending providers to authorize care they believe to be medically unnecessary.
(f) Coverage for the newly born child must be no less than the coverage of the child's mother for no less than three weeks, even if there are separate hospital admissions.
(4) A carrier that provides coverage for maternity services may not deselect, terminate the services of, require additional documentation from, require additional utilization review of, reduce payments to, or otherwise provide financial disincentives to any attending provider or health care facility solely as a result of the attending provider or health care facility ordering care consistent with this section. This section does not prevent any insurer from reimbursing an attending provider or health care facility on a capitated, case rate, or other financial incentive basis.
(5) Every carrier that provides coverage for maternity services must provide notice to policyholders regarding the coverage required under this section. The notice must be in writing and must be transmitted at the earliest of the next mailing to the policyholder, the yearly summary of benefits sent to the policyholder, or January 1 of the year following June 6, 1996.
(6) This section does not establish a standard of medical care.
(7) This section applies to coverage for maternity services under a contract issued or renewed by a health carrier after June 6, 1996, and applies to plans operating under the health care authority under chapter 41.05 RCW beginning January 1, 1998.
[ 2020 c 80 s 37; 2003 c 248 s 14; 1996 c 281 s 1.]
Notes:
*Reviser's note: The term "advanced registered nurse practitioner" was changed to "advanced practice registered nurse" by 2024 c 239 s 1, effective June 30, 2027.
Effective date—2020 c 80 ss 12-59: See note following RCW 7.68.030.
Intent—2020 c 80: See note following RCW 18.71A.010.
Short title—1996 c 281: "This act shall be known as "the Erin Act."" [ 1996 c 281 s 3.]
PDF
RCW 48.43.115
Maternity services—Intent—Definitions—Patient preference—Clinical sovereignty of provider—Notice to policyholders—Application. (Effective June 30, 2027.)
(1) The legislature recognizes the role of health care providers as the appropriate authority to determine and establish the delivery of quality health care services to maternity patients and their newly born children. It is the intent of the legislature to recognize patient preference and the clinical sovereignty of providers as they make determinations regarding services provided and the length of time individual patients may need to remain in a health care facility after giving birth. It is not the intent of the legislature to diminish a carrier's ability to utilize managed care strategies but to ensure the clinical judgment of the provider is not undermined by restrictive carrier contracts or utilization review criteria that fail to recognize individual postpartum needs.
(2) Unless otherwise specifically provided, the following definitions apply throughout this section:
(a) "Attending provider" means a provider who: Has clinical hospital privileges consistent with RCW 70.43.020; is included in a provider network of the carrier that is providing coverage; and is a physician licensed under chapter 18.57 or 18.71 RCW, a certified nurse midwife licensed under chapter 18.79 RCW, a midwife licensed under chapter 18.50 RCW, a physician's assistant licensed under chapter 18.71A RCW, or an advanced practice registered nurse licensed under chapter 18.79 RCW.
(b) "Health carrier" or "carrier" means disability insurers regulated under chapter 48.20 or 48.21 RCW, health care services contractors regulated under chapter 48.44 RCW, health maintenance organizations regulated under chapter 48.46 RCW, plans operating under the health care authority under chapter 41.05 RCW, the state health insurance pool operating under chapter 48.41 RCW, and insuring entities regulated under this chapter.
(3)(a) Every health carrier that provides coverage for maternity services must permit the attending provider, in consultation with the mother, to make decisions on the length of inpatient stay, rather than making such decisions through contracts or agreements between providers, hospitals, and insurers. These decisions must be based on accepted medical practice.
(b) Covered eligible services may not be denied for inpatient, postdelivery care to a mother and her newly born child after a vaginal delivery or a cesarean section delivery for such care as ordered by the attending provider in consultation with the mother.
(c) At the time of discharge, determination of the type and location of follow-up care must be made by the attending provider in consultation with the mother rather than by contract or agreement between the hospital and the insurer. These decisions must be based on accepted medical practice.
(d) Covered eligible services may not be denied for follow-up care, including in-person care, as ordered by the attending provider in consultation with the mother. Coverage for providers of follow-up services must include, but need not be limited to, attending providers as defined in this section, home health agencies licensed under chapter 70.127 RCW, and registered nurses licensed under chapter 18.79 RCW.
(e) This section does not require attending providers to authorize care they believe to be medically unnecessary.
(f) Coverage for the newly born child must be no less than the coverage of the child's mother for no less than three weeks, even if there are separate hospital admissions.
(4) A carrier that provides coverage for maternity services may not deselect, terminate the services of, require additional documentation from, require additional utilization review of, reduce payments to, or otherwise provide financial disincentives to any attending provider or health care facility solely as a result of the attending provider or health care facility ordering care consistent with this section. This section does not prevent any insurer from reimbursing an attending provider or health care facility on a capitated, case rate, or other financial incentive basis.
(5) Every carrier that provides coverage for maternity services must provide notice to policyholders regarding the coverage required under this section. The notice must be in writing and must be transmitted at the earliest of the next mailing to the policyholder, the yearly summary of benefits sent to the policyholder, or January 1 of the year following June 6, 1996.
(6) This section does not establish a standard of medical care.
(7) This section applies to coverage for maternity services under a contract issued or renewed by a health carrier after June 6, 1996, and applies to plans operating under the health care authority under chapter 41.05 RCW beginning January 1, 1998.
[ 2025 c 58 s 5105; 2020 c 80 s 37; 2003 c 248 s 14; 1996 c 281 s 1.]
Notes:
Effective date—2025 c 58 ss 5058-5170: See note following RCW 7.68.030.
Explanatory note—2025 c 58: See note following RCW 1.16.050.
Effective date—2020 c 80 ss 12-59: See note following RCW 7.68.030.
Intent—2020 c 80: See note following RCW 18.71A.010.
Short title—1996 c 281: "This act shall be known as "the Erin Act."" [ 1996 c 281 s 3.]

catchline: Maternity services—Intent—Definitions—Patient preference—Clinical sovereignty of provider—Notice to policyholders—Application. (Effective until June 30, 2027.)


title: RCW 48.43.121

text:
(1) For health plans issued or renewed on or after January 1, 2025, a health carrier shall provide coverage for ground ambulance transports to behavioral health emergency services providers for enrollees who are experiencing an emergency medical condition as defined in RCW 48.43.005. A health carrier may not require prior authorization of ground ambulance services if a prudent layperson acting reasonably would have believed that an emergency medical condition existed.
(2) Coverage of ground ambulance transports to behavioral health emergency services providers may be subject to applicable in-network copayments, coinsurance, and deductibles, as provided in chapter 48.49 RCW.
[ 2024 c 218 s 12.]

catchline: Ground ambulance services organizations—Coverage.


title: RCW 48.43.125

text:
(1) A carrier that provides coverage for a person at a long-term care facility following the person's hospitalization shall, upon the request of the person or his or her legal representative as authorized in RCW 7.70.065, provide such coverage at the facility in which the person resided immediately prior to the hospitalization if:
(a) The person's primary care physician determines that the medical care needs of the person can be met at the requested facility;
(b) The requested facility has all applicable licenses and certifications, and is not under a stop placement order that prevents the person's readmission;
(c) The requested facility agrees to accept payment from the carrier for covered services at the rate paid to similar facilities that otherwise contract with the carrier to provide such services; and
(d) The requested facility, with regard to the following, agrees to abide by the standards, terms, and conditions required by the carrier of similar facilities with which the carrier otherwise contracts: (i) Utilization review, quality assurance, and peer review; and (ii) management and administrative procedures, including data and financial reporting that may be required by the carrier.
(2) For purposes of this section, "long-term care facility" or "facility" means a nursing facility licensed under chapter 18.51 RCW, continuing care retirement community defined under RCW 70.38.025, or assisted living facility licensed under chapter 18.20 RCW.
[ 2012 c 10 s 43; 1999 c 312 s 2.]
Notes:
Application—2012 c 10: See note following RCW 18.20.010.
Findings—1999 c 312: "The legislature finds that a long-term care facility is home for any individual who resides there, and the individual has the right to receive services in his or her own home and to be cared for by the organization with which he or she has a contractual agreement to provide housing and related services. The legislature further finds that restricting individuals from returning to the long-term care facility in which they were residing prior to hospitalization may detrimentally impact the health and well-being of frail individuals and their families." [ 1999 c 312 s 1.]
Short title—1999 c 312: "This act may be known and cited as the Kitson act." [ 1999 c 312 s 3.]

catchline: Coverage at a long-term care facility following hospitalization—Definition.


title: RCW 48.43.135

text:
(1) For nongrandfathered group health plans other than small group health plans issued or renewed on or after January 1, 2024, and for health plans issued or renewed on or after January 1, 2026, a health carrier shall include coverage for hearing instruments, including bone conduction hearing devices. This section does not include coverage of over-the-counter hearing instruments.
(2) Coverage shall also include the initial assessment, fitting, adjustment, auditory training, and ear molds as necessary to maintain optimal fit. Coverage of the services in this subsection shall include services for enrollees who intend to obtain or have already obtained any hearing instrument, including an over-the-counter hearing instrument.
(3)(a) Until the date specified in (b) of this subsection, a health carrier shall provide coverage for hearing instruments as provided in subsection (1) of this section at no less than $3,000 per ear with hearing loss every 36 months.
(b) For health plans issued or renewed on or after January 1, 2026, a health carrier shall provide coverage for hearing instruments as provided in subsection (1) of this section every 36 months per ear with hearing loss and may not establish any lifetime or annual limit on the dollar amount of coverage for services described in subsection (1) or (2) of this section for any individual, whether provided in-network or out-of-network.
(c) A health carrier may require prior authorization or adopt other appropriate utilization controls in approving coverage for medically necessary hearing instruments.
(4) The services and hearing instruments covered under this section are not subject to the enrollee's deductible unless the health plan is offered as a qualifying health plan for a health savings account. For such a qualifying health plan, the carrier may apply a deductible to coverage of the services covered under this section only at the minimum level necessary to preserve the enrollee's ability to claim tax exempt contributions and withdrawals from the enrollee's health savings account under internal revenue service laws and regulations.
(5) Coverage for a minor under 18 years of age shall be available under this section only after the minor has received medical clearance within the preceding six months from:
(a) An otolaryngologist for an initial evaluation of hearing loss; or
(b) A licensed physician, which indicates there has not been a substantial change in clinical status since the initial evaluation by an otolaryngologist.
(6) For the purposes of this section:
(a) "Hearing instrument" has the same meaning as defined in RCW 18.35.010.
(b) "Over-the-counter hearing instrument" has the same meaning as "over-the-counter hearing aid" in 21 C.F.R. Sec. 800.30 as of December 28, 2022.
[ 2025 c 243 s 9; 2023 c 245 s 1.]

catchline: Hearing instruments—Coverage.


title: RCW 48.43.176

text:
(1) Each health benefit plan issued or renewed after December 31, 2015, must offer benefits or coverage for medically necessary elemental formula, regardless of delivery method, when a licensed physician or other health care provider with prescriptive authority:
(a) Diagnoses a patient with an eosinophilic gastrointestinal associated disorder; and
(b) Orders and supervises the use of the elemental formula.
(2) Nothing in this section prohibits a health benefit plan from requiring prior authorization or imposing other appropriate utilization controls in approving coverage for medically necessary elemental formula.
[ 2014 c 115 s 2.]

catchline: Eosinophilic gastrointestinal associated disorder—Elemental formula.


title: RCW 48.43.180

text:
Notwithstanding any provision of any certified health plan covering dental care as provided for in this chapter, effective January 1, 1995, benefits shall not be denied thereunder for any service performed by a denturist licensed under chapter 18.30 RCW if (1) the service performed was within the lawful scope of such person's license, and (2) such plan would have provided benefits if such service had been performed by a dentist licensed under chapter 18.32 RCW.
[ 1995 c 1 s 23 (Initiative Measure No. 607, approved November 8, 1994).]
Notes:
Short title—1995 c 1 (Initiative Measure No. 607): See RCW 18.30.900.

catchline: Denturist services.


title: RCW 48.43.185

text:
(1) Each group health benefit plan that provides coverage for hospital, medical, or ambulatory surgery center services must cover general anesthesia services and related facility charges in conjunction with any dental procedure performed in a hospital or ambulatory surgical center if such anesthesia services and related facility charges are medically necessary because the covered person:
(a) Is under the age of seven, or physically or developmentally disabled, with a dental condition that cannot be safely and effectively treated in a dental office; or
(b) Has a medical condition that the person's physician determines would place the person at undue risk if the dental procedure were performed in a dental office. The procedure must be approved by the person's physician.
(2) Each group health benefit plan or group dental plan that provides coverage for dental services must cover medically necessary general anesthesia services in conjunction with any covered dental procedure performed in a dental office if the general anesthesia services are medically necessary because the covered person is under the age of seven or physically or developmentally disabled.
(3) This section does not prohibit a group health benefit plan or group dental plan from:
(a) Applying cost-sharing requirements, maximum annual benefit limitations, and prior authorization requirements to the services required under this section; or
(b) Covering only those services performed by a health care provider, or in a health care facility, that is part of its provider network; nor does it limit the health carrier in negotiating rates and contracts with specific providers.
(4) This section does not apply to medicare supplement policies, or supplemental contracts covering a specified disease or other limited benefits.
(5) For the purpose of this section, "general anesthesia services" means services to induce a state of unconsciousness accompanied by a loss of protective reflexes, including the ability to maintain an airway independently and respond purposefully to physical stimulation or verbal command.
(6) This section applies to group health benefit plans and group dental plans issued or renewed on or after January 1, 2002.
[ 2001 c 321 s 2.]

catchline: General anesthesia services for dental procedures.


title: RCW 48.43.190

text:
(1)(a) A health carrier may not pay a chiropractor less for a service or procedure identified under a particular physical medicine and rehabilitation code, evaluation and management code, or spinal manipulation code, as listed in a nationally recognized services and procedures code book such as the American medical association current procedural terminology code book, than it pays any other type of provider licensed under Title 18 RCW for a service or procedure under the same or substantially similar code, except as provided in (b) of this subsection. A carrier may not circumvent this requirement by creating a chiropractor-specific code not listed in the nationally recognized code book otherwise used by the carrier for provider payment.
(b) This section does not affect a health carrier's:
(i) Implementation of a health care quality improvement program to promote cost-effective and clinically efficacious health care services, including but not limited to pay-for-performance payment methodologies and other programs fairly applied to all health care providers licensed under Title 18 RCW that are designed to promote evidence-based and research-based practices;
(ii) Health care provider contracting to comply with the network adequacy standards;
(iii) Authority to pay in-network providers differently than out-of-network providers; and
(iv) Authority to pay a chiropractor less than another provider for procedures or services under the same or a substantially similar code based upon differences in the cost of maintaining a practice or carrying malpractice insurance, as recognized by a nationally accepted reimbursement methodology.
(c) This section does not, and may not be construed to:
(i) Require the payment of provider billings that do not meet the definition of a clean claim as set forth in rules adopted by the commissioner;
(ii) Require any health plan to include coverage of any condition; or
(iii) Expand the scope of practice for any health care provider.
(2) This section applies only to payments made on or after January 1, 2009.
[ 2018 c 181 s 1; 2008 c 304 s 1.]
Notes:
Rules—2018 c 181 s 1: "The office of the insurance commissioner may adopt any rules necessary to implement section 1 of this act." [ 2018 c 181 s 2.]
Effective date—2018 c 181 s 1: "Section 1 of this act takes effect January 1, 2019." [ 2018 c 181 s 3.]

catchline: Payment of chiropractic services—Parity.