title: RCW 48.21.047

text:
(1) An insurer may not offer any health benefit plan to any small employer without complying with RCW 48.21.045(3).
(2) Employers purchasing health plans provided through associations or through member-governed groups formed specifically for the purpose of purchasing health care are not small employers and the plans are not subject to RCW 48.21.045(3).
(3) For purposes of this section, "health benefit plan," "health plan," and "small employer" mean the same as defined in RCW 48.43.005.
(4) For purposes of this section, "census date" has the same meaning as defined in RCW 48.44.010.
[ 2010 c 292 s 8; 2005 c 223 s 11; 1995 c 265 s 22.]
Notes:
Application—2010 c 292: See note following RCW 48.43.005.
Captions not law—Effective dates—Savings—Severability—1995 c 265: See notes following RCW 70.47.015.

catchline: Requirements for plans offered to small employers—Definitions.


doc_type: statute

jurisdiction: wa

title: RCW 48.21.050

text:
Every policy of group or blanket disability insurance shall contain in substance the provisions as set forth in RCW 48.21.060 to 48.21.090, inclusive, or provisions which in the opinion of the commissioner are more favorable to the individuals insured, or at least as favorable to such individuals and more favorable to the policyholder. No such policy of group or blanket disability insurance shall contain any provision relative to notice or proof of loss, or to the time for paying benefits, or to the time within which suit may be brought upon the policy, which in the opinion of the commissioner is less favorable to the individuals insured than would be permitted by the standard provisions required for individual disability insurance policies.
[1947 c 79 s .21.05; Rem. Supp. 1947 s 45.21.05.]

license: public-domain-government-work

rule_set: Revised Code of Washington

catchline: Standard provisions required.

code: rcw

unit: section

court: Washington State Legislature


title: RCW 48.21.060

text:
There shall be a provision that a copy of the application, if any, of the policyholder shall be attached to the policy when issued; that all statements made by the policyholder or by the individuals insured shall in the absence of fraud be deemed representations and not warranties, and that no statement made by any individual insured shall be used in any contest unless a copy of the instrument containing the statement is or has been furnished to such individual or to his or her beneficiary, if any.
[ 2009 c 549 s 7102; 1947 c 79 s .21.06; Rem. Supp. 1947 s 45.21.06.]

catchline: The contract—Representations.


title: RCW 48.21.070

text:
There shall be a provision that all premiums due under the policy shall be remitted by the employer or employers of the persons insured, by the policyholder, or by some other designated person acting on behalf of the association or group insured, to the insurer on or before the due date thereof with such period of grace as may be specified therein.
[1947 c 79 s .21.07; Rem. Supp. 1947 s 45.21.07.]

catchline: Payment of premiums.


title: RCW 48.21.075

text:
Any employee whose compensation includes group disability or blanket disability insurance providing health care services, the premiums for which are paid in full or in part by an employer including the state of Washington, its political subdivisions, or municipal corporations, or paid by payroll deduction, may pay the premiums as they become due directly to the policyholder whenever the employee's compensation is suspended or terminated directly or indirectly as the result of a strike, lockout, or other labor dispute, for a period not exceeding six months and at the rate and coverages as the policy provides. During that period of time the policy may not be altered or changed. Nothing in this section shall be deemed to impair the right of the insurer to make normal decreases or increases of the premium rate upon expiration and renewal of the policy, in accordance with the provisions of the policy. Thereafter, if such insurance coverage is no longer available, then the employee shall be given the opportunity to purchase an individual policy at a rate consistent with rates filed by the insurer with the commissioner. When the employee's compensation is so suspended or terminated, the employee shall be notified immediately by the policyholder in writing, by mail addressed to the address last on record with the policyholder, that the employee may pay the premiums to the policyholder as they become due as provided in this section.
Payment of the premiums must be made when due or the insurance coverage may be terminated by the insurer.
The provisions of any insurance policy contrary to provisions of this section are void and unenforceable after May 29, 1975.
[ 1975 1st ex.s. c 117 s 1.]
Notes:
Severability—1975 1st ex.s. c 117: "If any provision of this 1975 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." [ 1975 1st ex.s. c 117 s 4.]

catchline: Payment of premiums by employee in event of suspension of compensation due to labor dispute.


title: RCW 48.21.080

text:
In group disability insurance policies there shall be a provision that the insurer shall issue to the employer, the policyholder, or other person or association in whose name such policy is issued, for delivery to each insured employee or member, a certificate setting forth in summary form a statement of the essential features of the insurance coverage, and to whom the benefits thereunder are payable described by name, relationship, or reference to the insurance records of the policyholder or insurer. If family members are insured, only one certificate need be issued for each family. This section shall not apply to blanket disability insurance policies.
[ 1961 c 194 s 6; 1947 c 79 s .21.08; Rem. Supp. 1947 s 45.21.08.]

catchline: Certificates of coverage.


title: RCW 48.21.090

text:
There shall be a provision specifying the ages, if any there be, to which the insurance provided therein shall be limited; and the ages, if any there be, for which additional restrictions are placed on benefits, and the additional restrictions placed on the benefits at such ages.
[1947 c 79 s .21.09; Rem. Supp. 1947 s 45.21.09.]

catchline: Age limitations.


title: RCW 48.21.100

text:
There may be a provision that the insurer shall have the right and opportunity to examine the person of the insured employee, member or dependent when and so often as it may reasonably require during the pendency of claim under the policy and also the right and opportunity to make an autopsy in case of death where it is not prohibited by law.
[1947 c 79 s .21.10; Rem. Supp. 1947 s 45.21.10.]

catchline: Examination and autopsy.


title: RCW 48.21.110

text:
The benefits payable under any policy or contract of group or blanket disability insurance shall be payable to the employee or other insured member of the group or to the beneficiary designated by him or her, other than the policyholder, employer or the association or any officer thereof as such, subject to provisions of the policy in the event there is no designated beneficiary as to all or any part of any sum payable at the death of the individual insured.
The policy may provide that any hospital, medical, or surgical benefits thereunder may be made payable jointly to the insured employee or member and the person furnishing such hospital, medical, or surgical services.
[ 2009 c 549 s 7103; 1955 c 303 s 17; 1947 c 79 s .21.11; Rem. Supp. 1947 s 45.21.11.]

catchline: Payment of benefits.


title: RCW 48.21.120

text:
Any contract of group disability insurance may provide for the readjustment of the rate of premium based on the experience thereunder at the end of the first year or of any subsequent year of insurance thereunder, and such readjustment may be made retroactive only for such policy year. Any refund under any plan for readjustment of the rate of premium based on the experience under group policies heretofore or hereafter issued, and any dividend paid under such policies may be used to reduce the employer's share of the cost of the coverage, except that if the aggregate refunds or dividends under such group policy and any other group policy or contract issued to the policyholder exceed the aggregate contributions of the employer toward the cost of the coverages, such excess shall be applied by the policyholder for the sole benefit of insured employees.
[1947 c 79 s .21.12; Rem. Supp. 1947 s 45.21.12.]

catchline: Readjustment of premiums—Dividends.


title: RCW 48.21.125

text:
An insurer may not deny coverage for the treatment of an injury solely because the injury was sustained as a consequence of the insured's being intoxicated or under the influence of a narcotic.
[ 2004 c 112 s 3.]
Notes:
Finding—Application—2004 c 112: See notes following RCW 48.20.385.

catchline: When injury caused by intoxication or use of narcotics.


title: RCW 48.21.130

text:
Notwithstanding any provision of any group disability insurance contract or blanket disability insurance contract, benefits shall not be denied thereunder for any medical or surgical service performed by a holder of a license issued pursuant to chapter 18.22 RCW provided that (1) the service performed was within the lawful scope of such person's license, and (2) such contract would have provided benefits if such service had been performed by a holder of a license issued pursuant to chapter 18.71 RCW.
[ 1963 c 87 s 2.]
Notes:
Application—1963 c 87: Nonapplicability to prior contracts and certain renewals, see note following RCW 48.20.390.

catchline: Podiatric medicine and surgery.


title: RCW 48.21.140

text:
Notwithstanding any provision of any group disability insurance contract or blanket disability insurance contract, benefits shall not be denied thereunder for any eye care service rendered by a holder of a license issued pursuant to chapter 18.53 RCW, provided, that (1) the service rendered was within the lawful scope of such person's license, and (2) such contract would have provided the benefits for such service if rendered by a holder of a license issued pursuant to chapter 18.71 RCW.
[ 1965 c 149 s 3.]
Notes:
Construction—1965 c 149: Nonapplicability to prior contracts and certain renewals, see note following RCW 48.20.410.

catchline: Optometry.


title: RCW 48.21.141

text:
Notwithstanding any provision of any group disability insurance contract or blanket disability insurance contract as provided for in this chapter, benefits shall not be denied thereunder for any health service performed by a holder of a license for registered nursing practice or *advanced registered nursing practice issued pursuant to chapter 18.79 RCW if (1) the service performed was within the lawful scope of such person's license, and (2) such contract would have provided benefits if such service had been performed by a holder of a license issued pursuant to chapter 18.71 RCW: PROVIDED, HOWEVER, That no provision of chapter 18.71 RCW shall be asserted to deny benefits under this section.
The provisions of this section are intended to be remedial and procedural to the extent they do not impair the obligation of any existing contract.
[ 1994 sp.s. c 9 s 730; 1973 1st ex.s. c 188 s 4.]
Notes:
*Reviser's note: The term "advanced registered nursing practice" was changed to "advanced practice registered nursing" by 2024 c 239 s 3, effective June 30, 2027.
Severability—Headings and captions not law—Effective date—1994 sp.s. c 9: See RCW 18.79.900 through 18.79.902.
Severability—1973 1st ex.s. c 188: See note following RCW 48.18.298.

catchline: Registered nurses or advanced registered nurses.


title: RCW 48.21.142

text:
Notwithstanding any provision of any group disability insurance contract or blanket disability insurance contract as provided for in this chapter, benefits shall not be denied thereunder for any health service performed by a holder of a license issued pursuant to chapter 18.25 RCW if (1) the service performed was within the lawful scope of such person's license, and (2) such contract would have provided benefits if such service had been performed by a holder of a license issued pursuant to chapter 18.71 RCW: PROVIDED, HOWEVER, That no provision of chapter 18.71 RCW shall be asserted to deny benefits under this section.
The provisions of this section are intended to be remedial and procedural to the extent they do not impair the obligation of any existing contract.
[ 1971 ex.s. c 13 s 2.]

catchline: Chiropractic.


title: RCW 48.21.143

text:
The legislature finds that diabetes imposes a significant health risk and tremendous financial burden on the citizens and government of the state of Washington, and that access to the medically accepted standards of care for diabetes, its treatment and supplies, and self-management training and education is crucial to prevent or delay the short and long-term complications of diabetes and its attendant costs.
(1) The definitions in this subsection apply throughout this section unless the context clearly requires otherwise.
(a) "Person with diabetes" means a person diagnosed by a health care provider as having insulin using diabetes, noninsulin using diabetes, or elevated blood glucose levels induced by pregnancy; and
(b) "Health care provider" means a health care provider as defined in RCW 48.43.005.
(2) All group disability insurance contracts and blanket disability insurance contracts providing health care services, issued or renewed after January 1, 1998, shall provide benefits for at least the following services and supplies for persons with diabetes:
(a) For group disability insurance contracts and blanket disability insurance contracts that include coverage for pharmacy services, appropriate and medically necessary equipment and supplies, as prescribed by a health care provider, that includes but is not limited to insulin, syringes, injection aids, blood glucose monitors, test strips for blood glucose monitors, visual reading and urine test strips, insulin pumps and accessories to the pumps, insulin infusion devices, prescriptive oral agents for controlling blood sugar levels, foot care appliances for prevention of complications associated with diabetes, and glucagon emergency kits; and
(b) For all group disability insurance contracts and blanket disability insurance contracts providing health care services, outpatient self-management training and education, including medical nutrition therapy, as ordered by the health care provider. Diabetes outpatient self-management training and education may be provided only by health care providers with expertise in diabetes. Nothing in this section prevents the insurer from restricting patients to seeing only health care providers who have signed participating provider agreements with the insurer or an insuring entity under contract with the insurer.
(3) Except as provided in RCW 48.43.780, coverage required under this section may be subject to customary cost-sharing provisions established for all other similar services or supplies within a policy.
(4) Health care coverage may not be reduced or eliminated due to this section.
(5) Services required under this section shall be covered when deemed medically necessary by the medical director, or his or her designee, subject to any referral and formulary requirements.
(6) The insurer need not include the coverage required in this section in a group contract offered to an employer or other group that offers to its eligible enrollees a self-insured health plan not subject to mandated benefits status under this title that does not offer coverage similar to that mandated under this section.
(7) This section does not apply to the health benefit plan that provides benefits identical to the schedule of services covered by the basic health plan.
[ 2020 c 346 s 8; 2020 c 245 s 4; 2004 c 244 s 10; 1997 c 276 s 3.]
Notes:
Reviser's note: This section was amended by 2020 c 245 s 4 and by 2020 c 346 s 8, each without reference to the other. Both amendments are incorporated in the publication of this section under RCW 1.12.025(2). For rule of construction, see RCW 1.12.025(1).
Intent—2020 c 346: See note following RCW 70.14.165.
Application—2004 c 244: See note following RCW 48.21.045.
Effective date—1997 c 276: See note following RCW 41.05.185.

catchline: Diabetes coverage—Definitions.


title: RCW 48.21.144

text:
Notwithstanding any provision of any group disability insurance contract or blanket disability insurance contract, benefits shall not be denied thereunder for any psychological service rendered by a holder of a license issued pursuant to chapter 18.83 RCW: PROVIDED, That (1) the service rendered was within the lawful scope of such person's license, and (2) such contract would have provided the benefits for such service if rendered by a holder of a license issued pursuant to chapter 18.71 RCW.
[ 1971 ex.s. c 197 s 2.]
Notes:
Application—1971 ex.s. c 197: See note following RCW 48.20.414.

catchline: Psychological services.


title: RCW 48.21.146

text:
Notwithstanding any provision of any group disability insurance contract or blanket disability insurance contract as provided for in this chapter, benefits shall not be denied thereunder for any health service performed by a holder of a license issued pursuant to chapter 18.32 RCW if (1) the service performed was within the lawful scope of such person's license, and (2) such contract would have provided benefits if such service had been performed by a holder of a license issued pursuant to chapter 18.71 RCW: PROVIDED, HOWEVER, That no provision of chapter 18.71 RCW shall be asserted to deny benefits under this section.
The provisions of this section are intended to be remedial and procedural to the extent they do not impair the obligation of any existing contract.
[ 1974 ex.s. c 42 s 2.]

catchline: Dentistry.


title: RCW 48.21.147

text:
(1) Notwithstanding any other provisions of law, no group disability insurance contract or blanket disability insurance contract of any disability insurer as provided for in this chapter subject to the jurisdiction of the state of Washington that covers any dental services, and no contract or participating provider agreement with a dentist may:
(a) Require, directly or indirectly, that a dentist who is a participating provider provide services to a subscriber at a fee set by, or at a fee subject to the approval of, the disability insurer unless the dental services are covered services, including services that would be reimbursable but for the application of contractual limitations such as benefit maximums, deductibles, coinsurance, waiting periods, or frequency limitations, under the applicable group plan or disability insurance policy; nor
(b) Prohibit, directly or indirectly, a dentist who is a participating provider from offering or providing to a subscriber dental services that are not covered services on any terms or conditions acceptable to the dentist and the subscriber.
(2) For the purposes of this section, "covered services" means dental services that are reimbursable under the applicable insurance policy, group plan, or subscriber agreement or would be reimbursable but for the application of contractual limitations such as benefit maximums, deductibles, coinsurance, waiting periods or frequency limitations.
[ 2010 c 228 s 2.]

catchline: Dental services that are not subject to contract or provider agreement.


title: RCW 48.21.148

text:
Notwithstanding any provision of any group disability insurance contract or blanket disability insurance contract 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 contract would have provided benefits if such service had been performed by a dentist licensed under chapter 18.32 RCW.
[ 1995 c 1 s 22 (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 48.21.150

text:
Any group disability insurance contract or blanket disability insurance contract, providing health care services, delivered or issued for delivery in this state more than one hundred twenty days after August 11, 1969, which provides that coverage of a dependent child of an employee or other member of the covered group shall terminate upon attainment of the limiting age for dependent children specified in the contract shall also provide in substance that attainment of such limiting age shall not operate to terminate the coverage of such child while the child is and continues to be both (1) incapable of self-sustaining employment by reason of developmental or physical disability and (2) chiefly dependent upon the employee or member for support and maintenance, provided proof of such incapacity and dependency is furnished to the insurer by the employee or member within thirty-one days of the child's attainment of the limiting age and subsequently as may be required by the insurer, but not more frequently than annually after the two year period following the child's attainment of the limiting age.
[ 2020 c 274 s 31; 1977 ex.s. c 80 s 32; 1969 ex.s. c 128 s 4.]
Notes:
Purpose—Intent—Severability—1977 ex.s. c 80: See notes following RCW 4.16.190.

catchline: Dependent child coverage—Continuation for incapacity.


title: RCW 48.21.155

text:
(1) Any group disability insurance contract except blanket disability insurance contract, providing hospital and medical expenses and health care services, renewed, delivered or issued for delivery in this state more than one hundred twenty days after February 16, 1974, which provides coverage for the dependent children of persons in the insured group, shall provide coverage for newborn infant children of persons in the insured group from and after the moment of birth. Coverage provided in accord with this section shall include, but not be limited to, coverage for congenital anomalies of such infant children from the moment of birth.
(2) If payment of an additional premium is required to provide coverage for a child, the contract may require that notification of birth of a newly born child and payment of the required premium must be furnished to the insurer. The notification period shall be no less than sixty days from the date of birth. This subsection applies to policies issued or renewed on or after January 1, 1984.
[ 1983 1st ex.s. c 32 s 20; 1974 ex.s. c 139 s 2.]

catchline: Dependent child coverage—From moment of birth—Congenital anomalies—Notification of birth.


title: RCW 48.21.157

text:
Any group disability insurance contract or blanket disability insurance contract that provides coverage for a participating member's dependent must offer each participating member the option of covering any dependent under the age of twenty-six.
[ 2011 c 314 s 17; 2007 c 259 s 20.]
Notes:
Effective date—2007 c 259 ss 18-22: See note following RCW 41.05.095.
Subheadings not law—2007 c 259: See note following RCW 7.70.060.

catchline: Option to cover dependents under age twenty-six.


title: RCW 48.21.160

text:
The legislature recognizes that chemical dependency is a disease and, as such, warrants the same attention from the health care industry as other similarly serious diseases warrant; the legislature further recognizes that health insurance contracts and contracts for health care services include inconsistent provisions providing benefits for the treatment of chemical dependency. In order to assist the many citizens of this state who suffer from the disease of chemical dependency, and who are presently effectively precluded from obtaining adequate coverage for medical assistance under the terms of their health insurance contract or health care service contract, the legislature hereby declares that provisions providing benefits for the treatment of chemical dependency shall be included in new contracts and that this section, RCW 48.21.180, 48.21.190, 48.44.240, 48.46.350, and RCW 48.21.195, 48.44.245, and 48.46.355 are necessary for the protection of the public health and safety. Nothing in this section, RCW 48.21.180, 48.21.190, 48.44.240, 48.46.350, and RCW 48.21.195, 48.44.245, and 48.46.355 shall be construed to relieve any person of any civil or criminal liability for any act or omission that is the result of a chemical dependency or to grant any person with a chemical dependency any special right, privilege, or status under the law against discrimination, chapter 49.60 RCW.
[ 1987 c 458 s 13; 1974 ex.s. c 119 s 1.]
Notes:
Effective date—1987 c 458 ss 13-20: "Sections 13 through 20 of this act shall take effect on January 1, 1988." [ 1987 c 458 s 24.]
Severability—1987 c 458: "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." [ 1987 c 458 s 25.]

catchline: Chemical dependency benefits—Legislative declaration.


title: RCW 48.21.180

text:
Each group disability insurance contract which is delivered or issued for delivery or renewed, on or after January 1, 1988, and which insures for hospital or medical care must contain provisions providing benefits for the treatment of chemical dependency rendered to the insured by a provider which is an "approved substance use disorder treatment program" under *RCW 70.96A.020(2).
[ 2018 c 201 s 8011; 2003 c 248 s 9; 1990 1st ex.s. c 3 s 7; 1987 c 458 s 14; 1974 ex.s. c 119 s 3.]
Notes:
*Reviser's note: RCW 70.96A.020 was repealed by 2016 sp.s. c 29 s 301.
Findings—Intent—Effective date—2018 c 201: See notes following RCW 41.05.018.
Effective date—Severability—1987 c 458: See notes following RCW 48.21.160.

catchline: Chemical dependency benefits—Contracts issued or renewed after January 1, 1988.


title: RCW 48.21.190

text:
RCW 48.21.160 through 48.21.190 and 48.44.240 as now or hereafter amended shall not apply to the renewal of a contract in force prior to the pertinent date provided for such contract under RCW 48.21.160 through 48.21.190 and 48.44.240 as now or hereafter amended where there exists a right of renewal on the part of the insured or subscriber without any change in any provision of the contract: PROVIDED FURTHER, That RCW 48.21.160 through 48.21.190 and 48.44.240 as now or hereafter amended shall not apply to contracts which provide only accident coverage, nor to any contract written as supplemental coverage to any federal or state programs of health care including, but not limited to, Title XVIII health insurance for the aged (commonly referred to as Medicare, Parts A and B), and amendments thereto.
[ 1975 1st ex.s. c 266 s 10; 1974 ex.s. c 119 s 5.]
Notes:
Severability—1975 1st ex.s. c 266: See note following RCW 48.01.010.

catchline: Chemical dependency benefits—RCW 48.21.160 through 48.21.190, 48.44.240 inapplicable, when.


title: RCW 48.21.195

text:
For the purposes of RCW 48.21.160 and 48.21.180 "chemical dependency" means an illness characterized by a physiological or psychological dependency, or both, on a controlled substance regulated under chapter 69.50 RCW and/or alcoholic beverages. It is further characterized by a frequent or intense pattern of pathological use to the extent the user exhibits a loss of self-control over the amount and circumstances of use; develops symptoms of tolerance or physiological and/or psychological withdrawal if use of the controlled substance or alcoholic beverage is reduced or discontinued; and the user's health is substantially impaired or endangered or his or her social or economic function is substantially disrupted.
[ 1987 c 458 s 15.]
Notes:
Effective date—Severability—1987 c 458: See notes following RCW 48.21.160.

catchline: "Chemical dependency" defined.


title: RCW 48.21.197

text:
By September 1, 1987, the insurance commissioner shall adopt rules governing benefits for treatment of chemical dependency under medical plans issued under chapters 48.21, 48.44, and 48.46 RCW. These rules shall recognize that many persons are dependent on both alcohol and drugs; they shall prohibit the stacking of benefits and shall require that benefits for chemical dependency be equivalent to benefits previously required for alcoholism.
[ 1987 c 458 s 21.]
Notes:
Severability—1987 c 458: See note following RCW 48.21.160.

catchline: Chemical dependency benefits—Rules.


title: RCW 48.21.200

text:
(1) No individual or group disability insurance policy, health care service contract, or health maintenance agreement providing hospital, medical or surgical expense benefits and which contains a provision for the reduction of benefits otherwise payable or available thereunder on the basis of other existing coverages, shall provide that such reduction will operate to reduce total benefits payable below an amount equal to one hundred percent of total allowable expenses.
(2) The commissioner shall by rule establish guidelines for the application of this section, including:
(a) The procedures by which persons covered under such policies, contracts, and agreements are to be made aware of the existence of such a provision;
(b) The benefits which may be subject to such a provision;
(c) The effect of such a provision on the benefits provided;
(d) Establishment of the order of benefit determination;
(e) Exceptions necessary to preserve policy, contract, or agreement requirements for use of particular health care facilities or providers; and
(f) Reasonable claim administration procedures to expedite claim payments and prevent duplication of payments or benefits under such a provision.
[ 2007 c 80 s 3; 1993 c 492 s 282. Prior: 1983 c 202 s 16; 1983 c 106 s 24; 1975 1st ex.s. c 266 s 20.]
Notes:
Findings—Intent—1993 c 492: See notes following RCW 43.20.050.
Short title—Savings—Reservation of legislative power—Effective dates—1993 c 492: See RCW 43.72.910 through 43.72.915.
Severability—1975 1st ex.s. c 266: See note following RCW 48.01.010.

catchline: Individual or group disability, health care service contract, health maintenance agreement—Reduction of benefits on basis of other existing coverages.


title: RCW 48.21.220

text:
(1) Every insurer entering into or renewing group or blanket disability insurance policies governed by this chapter shall offer optional coverage for home health care and hospice care for persons who are homebound and would otherwise require hospitalization. Such optional coverage need only be offered in conjunction with a policy that provides payment for hospitalization as a part of health care coverage. Persons seeking such services for palliative care in conjunction with treatment or management of serious or life-threatening illness need not be homebound in order to be eligible for coverage under this section.
(2) Home health care and hospice care coverage offered under subsection (1) of this section shall conform to the following standards, limitations, and restrictions in addition to those set forth in chapter 70.126 RCW:
(a) The coverage may include reasonable deductibles, coinsurance provisions, and internal maximums;
(b) The coverage should be structured to create incentives for the use of home health care and hospice care as an alternative to hospitalization;
(c) The coverage may contain provisions for utilization review and quality assurance;
(d) The coverage may require that home health agencies and hospices have written treatment plans approved by a physician licensed under chapter 18.57 or 18.71 RCW, and may require such treatment plans to be reviewed at designated intervals;
(e) The coverage shall provide benefits for, and restrict benefits to, services rendered by home health and hospice agencies licensed by the department of social and health services;
(f) Hospice care coverage shall provide benefits for terminally ill patients for an initial period of care of not less than six months and may provide benefits for an additional six months of care in cases where the patient is facing imminent death or is entering remission if certified in writing by the attending physician;
(g) Home health care coverage shall provide benefits for a minimum of one hundred thirty health care visits per calendar year. However, a visit of any duration by an employee of a home health agency for the purpose of providing services under the plan of treatment constitutes one visit;
(h) The coverage may be structured so that services or supplies included in the primary contract are not duplicated in the optional home health and hospice coverage.
(3) The insurance commissioner shall adopt any rules necessary to implement this section.
(4) The requirements of this section shall not apply to contracts or policies governed by chapter 48.66 RCW.
(5) An insurer, as a condition of reimbursement, may require compliance with home health and hospice certification regulations established by the United States department of health and human services.
[ 2015 c 22 s 1; 1988 c 245 s 31; 1984 c 22 s 1; 1983 c 249 s 1.]
Notes:
Application—2015 c 22: "This act applies to plans issued or renewed after December 31, 2016." [ 2015 c 22 s 4.]
Effective date—1984 c 22: "This act shall take effect July 1, 1984." [ 1984 c 22 s 8.]
Effective date—1983 c 249: See note following RCW 70.126.001.
Home health care, hospice care, rules: Chapter 70.126 RCW.

catchline: Home health care, hospice care, optional coverage required—Standards, limitations, restrictions—Rules—Medicare supplemental contracts excluded.


title: RCW 48.21.223

text:
(1) Each health plan issued or renewed on or after January 1, 2012, that provides coverage for cancer chemotherapy treatment must provide coverage for prescribed, self-administered anticancer medication that is used to kill or slow the growth of cancerous cells on a basis at least comparable to cancer chemotherapy medications administered by a health care provider or facility as defined in *RCW 48.43.005 (25) and (26).
(2) Nothing in this section may be interpreted to prohibit a health plan from administering a formulary or preferred drug list, requiring prior authorization, or imposing other appropriate utilization controls in approving coverage for any chemotherapy.
[ 2020 c 18 s 20; 2011 c 159 s 4.]
Notes:
*Reviser's note: RCW 48.43.005 was alphabetized pursuant to RCW 1.08.015(2)(k), changing subsections (25) and (26) to subsections (27) and (28). Subsequently, RCW 48.43.005 was amended by 2024 c 218 s 1, changing subsections (27) and (28) to subsections (29) and (30).
Explanatory statement—2020 c 18: See note following RCW 43.79A.040.
Findings—2011 c 159: See note following RCW 41.05.175.

catchline: Prescribed, self-administered anticancer medication.


title: RCW 48.21.225

text:
Each group disability insurance policy issued or renewed after January 1, 1990, that provides coverage for hospital or medical expenses shall provide coverage for screening or diagnostic mammography services, provided that such services are delivered upon the recommendation of the patient's physician or *advanced registered nurse practitioner as authorized by the state board of nursing pursuant to chapter 18.79 RCW or physician assistant pursuant to chapter 18.71A RCW.
This section shall not be construed to prevent the application of standard policy provisions, other than the cost-sharing prohibition provided in RCW 48.43.076, that are applicable to other benefits. This section does not limit the authority of an insurer to negotiate rates and contract with specific providers for the delivery of mammography services. This section shall not apply to medicare supplement policies or supplemental contracts covering a specified disease or other limited benefits.
[ 2025 c 58 s 5049; 2023 c 366 s 4; 1994 sp.s. c 9 s 731; 1989 c 338 s 2.]
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.
Expiration date—2025 c 58 ss 5004, 5005, 5006, 5010, 5012, 5013, 5014, 5016, 5017, 5018, 5019, 5020, 5024, 5029, 5030, 5043, 5044, 5045, 5047, 5048, 5049, 5051, 5052, 5053, and 5055: See note following RCW 18.79.040.
Explanatory note—2025 c 58: See note following RCW 1.16.050.
Intent—2023 c 366: See note following RCW 48.43.076.
Severability—Headings and captions not law—Effective date—1994 sp.s. c 9: See RCW 18.79.900 through 18.79.902.
PDF
RCW 48.21.225
Mammograms—Insurance coverage. (Effective June 30, 2027.)
Each group disability insurance policy issued or renewed after January 1, 1990, that provides coverage for hospital or medical expenses shall provide coverage for screening or diagnostic mammography services, provided that such services are delivered upon the recommendation of the patient's physician or advanced practice registered nurse as authorized by the state board of nursing pursuant to chapter 18.79 RCW or physician assistant pursuant to chapter 18.71A RCW.
This section shall not be construed to prevent the application of standard policy provisions, other than the cost-sharing prohibition provided in RCW 48.43.076, that are applicable to other benefits. This section does not limit the authority of an insurer to negotiate rates and contract with specific providers for the delivery of mammography services. This section shall not apply to medicare supplement policies or supplemental contracts covering a specified disease or other limited benefits.
[ 2025 c 58 s 5101; 2023 c 366 s 4; 1994 sp.s. c 9 s 731; 1989 c 338 s 2.]
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.
Intent—2023 c 366: See note following RCW 48.43.076.
Severability—Headings and captions not law—Effective date—1994 sp.s. c 9: See RCW 18.79.900 through 18.79.902.

catchline: Mammograms—Insurance coverage. (Effective until June 30, 2027.)


title: RCW 48.21.227

text:
(1) Each group disability insurance policy issued or renewed after December 31, 2006, that provides coverage for hospital or medical expenses shall provide coverage for prostate cancer screening, provided that the screening is delivered upon the recommendation of the patient's physician, *advanced registered nurse practitioner, or physician assistant.
(2) This section shall not be construed to prevent the application of standard policy provisions applicable to other benefits, such as deductible or copayment provisions. This section does not limit the authority of an insurer to negotiate rates and contract with specific providers for the delivery of prostate cancer screening services. This section shall not apply to medicare supplemental policies or supplemental contracts covering a specified disease or other limited benefits.
[ 2006 c 367 s 3.]
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.
PDF
RCW 48.21.227
Prostate cancer screening. (Effective June 30, 2027.)
(1) Each group disability insurance policy issued or renewed after December 31, 2006, that provides coverage for hospital or medical expenses shall provide coverage for prostate cancer screening, provided that the screening is delivered upon the recommendation of the patient's physician, advanced practice registered nurse, or physician assistant.
(2) This section shall not be construed to prevent the application of standard policy provisions applicable to other benefits, such as deductible or copayment provisions. This section does not limit the authority of an insurer to negotiate rates and contract with specific providers for the delivery of prostate cancer screening services. This section shall not apply to medicare supplemental policies or supplemental contracts covering a specified disease or other limited benefits.
[ 2025 c 58 s 5102; 2006 c 367 s 3.]
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.

catchline: Prostate cancer screening. (Effective until June 30, 2027.)


title: RCW 48.21.230

text:
(1) Each group disability insurance contract issued or renewed after July 24, 1983, which insures for hospital or medical care shall provide coverage for reconstructive breast surgery resulting from a mastectomy which resulted from disease, illness, or injury.
(2) Each group disability insurance contract issued or renewed after January 1, 1986, which insures for hospital or medical care shall provide coverage for all stages of one reconstructive breast reduction on the nondiseased breast to make it equal in size with the diseased breast after definitive reconstructive surgery on the diseased breast has been performed.
[ 1985 c 54 s 6; 1983 c 113 s 2.]
Notes:
Effective date—1985 c 54: See note following RCW 48.20.397.

catchline: Reconstructive breast surgery.


title: RCW 48.21.235

text:
No person engaged in the business of insurance under this chapter may refuse to issue any contract of insurance or cancel or decline to renew the contract solely because of a mastectomy or lumpectomy performed on the insured or prospective insured more than five years previously. The amount of benefits payable, or any term, rate, condition, or type of coverage shall not be restricted, modified, excluded, increased, or reduced solely on the basis of a mastectomy or lumpectomy performed on the insured or prospective insured more than five years previously.
[ 1985 c 54 s 2.]
Notes:
Effective date—1985 c 54: See note following RCW 48.20.397.

catchline: Mastectomy, lumpectomy.


title: RCW 48.21.241

text:
(1) For the purposes of this section, "mental health services" means:
(a) For health benefit plans that provide coverage for medical and surgical services issued or renewed before January 1, 2021, medically necessary outpatient and inpatient services provided to treat mental disorders covered by the diagnostic categories listed in the most current version of the diagnostic and statistical manual of mental disorders, published by the American psychiatric association, on June 11, 2020, or such subsequent date as may be provided by the insurance commissioner by rule, consistent with the purposes of chapter 6, Laws of 2005, with the exception of the following categories, codes, and services: (i) Substance related disorders; (ii) life transition problems, currently referred to as "V" codes, and diagnostic codes 302 through 302.9 as found in the diagnostic and statistical manual of mental disorders, 4th edition, published by the American psychiatric association; (iii) skilled nursing facility services, home health care, residential treatment, and custodial care; and (iv) court ordered treatment unless the insurer's medical director or designee determines the treatment to be medically necessary; and
(b) For health benefit plans that provide coverage for medical and surgical services issued or renewed on or after January 1, 2021, medically necessary outpatient and inpatient services provided to treat mental health and substance use disorders covered by the diagnostic categories listed in the most current version of the diagnostic and statistical manual of mental disorders, published by the American psychiatric association, on June 11, 2020, or such subsequent date as may be provided by the insurance commissioner by rule, consistent with the purposes of chapter 6, Laws of 2005.
(2) All group disability insurance contracts and blanket disability insurance contracts providing health benefit plans that provide coverage for medical and surgical services shall provide coverage for:
(a) Mental health services. The copayment or coinsurance for mental health services may be no more than the copayment or coinsurance for medical and surgical services otherwise provided under the health benefit plan. Wellness and preventive services that are provided or reimbursed at a lesser copayment, coinsurance, or other cost sharing than other medical and surgical services are excluded from this comparison. If the health benefit plan imposes a maximum out-of-pocket limit or stop loss, it shall be a single limit or stop loss for medical, surgical, and mental health services. If the health benefit plan imposes any deductible, mental health services shall be included with medical and surgical services for the purpose of meeting the deductible requirement. Treatment limitations or any other financial requirements on coverage for mental health services are only allowed if the same limitations or requirements are imposed on coverage for medical and surgical services; and
(b) Prescription drugs intended to treat any of the disorders covered in subsection (1) of this section to the same extent, and under the same terms and conditions, as other prescription drugs covered by the health benefit plan.
(3) This section does not prohibit a requirement that mental health services be medically necessary, if a comparable requirement is applicable to medical and surgical services.
(4) Nothing in this section shall be construed to prevent the management of mental health services if a comparable requirement is applicable to medical and surgical services.
[ 2020 c 228 s 3; 2007 c 8 s 2; 2006 c 74 s 1; 2005 c 6 s 3.]
Notes:
Effective date—2007 c 8: See note following RCW 48.20.580.
Effective date—2006 c 74: "This act is necessary for the immediate preservation of the public peace, health, or safety, or support of the state government and its existing public institutions, and takes effect immediately [March 15, 2006]." [ 2006 c 74 s 4.]
Findings—Intent—Severability—2005 c 6: See notes following RCW 41.05.600.

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


title: RCW 48.21.242

text:
An insurer providing group disability insurance coverage for health care in this state shall waive a preauthorization requirement from the insurer before an insured or the insured's covered dependents receive mental health care and treatment rendered by a state hospital if the insured or any of the insured's covered dependents are involuntarily committed to a state hospital as defined in RCW 72.23.010.
[ 1993 c 272 s 3.]
Notes:
Savings—Severability—1993 c 272: See notes following RCW 43.20B.347.

catchline: Mental health treatment—Waiver of preauthorization for persons involuntarily committed.


title: RCW 48.21.244

text:
On or after January 1, 1990, every group disability contract entered into or renewed that covers hospital, medical, or surgical expenses on a group basis, and which provides benefits for pregnancy, childbirth, or related medical conditions to enrollees of such groups, shall offer benefits for prenatal diagnosis of congenital disorders of the fetus by means of screening and diagnostic procedures during pregnancy to such enrollees when those services are determined to be medically necessary by the disability contractor in accord with standards set in rule by the board of health. Every group disability contractor shall communicate the availability of such coverage to all group disability contract holders and to all groups with whom they are negotiating.
[ 1988 c 276 s 6.]
Notes:
Prenatal testing—Limitation on changes to coverage: RCW 48.42.090.

catchline: Benefits for prenatal diagnosis of congenital disorders—Contracts entered into or renewed on or after January 1, 1990.


title: RCW 48.21.250

text:
Every insurer that issues policies providing group coverage for hospital or medical expense shall offer the policyholder an option to include a policy provision granting a person who becomes ineligible for coverage under the group policy, the right to continue the group benefits for a period of time and at a rate agreed upon. The policy provision shall provide that when such coverage terminates, the covered person may convert to a policy as provided in RCW 48.21.260.
[ 1984 c 190 s 2.]
Notes:
Legislative intent—1984 c 190: "The legislature recognizes that when people covered by a group health insurance policy lose their group insurance benefits because they are no longer eligible, they need time to obtain a suitable form of replacement coverage or time to complete a reasonable course of medical treatment for a health condition that existed when the group benefits ended.
Spouses and dependents can lose their group insurance and may not have any other health insurance when one spouse covered under a group policy dies, obtains a divorce, or becomes unemployed. Often the cost of an individual policy prevents these persons from obtaining any other health insurance.
The intent of this act is to require insurers, health care service contractors, and health maintenance organizations to:
(1) Offer to the contract holder the option to continue health and medical benefits for employees, members, spouses, or dependents whose eligibility for coverage under a group policy, contract, or agreement is terminated; and
(2) Provide a conversion policy, contract, or agreement to employees, members, spouses, or dependents whose eligibility for coverage under a group policy, contract, or agreement is terminated." [ 1984 c 190 s 1.]
Application—1984 c 190 ss 2, 5, and 8: "Sections 2, 5, and 8 of this act shall apply to any policy, contract, or agreement issued, renewed, or amended on or after January 1, 1985." [ 1984 c 190 s 12.]
Severability—1984 c 190: "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." [ 1984 c 190 s 13.]

catchline: Continuation option to be offered.


title: RCW 48.21.260

text:
(1) Except as otherwise provided by this section, any group disability insurance policy that provides benefits for hospital or medical expenses must contain a provision granting a person covered by the group policy the right to obtain a conversion policy from the insurer upon termination of the person's eligibility for coverage under the group policy.
(2) An insurer need not offer a conversion policy to:
(a) A person whose coverage under the group policy ended when the person's employment or membership was terminated for misconduct: PROVIDED, That when a person's employment or membership is terminated for misconduct, a conversion policy shall be offered to the spouse and/or dependents of the terminated employee or member. The policy shall include in the conversion provisions the same conversion rights and conditions which are available to employees or members and their spouses and/or dependents who are terminated for reasons other than misconduct;
(b) A person who is eligible for federal medicare coverage; or
(c) A person who is covered under another group plan, policy, contract, or agreement providing benefits for hospital or medical care.
(3) To obtain the conversion policy, a person must submit a written application and the first premium payment for the conversion policy not later than thirty-one days after the date the person's group coverage terminates or thirty-one days after the date the person received notice of termination of coverage, whichever is later. The conversion policy shall become effective, without lapse of coverage, immediately following termination of coverage under the group policy.
(4) If an insurer or group policyholder does not renew, cancels, or otherwise terminates the group policy, the insurer must offer a conversion policy to any person who was covered under the terminated policy unless the person is eligible to obtain group hospital or medical expense coverage within thirty-one days after such nonrenewal, cancellation, or termination of the group policy or thirty-one days after the date the person received notice of termination of coverage, whichever is later.
(5) The insurer shall determine the premium for the conversion policy in accordance with the insurer's table of premium rates applicable to the age and class of risk of each person to be covered under the policy and the type and amount of benefits provided.
[ 2010 c 110 s 1; 1984 c 190 s 3.]
Notes:
Application—2010 c 110: "This act applies to any group disability insurance policy, group health care service contract, and group health maintenance agreement issued, entered into, or renewed on or after January 1, 2011." [ 2010 c 110 s 4.]
Legislative intent—Severability—1984 c 190: See notes following RCW 48.21.250.

catchline: Conversion policy to be offered—Exceptions, conditions.


title: RCW 48.21.270

text:
(1) An insurer shall not require proof of insurability as a condition for issuance of the conversion policy.
(2) A conversion policy may not contain an exclusion for preexisting conditions for any applicant.
(3) An insurer must offer at least three policy benefit plans that comply with the following:
(a) A major medical plan with a five thousand dollar deductible per person;
(b) A comprehensive medical plan with a five hundred dollar deductible per person; and
(c) A basic medical plan with a one thousand dollar deductible per person.
(4) The insurance commissioner may revise the deductible amounts in subsection (3) of this section from time to time to reflect changing health care costs.
(5) The insurance commissioner shall adopt rules to establish minimum benefit standards for conversion policies.
(6) The commissioner shall adopt rules to establish specific standards for conversion policy provisions. These rules may include but are not limited to:
(a) Terms of renewability;
(b) Nonduplication of coverage;
(c) Benefit limitations, exceptions, and reductions; and
(d) Definitions of terms.
[ 2019 c 33 s 4; 2011 c 314 s 2; 1984 c 190 s 4.]
Notes:
Effective date—2019 c 33: See note following RCW 48.43.005.
Legislative intent—Severability—1984 c 190: See notes following RCW 48.21.250.

catchline: Conversion policy—Restrictions and requirements—Rules.


title: RCW 48.21.280

text:
(1) Any group disability insurance contract, except a blanket disability insurance contract, providing hospital and medical expenses and health care services, delivered or issued for delivery in this state, which provides coverage for dependent children, as defined in the contract of the insured, shall cover adoptive children placed with the insured on the same basis as other dependents, as provided in RCW 48.01.180.
(2) If payment of an additional premium is required to provide coverage for a child, the contract may require that notification of placement of a child for adoption and payment of the required premium must be furnished to the insurer. The notification period shall be no less than sixty days from the date of placement.
[ 1986 c 140 s 3.]
Notes:
Effective date, application—Severability—1986 c 140: See notes following RCW 48.01.180.

catchline: Coverage for adopted children.


title: RCW 48.21.290

text:
Upon application by an insured, a rider shall be canceled if at least five years after its issuance, no health care services have been received by the insured during that time for the condition specified in the rider, and a physician, selected by the carrier for that purpose, agrees in writing to the full medical recovery of the insured from that condition, such agreement not to be unreasonably withheld. The option of the insured to apply for cancellation shall be disclosed on the face of the rider in clear and conspicuous language.
For purposes of this section, a rider is a legal document that modifies a contract to exclude, limit, or reduce coverage or benefits for specifically named or described preexisting diseases or physical conditions.
[ 1987 c 37 s 2.]

catchline: Cancellation of rider.


title: RCW 48.21.300

text:
(1) The legislature finds that:
(a) Phenylketonuria is a rare inherited genetic disorder.
(b) Children with phenylketonuria are unable to metabolize an essential amino acid, phenylalanine, which is found in the proteins of most food.
(c) To remain healthy, children with phenylketonuria must maintain a strict diet and ingest a mineral and vitamin-enriched formula.
(d) Children who do not maintain their diets with the formula acquire severe mental and physical difficulties.
(e) Originally, the formulas were listed as prescription drugs but were reclassified as medical foods to increase their availability.
(2) Subject to requirements and exceptions which may be established by rules adopted by the commissioner, any group disability insurance contract delivered or issued for delivery or renewed in this state on or after September 1, 1988, that insures for hospital or medical expenses shall provide coverage for the formulas necessary for the treatment of phenylketonuria.
[ 1988 c 173 s 2.]

catchline: Phenylketonuria.


title: RCW 48.21.310

text:
(1) Each employer-sponsored group policy for comprehensive health insurance which is entered into, or renewed, on or after twelve months after July 23, 1989, shall include coverage for neurodevelopmental therapies for covered individuals age six and under.
(2) Benefits provided under this section shall cover the services of those authorized to deliver occupational therapy, speech therapy, and physical therapy. Benefits shall be payable only where the services have been delivered pursuant to the referral and periodic review of a holder of a license issued pursuant to chapter 18.71 or 18.57 RCW or where covered services have been rendered by such licensee. Nothing in this section shall prohibit an insurer from negotiating rates with qualified providers.
(3) Benefits provided under this section shall be for medically necessary services as determined by the insurer. Benefits shall be payable for services for the maintenance of an insured in cases where significant deterioration in the patient's condition would result without the service. Benefits shall be payable to restore and improve function.
(4) It is the intent of this section that employers purchasing comprehensive health insurance, including the benefits required by this section, together with the insurer, retain authority to design and employ utilization and cost controls. Therefore, benefits delivered under this section may be subject to contractual provisions regarding deductible amounts and/or copayments established by the employer purchasing insurance and the insurer. Benefits provided under this section may be subject to standard waiting periods for preexisting conditions, and may be subject to the submission of written treatment plans.
(5) In recognition of the intent expressed in subsection (4) of this section, benefits provided under this section may be subject to contractual provisions establishing annual and/or lifetime benefit limits. Such limits may define the total dollar benefits available or may limit the number of services delivered as agreed by the employer purchasing insurance and the insurer.
[ 1989 c 345 s 2.]

catchline: Neurodevelopmental therapies—Employer-sponsored group contracts.


title: RCW 48.21.320

text:
(1) Except as provided in this section, a group disability policy entered into or renewed after December 31, 1989, shall offer optional coverage for the treatment of temporomandibular joint disorders.
(a) Insurers offering medical coverage only may limit benefits in such coverages to medical services related to treatment of temporomandibular joint disorders. Insurers offering dental coverage only may limit benefits in such coverage to dental services related to treatment of temporomandibular joint disorders. No insurer offering medical coverage only may define all temporomandibular joint disorders as purely dental in nature, and no insurer offering dental coverage only may define all temporomandibular joint disorders as purely medical in nature.
(b) Insurers offering optional temporomandibular joint disorder coverage as provided in this section may, but are not required to, offer lesser or no temporomandibular joint disorder coverage as part of their basic group disability contract.
(c) Benefits and coverage offered under this section may be subject to negotiation to promote broad flexibility in potential benefit coverage. This flexibility shall apply to services to be reimbursed, determination of treatments to be considered medically necessary, systems through which services are to be provided, including referral systems and use of other providers, and related issues.
(2) Unless otherwise directed by law, the insurance commissioner shall adopt rules, to be implemented on January 1, 1993, establishing minimum benefits, terms, definitions, conditions, limitations, and provisions for the use of reasonable deductibles and copayments.
(3) An insurer need not make the offer of coverage required by this section to an employer or other group that offers to its eligible enrollees a self-insured health plan not subject to mandated benefit statutes under Title 48 RCW that does not provide coverage for temporomandibular joint disorders.
[ 1989 c 331 s 2.]
Notes:
Legislative finding—1989 c 331: "The legislature finds that:
(1) Temporomandibular joint disorders are conditions for which treatment often is not covered in medical and dental group insurance contracts;
(2) Individuals with temporomandibular joint disorders experience substantial pain and financial hardship;
(3) Public awareness is needed concerning temporomandibular joint disorders and would be promoted by a mandated offering of temporomandibular joint disorders coverage to group purchasers; and
(4) A mandated offering of temporomandibular joint disorders coverage shall not prescribe minimum initial benefits so that the insurers and the purchasers are allowed broad flexibility in benefit design and application." [ 1989 c 331 s 1.]
Effective date—1989 c 331: "This act shall take effect January 1, 1990, but the insurance commissioner may immediately take such steps as are necessary to ensure that this act is fully implemented on its effective date." [ 1989 c 331 s 6.]

catchline: Temporomandibular joint disorders—Insurance coverage.


title: RCW 48.21.325

text:
Group disability insurance companies who through an authorized representative have first approved, by any means, an individual prescription claim as eligible may not reject that claim at some later date. Pharmacists or drug dispensing outlets who obtain preapproval of claims shall keep a written record of the preapproval that consists of identification by name and telephone number of the person who approved the claim.
[ 1993 c 253 s 3.]
Notes:
Findings—Effective date—1993 c 253: See notes following RCW 48.20.525.

catchline: Prescriptions—Preapproval of individual claims—Subsequent rejection prohibited—Written record required.


title: RCW 48.21.330

text:
For the purposes of this chapter, a nonresident pharmacy is defined as any pharmacy located outside this state that ships, mails, or delivers, in any manner, except when delivered in person to an enrolled participant or his/her representative, controlled substances, legend drugs, or devices into this state.
After October 1, 1991, an insurer providing coverage of prescription drugs from nonresident pharmacies may only provide coverage from licensed nonresident pharmacies. The insurers shall obtain proof of current licensure in conformity with this section and RCW 18.64.350 through 18.64.400 from the nonresident pharmacy and keep that proof of licensure on file.
The department may request from the insurer the proof of current licensure for all nonresident pharmacies through which the insurer is providing coverage for prescription drugs for residents of the state of Washington. This information, which may constitute a full or partial customer list, shall be confidential and exempt from public disclosure, and from the requirements of chapter 42.56 RCW. The board or the department shall not be restricted in the disclosure of the name of a nonresident pharmacy that is or has been licensed under RCW 18.64.360 or 18.64.370 or of the identity of a nonresident pharmacy disciplined under RCW 18.64.350 through 18.64.400.
[ 2005 c 274 s 311; 1991 c 87 s 8.]
Notes:
Effective date—1991 c 87: See note following RCW 18.64.350.

catchline: Nonresident pharmacies.


title: RCW 48.21.370

text:
The commissioner shall adopt rules setting forth the content of a standard disclosure form to be delivered to all applicants for group illness-triggered fixed payment insurance, hospital confinement fixed payment insurance, or other fixed payment insurance. The standard disclosure shall provide information regarding the level, type, and amount of benefits provided and the limitations, exclusions, and exceptions under the policy, as well as additional information to enhance consumer understanding. The disclosure shall specifically disclose that the coverage is not comprehensive in nature and will not cover the cost of most hospital and other medical services. Such disclosure form must be filed for approval with the commissioner prior to use. The standard disclosure form must be provided to the master policyholders at the time of solicitation and completion of the application and to all enrollees at the time of enrollment. All advertising and marketing materials other than the standard disclosure form must be filed with the commissioner at least thirty days prior to use.
[ 2007 c 296 s 4.]

catchline: Fixed payment insurance—Standard disclosure form.


title: RCW 48.21.375

text:
Illness-triggered fixed payment insurance, hospital confinement fixed payment insurance, or other fixed payment insurance policies are not considered to provide coverage for hospital or medical expenses or care under this chapter, if the benefits provided are a fixed dollar amount that is paid regardless of the amount charged. The benefits may not be related to, or be a percentage of, the amount charged by the provider of service and must be offered as an independent and noncoordinated benefit with any other health plan as defined in RCW 48.43.005(33).
[ 2025 c 58 s 2031; 2007 c 296 s 5.]
Notes:
Explanatory note—2025 c 58: See note following RCW 1.16.050.

catchline: Fixed payment insurance—Benefit restrictions.


title: RCW 48.21.380

text:
(1) A disability insurer may include the following noninsurance benefits as part of a policy or certificate of group disability insurance, with the prior approval of the commissioner and where such benefits bear a reasonable relationship to the disability insurance with which they are intended to be offered:
(a) Will preparation services;
(b) Financial planning and estate planning services;
(c) Probate and estate settlement services;
(d) Grief counseling;
(e) Funeral planning and funeral services, but it must be disclosed that this noninsurance benefit does not constitute an insurance funded prearrangement contract, pursuant to RCW 18.39.255; and
(f) Such other services as the commissioner may identify by rule.
(2) The commissioner may adopt rules to regulate the disclosure of noninsurance benefits permitted under this section, including but not limited to guidelines regarding the coverage provided under the policy or certificate of insurance.
(3) Those providing the services listed in subsection (1) of this section must be appropriately licensed.
(4) This section does not require the commissioner to approve any particular proposed noninsurance benefit. The commissioner may disapprove any proposed noninsurance benefit that the commissioner determines may tend to promote or facilitate the violation of any other section of this title.
(5) This section does not expand, limit, or otherwise affect the authority and ethical obligations of those who are authorized by the state supreme court to practice law in this state. This section does not limit the prohibition against the unauthorized practice of law under chapter 2.48 RCW.
(6) This section does not affect the application of chapter 21.20 RCW.
(7) This section does not affect wellness programs as described in RCW 48.30.140(6).
[ 2017 c 32 s 2; 2016 c 143 s 2.]

catchline: Noninsurance benefits.


title: RCW 48.21.900

text:
For the purposes of this chapter, the terms spouse, marriage, marital, husband, wife, widow, widower, next of kin, and family shall be interpreted as applying equally to state registered domestic partnerships or individuals in state registered domestic partnerships as well as to marital relationships and married persons, and references to dissolution of marriage shall apply equally to state registered domestic partnerships that have been terminated, dissolved, or invalidated, to the extent that such interpretation does not conflict with federal law. Where necessary to implement chapter 521, Laws of 2009, gender-specific terms such as husband and wife used in any statute, rule, or other law shall be construed to be gender neutral, and applicable to individuals in state registered domestic partnerships.
[ 2009 c 521 s 116.]

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


title: RCW 48.212.005

text:
The intent of this chapter is to promote the public interest, support the availability of supplemental long-term care coverage, establish standards for supplemental long-term care coverage, facilitate public understanding and comparison of supplemental long-term care contract benefits, protect persons insured under supplemental long-term care insurance policies and certificates, protect applicants for supplemental long-term care policies from unfair or deceptive sales or enrollment practices, and provide for flexibility and innovation in the development of supplemental long-term care insurance coverage.
[ 2025 c 380 s 17.]
Notes:
Effective date—2025 c 380 ss 17-39, 47, and 48: "Sections 17 through 39, 47, and 48 of this act take effect May 1, 2026." [ 2025 c 380 s 49.]

catchline: Intent.


title: RCW 48.212.010

text:
(1) This chapter applies to all supplemental long-term care insurance policies, contracts, or riders delivered or issued for delivery in this state on or after May 1, 2026. This chapter does not supersede the obligations of entities subject to this chapter to comply with other applicable laws to the extent that they do not conflict with this chapter, except that laws and regulations designed and intended to apply to medicare supplement insurance policies shall not be applied to supplemental long-term care insurance.
(2) Coverage advertised, marketed, or offered as supplemental long-term care insurance must comply with this chapter. Any coverage, policy, or rider advertised, marketed, or offered as supplemental long-term care or nursing home insurance shall comply with this chapter.
(3) This chapter is not intended to prohibit approval of supplemental long-term care funded through life insurance policies, contracts, or riders, provided the policy meets the definition of supplemental long-term care insurance and provides all required benefits of this chapter.
[ 2025 c 380 s 18.]
Notes:
Effective date—2025 c 380 ss 17-39, 47, and 48: See note following RCW 48.212.005.

catchline: Application.


title: RCW 48.212.020

text:
The definitions in this section apply throughout this chapter unless the context clearly requires otherwise.
(1) "Applicant" means: (a) In the case of an individual supplemental long-term care insurance policy, the person who seeks to contract for benefits; and (b) in the case of a group supplemental long-term care insurance policy, the proposed certificate holder.
(2) "Certificate" includes any certificate issued under a group supplemental long-term care insurance policy that has been delivered or issued for delivery in this state.
(3) "Commissioner" means the insurance commissioner of Washington state.
(4) "Issuer" includes insurance companies, fraternal benefit societies, health care service contractors, health maintenance organizations, or other entity delivering or issuing for delivery any supplemental long-term care insurance policy, contract, or rider.
(5) "Group supplemental long-term care insurance" means a supplemental long-term care insurance policy or contract that is delivered or issued for delivery in this state and is issued to:
(a) One or more employers; one or more labor organizations; or a trust or the trustees of a fund established by one or more employers or labor organizations for current or former employees, current or former members of the labor organizations, or a combination of current and former employees or members, or a combination of such employers, labor organizations, trusts, or trustees; or
(b) A professional, trade, or occupational association for its members or former or retired members, if the association:
(i) Is composed of persons who are or were all actively engaged in the same profession, trade, or occupation; and
(ii) Has been maintained in good faith for purposes other than obtaining insurance; or
(c)(i) An association, trust, or the trustees of a fund established, created, or maintained for the benefit of members of one or more associations. Before advertising, marketing, or offering supplemental long-term care coverage in this state, the association or associations, or the insurer of the association or associations, must file evidence with the commissioner that the association or associations have at the time of such filing at least 100 persons who are members and that the association or associations have been organized and maintained in good faith for purposes other than that of obtaining insurance; have been in active existence for at least one year; and have a constitution and bylaws that provide that:
(A) The association or associations hold regular meetings at least annually to further the purposes of the members;
(B) Except for credit unions, the association or associations collect dues or solicit contributions from members; and
(C) The members have voting privileges and representation on the governing board and committees of the association.
(ii) Thirty days after filing the evidence in accordance with this section, the association or associations will be deemed to have satisfied the organizational requirements, unless the commissioner makes a finding that the association or associations do not satisfy those organizational requirements; or
(d) A group other than as described in (a), (b), or (c) of this subsection subject to a finding by the commissioner that:
(i) The issuance of the group policy is not contrary to the best interest of the public;
(ii) The issuance of the group policy would result in economies of acquisition or administration; and
(iii) The benefits are reasonable in relation to the premiums charged.
(6) "Policy" includes a document such as an insurance policy, contract, subscriber agreement, rider, or endorsement delivered or issued for delivery in this state by an insurer, fraternal benefit society, health care service contractor, health maintenance organization, or any similar entity authorized by the insurance commissioner to transact the business of supplemental long-term care insurance.
(7) "Qualified supplemental long-term care insurance contract" or "federally tax-qualified supplemental long-term care insurance contract" means:
(a) An individual or group insurance contract that meets the requirements of section 7702B(b) of the internal revenue code of 1986, as amended; or
(b) The portion of a life insurance contract that provides supplemental long-term care insurance coverage by rider or as part of the contract and that satisfies the requirements of sections 7702B(b) and (e) of the internal revenue code of 1986, as amended.
(8) "Supplemental long-term care insurance" means an insurance policy, contract, or rider that is advertised, marketed, offered, or designed to provide coverage for at least 12 consecutive months for a covered person after benefits provided under chapter 50B.04 RCW have been exhausted. Supplemental long-term care insurance may be on an expense incurred, indemnity, prepaid, or other basis, for one or more necessary or medically necessary diagnostic, preventive, therapeutic, rehabilitative, maintenance, or personal care services, provided in a setting other than an acute care unit of a hospital. Supplemental long-term care insurance includes any policy, contract, or rider that provides for payment of benefits based upon cognitive impairment or the loss of functional capacity that supplements benefits provided in chapter 50B.04 RCW.
(a) Supplemental long-term care insurance includes group and individual life insurance policies or riders that provide directly or supplement long-term care insurance and that supplements benefits provided in chapter 50B.04 RCW. However, supplemental long-term care insurance does not include life insurance policies that: (i) Accelerate the death benefit specifically for one or more of the qualifying events of terminal illness, medical conditions requiring extraordinary medical intervention, or permanent institutional confinement; (ii) provide the option of a lump sum payment for those benefits; and (iii) do not condition the benefits or the eligibility for the benefits upon the receipt of long-term care.
(b) Supplemental long-term care insurance also includes qualified supplemental long-term care insurance contracts.
(c) Supplemental long-term care insurance does not include any insurance policy, contract, or rider that is offered primarily to provide coverage for basic medicare supplement, basic hospital expense, basic medical-surgical expense, hospital confinement indemnity, major medical expense, disability income, related income, asset protection, accident only, specified disease, specified accident, or limited benefit health. These may not be marketed to consumers as providing coverage that is supplemental to the long-term care benefits provided in chapter 50B.04 RCW.
[ 2025 c 380 s 19.]
Notes:
Effective date—2025 c 380 ss 17-39, 47, and 48: See note following RCW 48.212.005.

catchline: Definitions.


title: RCW 48.212.030

text:
(1) A supplemental long-term care insurance policy, contract, rider, or certificate form or application form shall not be issued, delivered, or used unless it has been filed with and approved by the commissioner.
(2) Rates, or modification of rates, for supplemental long-term care policies or certificates shall not be used until filed with and approved by the commissioner.
(3) A form or rate shall not knowingly be issued, delivered, or used if the commissioner's approval does not then exist.
[ 2025 c 380 s 20.]
Notes:
Effective date—2025 c 380 ss 17-39, 47, and 48: See note following RCW 48.212.005.

catchline: Documents filed with commissioner—Requirements.


title: RCW 48.212.040

text:
A group supplemental long-term care insurance policy may not be offered to a resident of this state under a group policy issued in another state to a group described in RCW 48.212.020(5)(d), unless this state or another state having statutory and regulatory supplemental long-term care insurance requirements substantially similar to those adopted in this state has made a determination that such requirements have been met.
[ 2025 c 380 s 21.]
Notes:
Effective date—2025 c 380 ss 17-39, 47, and 48: See note following RCW 48.212.005.

catchline: Group policy issued in another state—Restrictions.


title: RCW 48.212.050

text:
(1) A supplemental long-term care insurance policy or certificate may not define "preexisting condition" more restrictively than as a condition for which medical advice or treatment was recommended by or received from a provider of health care services, within six months preceding the effective date of coverage of an insured person, unless the policy or certificate applies to group supplemental long-term care insurance under RCW 48.212.020(5) (a), (b), or (c).
(2) A supplemental long-term care insurance policy or certificate may not exclude coverage for a loss or confinement that is the result of a preexisting condition unless the loss or confinement begins within six months following the effective date of coverage of an insured person, unless the policy or certificate applies to a group as defined in RCW 48.212.020(5)(a).
(3) The commissioner may extend the limitation periods for specific age group categories in specific policy forms upon finding that the extension is in the best interest of the public.
(4) An issuer may use an application form designed to elicit the complete health history of an applicant and underwrite in accordance with that issuer's established underwriting standards, based on the answers on that application. Unless otherwise provided in the policy or certificate and regardless of whether it is disclosed on the application, a preexisting condition need not be covered until the waiting period expires.
(5) A supplemental long-term care insurance policy or certificate may not exclude or use waivers or riders to exclude, limit, or reduce coverage or benefits for specifically named or described preexisting diseases or physical conditions beyond the waiting period.
[ 2025 c 380 s 22.]
Notes:
Effective date—2025 c 380 ss 17-39, 47, and 48: See note following RCW 48.212.005.

catchline: Preexisting conditions.


title: RCW 48.212.060

text:
(1) No supplemental long-term care insurance policy may:
(a) Be canceled, nonrenewed, or otherwise terminated on the grounds of the age or the deterioration of the mental or physical health of the insured individual or certificate holder;
(b) Contain a provision establishing a new waiting period in the event existing coverage is converted to or replaced by a new or other form within the same company, except with respect to an increase in benefits voluntarily selected by the insured individual or group policyholder;
(c) Provide coverage for skilled nursing care only or provide significantly more coverage for skilled care in a facility than coverage for lower levels of care;
(d) Condition eligibility for any benefits on a prior hospitalization requirement;
(e) Condition eligibility for benefits provided in an institutional care setting on the receipt of a higher level of institutional care;
(f) Condition eligibility for any benefits other than waiver of premium, postconfinement, postacute care, or recuperative benefits on a prior institutionalization requirement;
(g) Include a postconfinement, postacute care, or recuperative benefit unless:
(i) Such requirement is clearly labeled in a separate paragraph of the policy or certificate entitled "Limitations or Conditions on Eligibility for Benefits"; and
(ii) Such limitations or conditions specify any required number of days of preconfinement or postconfinement;
(h) Condition eligibility for noninstitutional benefits on the prior receipt of institutional care;
(i)(i) Provide for a deductible that is greater than the maximum dollar equivalent provided in RCW 50B.04.060(3)(b), including inflation adjustments provided in RCW 50B.04.010(3), without the limitation provided in RCW 50B.04.050(2). The issuer may provide for a deductible that is less than the maximum dollar equivalent provided in RCW 50B.04.060(3)(b), especially for a policyholder born before 1968;
(ii) The issuer must accept notice from the department of social and health services that the policyholder has exhausted the benefits provided under chapter 50B.04 RCW as evidence of satisfying the deductible. However, for a policyholder born before 1968, the department must provide the amount of benefits paid under chapter 50B.04 RCW as evidence of payment toward the deductible;
(j) Include an elimination period of greater than 12 months. Any period of time the policyholder is considered an eligible beneficiary as defined in RCW 50B.04.010 must count toward any elimination period in a supplemental long-term care insurance policy. If the policy includes a deductible and an elimination period, the policy may provide that the elimination period is satisfied after the later of when the deductible or the elimination period has been met; and
(k) Require a policyholder to undergo a functional assessment to satisfy a benefit trigger to determine that the elimination period has begun or ended. However, the issuer may require the policyholder to undergo a functional assessment and apply a benefit trigger for purposes of approving a claim and authorizing benefits.
(2) A supplemental long-term care insurance policy or certificate may be field-issued if the compensation to the field issuer is not based on the number of policies or certificates issued. For purposes of this section, "field-issued" means a policy or certificate issued by a producer or a third-party administrator of the policy pursuant to the underwriting authority by an issuer and using the issuer's underwriting guidelines.
[ 2025 c 380 s 23.]
Notes:
Effective date—2025 c 380 ss 17-39, 47, and 48: See note following RCW 48.212.005.

catchline: Prohibited policy terms and practices.


title: RCW 48.212.070

text:
(1) Supplemental long-term care insurance applicants may return a policy or certificate for any reason within 30 days after its delivery and to have the premium refunded.
(2) All supplemental long-term care insurance policies and certificates must have a notice prominently printed on or attached to the first page of the policy stating that the applicant may return the policy or certificate within 30 days after its delivery and to have the premium refunded.
(3) Refunds or denials of applications must be made within 30 days of the return or denial.
(4) This section does not apply to certificates issued pursuant to a policy issued to a group defined in RCW 48.212.020(5)(a).
[ 2025 c 380 s 24.]
Notes:
Effective date—2025 c 380 ss 17-39, 47, and 48: See note following RCW 48.212.005.

catchline: Returns of policies or certificates.


title: RCW 48.212.080

text:
(1) An outline of coverage must be delivered to a prospective applicant for supplemental long-term care insurance at the time of initial solicitation through means that prominently direct the attention of the recipient to the document and its purpose.
(a) The commissioner must prescribe a standard format, including style, arrangement, overall appearance, and the content of an outline of coverage. The outline of coverage must also include a disclosure:
(i) Of how the supplemental long-term care insurance interacts with benefits provided in chapter 50B.04 RCW and any potential gaps in coverage or discontinuities of care between benefits provided under chapter 50B.04 RCW and the policy;
(ii) That the premiums may increase over time and an explanation of the conditions that may result in an increase in premiums;
(iii) If the policyholder's circumstances change or premiums increase and the policyholder is unable or unwilling to pay the increased premiums, the options available to the consumer, including a reduction in benefits and nonforfeiture of premiums;
(iv) That premiums continue after retirement;
(v) When premium payments are no longer required under the policy, known as a waiver of premiums; and
(vi) That the purchase of the policy does not qualify the policyholder to apply to be exempt from premium assessments under RCW 50B.04.085.
(b) When an insurance producer makes a solicitation in person, the insurance producer must deliver an outline of coverage before presenting an application or enrollment form.
(c) In a direct response solicitation, the outline of coverage must be presented with an application or enrollment form. The disclosures required under (a) of this subsection are required in any marketing materials.
(d) If a policy is issued to a group as defined in RCW 48.212.020(5)(a), an outline of coverage is not required to be delivered, if the information that the commissioner requires to be included in the outline of coverage is in other materials relating to enrollment. Upon request, any such materials must be made available to the commissioner.
(2) If an issuer approves an application for a supplemental long-term care insurance contract or certificate, the issuer must deliver the contract or certificate of insurance to the applicant within 30 days after the date of approval. A policy summary must be delivered with an individual life insurance policy that provides supplemental long-term care benefits within the policy or by rider. In a direct response solicitation, the issuer must deliver the policy summary, upon request, before delivery of the policy, if the applicant requests a summary.
(a) The policy summary must include:
(i) An explanation of how the supplemental long-term care benefit interacts with other components of the policy, including deductions from any applicable death benefits;
(ii) An illustration of the amount of benefits, the length of benefits, and the guaranteed lifetime benefits if any, for each covered person;
(iii) Any exclusions, reductions, and limitations on benefits of supplemental long-term care;
(iv) A statement that any supplemental long-term care inflation protection option required by RCW 48.212.140 is not available under this policy; and
(v) If applicable to the policy type, the summary must also include:
(A) A disclosure of the effects of exercising other rights under the policy;
(B) A disclosure of guarantees related to long-term care costs of insurance charges; and
(C) Current and projected maximum lifetime benefits.
(b) The provisions of the policy summary may be incorporated into a basic illustration required under chapter 48.23A RCW, or into the policy summary which is required under rules adopted by the commissioner.
[ 2025 c 380 s 25.]
Notes:
Effective date—2025 c 380 ss 17-39, 47, and 48: See note following RCW 48.212.005.

catchline: Outline of coverage—Contract delivery—Policy summary.


title: RCW 48.212.090

text:
A supplemental long-term care insurance policy, contract, or rider must:
(1) Allow the policyholder options for reduction of benefits or nonforfeiture of premiums as provided in RCW 48.212.150 if the premiums increase or the policyholder's circumstances change and the policyholder is unable or unwilling to pay the increased premiums;
(2) Allow for continuity of coverage of care settings and providers, including family providers, that the policyholder was receiving as benefits under the program provided in chapter 50B.04 RCW unless there is substantial clinical or other information showing that the current care setting or provider cannot meet the care and safety needs of the policyholder. If the issuer makes a determination that the care setting or providers are not suited to meeting the care and safety needs of the policyholder, the issuer may require a change of care setting or provider under the policy, effective 90 days after the transition from the benefits provided under chapter 50B.04 RCW. The policyholder may appeal the determination through an independent third-party review as tracked by the commissioner. The issuer may audit for fraudulent claims where the care being claimed is not being provided; and
(3) Cover family providers, provided they are suited to meet the care and safety needs of the policyholder.
[ 2025 c 380 s 26.]
Notes:
Effective date—2025 c 380 ss 17-39, 47, and 48: See note following RCW 48.212.005.

catchline: Required options for policyholders.


title: RCW 48.212.100

text:
(1) When a policyholder purchases a supplemental long-term care insurance policy, the issuer must request written consent from the policyholder to share information with the department of social and health services. If the policyholder provides written consent, the issuer must inform the department of social and health services that the policyholder has purchased a supplemental long-term care insurance policy and share any information with the department for the purposes of any potential care coordination.
(2) Only basic demographic information that would allow a person to be identified in the program provided in chapter 50B.04 RCW may be shared if the individual consents to sharing information. No health care information as defined in RCW 70.02.010 or data on claims may be shared.
[ 2025 c 380 s 27.]
Notes:
Effective date—2025 c 380 ss 17-39, 47, and 48: See note following RCW 48.212.005.

catchline: Consent to share information—Limitations on sharing.


title: RCW 48.212.110

text:
If a supplemental long-term care benefit funded through a life insurance policy by the acceleration of the death benefit is in benefit payment status, a monthly report must be provided to the policyholder. The report must include:
(1) A record of all supplemental long-term care benefits paid out during the month;
(2) An explanation of any changes in the policy resulting from paying the supplemental long-term care benefits, such as a change in the death benefit or cash values; and
(3) The amount of supplemental long-term care benefits that remain to be paid.
[ 2025 c 380 s 28.]
Notes:
Effective date—2025 c 380 ss 17-39, 47, and 48: See note following RCW 48.212.005.

catchline: Supplemental long-term care benefits funded by specific life insurance policies—Reporting.


title: RCW 48.212.120

text:
Within 30 business days after receipt of all the requested additional information, an insurer must pay a claim for benefits under a supplemental long-term care insurance policy or certificate if it is a clean claim, or send a written notice that the insurer is declining to pay all or part of the claim and the specific reason or reasons for denial.
[ 2025 c 380 s 29.]
Notes:
Effective date—2025 c 380 ss 17-39, 47, and 48: See note following RCW 48.212.005.

catchline: Deadline to pay or decline to pay claims.


title: RCW 48.212.130

text:
(1) An issuer may rescind a supplemental long-term care insurance policy or certificate or deny an otherwise valid supplemental long-term care insurance claim if:
(a) A policy or certificate has been in force for less than six months and upon a showing of misrepresentation that is material to the acceptance for coverage; or
(b) A policy or certificate has been in force for at least six months but less than two years, upon a showing of misrepresentation that is both material to the acceptance for coverage and that pertains to the condition for which benefits are sought.
(2) After a policy or certificate has been in force for two years it is not contestable upon the grounds of misrepresentation alone. Such a policy or certificate may be contested only upon a showing that the insured knowingly and intentionally misrepresented relevant facts relating to the insured's health.
(3) An issuer's payments for benefits under a supplemental long-term care insurance policy or certificate may not be recovered by the issuer if the policy or certificate is rescinded.
(4) This section does not apply to the remaining death benefit of a life insurance policy that accelerates benefits for supplemental long-term care that are governed by RCW 48.23.050 the state's life insurance incontestability clause. In all other situations, this section applies to life insurance policies that accelerate benefits for supplemental long-term care.
[ 2025 c 380 s 30.]
Notes:
Effective date—2025 c 380 ss 17-39, 47, and 48: See note following RCW 48.212.005.

catchline: Recission of policy or certificate.


title: RCW 48.212.140

text:
(1) The commissioner must establish minimum standards for inflation protection features.
(2) An issuer must comply with the rules adopted by the commissioner that establish minimum standards for inflation protection features.
[ 2025 c 380 s 31.]
Notes:
Effective date—2025 c 380 ss 17-39, 47, and 48: See note following RCW 48.212.005.

catchline: Inflation protection features—Rules.


title: RCW 48.212.150

text:
(1) Except as provided by this section, a supplemental long-term care insurance policy may not be delivered or issued for delivery in this state unless the policyholder or certificate holder has been offered the option of purchasing a policy or certificate that includes a nonforfeiture benefit. The offer of a nonforfeiture benefit may be in the form of a rider that is attached to the policy. If a policyholder or certificate holder declines the nonforfeiture benefit, the issuer must provide a contingent benefit upon lapse that is available for a specified period of time following a substantial increase in premium rates.
(2) If a group supplemental long-term care insurance policy is issued, the offer required in subsection (1) of this section must be made to the group policyholder. However, if the policy is issued as group supplemental long-term care insurance as defined in RCW 48.212.020(5)(d) other than to a continuing care retirement community or other similar entity, the offering must be made to each proposed certificate holder.
(3) The commissioner must adopt rules specifying the type or types of nonforfeiture benefits to be offered as part of supplemental long-term care insurance policies and certificates, the standards for nonforfeiture benefits, and the rules regarding contingent benefit upon lapse, including a determination of the specified period of time during which a contingent benefit upon lapse will be available and the substantial premium rate increase that triggers a contingent benefit upon lapse.
[ 2025 c 380 s 32.]
Notes:
Effective date—2025 c 380 ss 17-39, 47, and 48: See note following RCW 48.212.005.

catchline: Nonforfeiture benefit option—Offer required—Rules.