title: RCW 48.43.761

text:
(1) Except as provided in subsection (2) of this section, a health plan issued or renewed on or after January 1, 2021, may not require an enrollee to obtain prior authorization for withdrawal management services or inpatient or residential substance use disorder treatment services in a behavioral health agency licensed or certified under RCW 71.24.037.
(2)(a) A health plan issued or renewed on or after January 1, 2021, must:
(i) Provide coverage for no less than two business days, excluding weekends and holidays, in a behavioral health agency that provides inpatient or residential substance use disorder treatment prior to conducting a utilization review; and
(ii) Provide coverage for no less than three days in a behavioral health agency that provides withdrawal management services prior to conducting a utilization review.
(b)(i) The health plan may not require an enrollee to obtain prior authorization for the services specified in (a) of this subsection as a condition for payment of services prior to the times specified in (a) of this subsection.
(ii) Once the times specified in (a) of this subsection have passed, the health plan may initiate utilization management review procedures if the behavioral health agency continues to provide services or is in the process of arranging for a seamless transfer to an appropriate facility or lower level of care under subsection (6) of this section. For a health plan issued or renewed on or after January 1, 2025, if a health plan authorizes inpatient or residential substance use disorder treatment services pursuant to (a)(i) of this subsection following the initial medical necessity review process under (c)(iii) of this subsection, the length of the initial authorization may not be less than 14 days from the date that the patient was admitted to the behavioral health agency. Any subsequent reauthorization that the health plan approves after the first 14 days must continue for no less than seven days prior to requiring further reauthorization. Nothing prohibits a health plan from requesting information to assist with a seamless transfer under this subsection.
(c)(i) The behavioral health agency under (a) of this subsection must notify an enrollee's health plan as soon as practicable after admitting the enrollee, but not later than twenty-four hours after admitting the enrollee. The time of notification does not reduce the requirements established in (a) of this subsection.
(ii) The behavioral health agency under (a) of this subsection must provide the health plan with its initial assessment and initial treatment plan for the enrollee within two business days of admission, excluding weekends and holidays, or within three days in the case of a behavioral health agency that provides withdrawal management services.
(iii) After the time period in (a) of this subsection and receipt of the material provided under (c)(ii) of this subsection, the plan may initiate a medical necessity review process. Medical necessity review must be based on the standard set of criteria established under RCW 41.05.528. In a review for inpatient or residential substance use disorder treatment services, a health plan may not make a determination that a patient does not meet medical necessity criteria based primarily on the patient's length of abstinence. If the patient's abstinence from substance use was due to incarceration, hospitalization, or inpatient treatment, a health plan may not consider the patient's length of abstinence in determining medical necessity. If the health plan determines within one business day from the start of the medical necessity review period and receipt of the material provided under (c)(ii) of this subsection that the admission to the facility was not medically necessary and advises the agency of the decision in writing, the health plan is not required to pay the facility for services delivered after the start of the medical necessity review period, subject to the conclusion of a filed appeal of the adverse benefit determination. If the health plan's medical necessity review is completed more than one business day after the start of the medical necessity review period and receipt of the material provided under (c)(ii) of this subsection, the health plan must pay for the services delivered from the time of admission until the time at which the medical necessity review is completed and the agency is advised of the decision in writing.
(3)(a) The behavioral health agency shall document to the health plan the patient's need for continuing care and justification for level of care placement following the current treatment period, based on the standard set of criteria established under RCW 41.05.528, with documentation recorded in the patient's medical record.
(b) For a health plan issued or renewed on or after January 1, 2025, for inpatient or residential substance use disorder treatment services, the health plan may not consider the patient's length of stay at the behavioral health agency when making decisions regarding the authorization to continue care at the behavioral health agency.
(4) Nothing in this section prevents a health carrier from denying coverage based on insurance fraud.
(5) If the behavioral health agency under subsection (2)(a) of this section is not in the enrollee's network:
(a) The health plan is not responsible for reimbursing the behavioral health agency at a greater rate than would be paid had the agency been in the enrollee's network; and
(b) The behavioral health agency may not balance bill, as defined in RCW 48.43.005.
(6) When the treatment plan approved by the health plan involves transfer of the enrollee to a different facility or to a lower level of care, the care coordination unit of the health plan shall work with the current agency to make arrangements for a seamless transfer as soon as possible to an appropriate and available facility or level of care. The health plan shall pay the agency for the cost of care at the current facility until the seamless transfer to the different facility or lower level of care is complete. A seamless transfer to a lower level of care may include same day or next day appointments for outpatient care, and does not include payment for nontreatment services, such as housing services. If placement with an agency in the health plan's network is not available, the health plan shall pay the current agency until a seamless transfer arrangement is made.
(7) The requirements of this section do not apply to treatment provided in out-of-state facilities.
(8) For the purposes of this section "withdrawal management services" means twenty-four hour medically managed or medically monitored detoxification and assessment and treatment referral for adults or adolescents withdrawing from alcohol or drugs, which may include induction on medications for addiction recovery.
[ 2024 c 366 s 7; 2020 c 345 s 3.]
Notes:
Findings—Intent—2024 c 366: See note following RCW 71.24.847.
Findings—Intent—2020 c 345: See note following RCW 41.05.526.

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


doc_type: statute

jurisdiction: wa

title: RCW 48.43.762

text:
(1) For health plans issued or renewed on or after January 1, 2023, health carriers must participate in the opioid overdose reversal medication bulk purchasing and distribution program established in RCW 70.14.170 once the program is operational. A health plan may not impose enrollee cost sharing related to opioid overdose reversal medication provided through the bulk purchasing and distribution program established in RCW 70.14.170.
(2) For health plans issued or renewed on or after January 1, 2025, a health carrier must reimburse a hospital or psychiatric hospital that bills for the following outpatient services:
(a) For opioid overdose reversal medication dispensed or distributed to a patient under RCW 70.41.485 as a separate reimbursable expense; and
(b) For the administration of long-acting injectable buprenorphine as a separate reimbursable expense.
(3) Reimbursements provided under subsection (2) of this section must be separate from any bundled payment for outpatient hospital or emergency department services.
[ 2024 c 366 s 17; 2021 c 273 s 11.]
Notes:
Findings—Intent—2024 c 366: See note following RCW 71.24.847.
Rules—2021 c 273 ss 7-12: See note following RCW 70.14.170.
Findings—Intent—2021 c 273: See note following RCW 70.41.480.

license: public-domain-government-work

rule_set: Revised Code of Washington

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

code: rcw

unit: section

court: Washington State Legislature


title: RCW 48.43.764

text:
When updated versions of the ASAM Criteria, treatment criteria for addictive, substance related, and co-occurring conditions, inclusive of adolescent and transition age youth versions, are published by the American society of addiction medicine, the health care authority and the office of the insurance commissioner shall jointly determine whether to use the updated version, and, if so, the date upon which the updated version must begin to be used by medicaid managed care organizations, carriers, and other relevant entities. Both agencies shall post notice of their decision on their websites. For purposes of the ASAM Criteria, 4th edition, medicaid managed care organizations and carriers shall begin to use the updated criteria no later than January 1, 2028, unless the health care authority and the office of the insurance commissioner jointly determine that it should not be used.
[ 2025 c 335 s 2; 2024 c 366 s 11.]
Notes:
Findings—Intent—2024 c 366: See note following RCW 71.24.847.

catchline: Standard set of criteria—Authority review.


title: RCW 48.43.765

text:
(1) The commissioner shall amend his or her rules on electronic provider directories to require health carriers to include a notation when any mental health provider or substance abuse provider is closed to new patients.
(2) Beginning January 1, 2020, a health carrier shall prominently post the information listed in (a) through (e) of this subsection on its website in an easily understandable format and in a manner that any interested party may obtain the information:
(a) Whether the health carrier classifies mental health treatment and substance abuse treatment as primary care or specialty care and the number of business days within which an enrollee must have access to covered mental health treatment services and substance abuse treatment services under network access standards pertaining to primary care or specialty care, as applicable, adopted by the commissioner;
(b) Information on actions an enrollee may take if he or she is unable to access covered mental health treatment services or substance abuse treatment services within the requisite number of business days, including any tools or resources the carrier makes available to enrollees to assist them in finding available providers and information on how to file a complaint with the office of the insurance commissioner;
(c) Any instances where the commissioner has taken disciplinary action against the health carrier for failing to comply with network access standards for covered mental health treatment services or substance abuse treatment services;
(d) A link to the commissioner's report published under subsection (5) of this section; and
(e) Resources for persons who are experiencing a mental health crisis including, but not limited to, information on the national suicide prevention lifeline.
(3) The commissioner shall, by rule, specify a model format for the information required to be posted on a health carrier's website under subsection (2) of this section.
(4) The commissioner may audit the information a health carrier provides under this section for accuracy.
(5) The commissioner shall annually publish on the commissioner's website a report on the number of consumer complaints per licensed health carrier the commissioner received in the previous calendar year regarding consumers who were not able to access covered mental health treatment services or substance abuse treatment services within the time limits established by the commissioner for primary care or specialty care.
[ 2019 c 11 s 1.]
Notes:
Short title—2019 c 11: "This act may be known and cited as Brennen's law." [ 2019 c 11 s 2.]

catchline: Health carrier network adequacy—Mental health and substance abuse treatment.


title: RCW 48.43.766

text:
(1) For the purposes of this section:
(a) "Clinical review criteria" means written guidelines, standards, protocols, or decision rules used by a health carrier, or health care benefit manager on behalf of a health carrier, during utilization review to evaluate the medical necessity of a patient's requested health care services.
(b) "Core treatment" means a standard treatment or course of treatment, therapy, service, or intervention indicated by generally accepted standards of mental health and substance use disorder care for a condition or disorder.
(c) "Generally accepted standards of mental health and substance use disorder care" means standards of care and clinical practice that are generally recognized by health care providers practicing in relevant clinical specialties such as psychiatry, psychology, clinical sociology, social work, addiction medicine and counseling, and behavioral health treatment.
(d) "Health plan" or "health benefit plan" means:
(i) A health plan as defined by RCW 48.43.005; or
(ii) A plan deemed by the commissioner to have a short-term limited purpose or duration, or to be a student-only health plan that is guaranteed renewable while the covered person is enrolled as a regular, full-time undergraduate student at an accredited higher education institution.
(e) "Medically necessary" means a service or product addressing the specific needs of a patient, for the purpose of screening, preventing, diagnosing, managing, or treating an illness, injury, condition, or its symptoms, including minimizing the progression of an illness, injury, condition, or its symptoms, in a manner that is:
(i) In accordance with generally accepted standards of mental health and substance use disorder care;
(ii) Clinically appropriate in terms of type, frequency, extent, site, and duration of a service or product; and
(iii) Not primarily for the economic benefit of the insurer or purchaser or for the convenience of the patient, treating physician, or other health care provider.
(f) "Mental health and substance use disorder services" means:
(i) For health benefit plans issued or renewed before January 1, 2021, medically necessary outpatient and inpatient services provided to treat mental disorders covered by the diagnostic categories listed in the most current version of the diagnostic and statistical manual of mental disorders, published by the American psychiatric association, on June 11, 2020, or such subsequent date as may be provided by the insurance commissioner by rule, consistent with the purposes of chapter 6, Laws of 2005, with the exception of the following categories, codes, and services: (A) Substance-related disorders; (B) 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; (C) skilled nursing facility services, home health care, residential treatment, and custodial care; and (D) court-ordered treatment, unless the insurer's medical director or designee determines the treatment to be medically necessary;
(ii) For a health benefit plan or a plan deemed by the commissioner to have a short-term limited purpose or duration, or to be a student-only health plan that is guaranteed renewable while the covered person is enrolled as a regular, full-time undergraduate student at an accredited higher education institution, issued or renewed on or after January 1, 2021, medically necessary outpatient services, residential care, partial hospitalization services, 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; and
(iii) For a health plan issued or renewed on or after January 1, 2027, medically necessary outpatient services, residential care, partial hospitalization services, inpatient services, and prescription drugs provided to treat mental health or substance use disorders covered by:
(A) 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 any subsequent version as determined by the insurance commissioner in rule consistent with this section and the goals listed in section 1, chapter 227, Laws of 2025;
(B) The diagnostic categories listed in the mental, behavioral, and neurodevelopmental chapters of the version available on January 13, 2025, of the international classification of diseases adopted by the federal department of health and human services through 42 C.F.R. Sec. 162.002 or any subsequent version as determined by the insurance commissioner in rule consistent with this section and the goals listed in section 1, chapter 227, Laws of 2025; or
(C) The diagnostic categories listed in the DC:0-5 diagnostic classification of mental health and developmental disorders of infancy and early childhood available on January 13, 2025, or any subsequent version as determined by the insurance commissioner in rule consistent with this section and the goals listed in section 1, chapter 227, Laws of 2025.
(g) "Nonprofit professional association" means a not-for-profit health care provider professional association or specialty society that is generally recognized by clinicians practicing in the relevant clinical specialty and issues peer-reviewed guidelines, criteria, or other clinical recommendations developed through a transparent process.
(h) "Utilization review" has the same meaning as in RCW 48.43.005.
(2) Each health plan providing coverage for medical and surgical services shall provide coverage for mental health and substance use disorder services. Any cost sharing for mental health and substance use disorder services and any treatment limitations related to mental health and substance use disorder services must comply with the quantitative and nonquantitative treatment limitation requirements in the provisions of 89 Fed. Reg. 77586 et seq., as published on September 23, 2024.
(3) Utilization review and clinical review criteria may not deviate from generally accepted standards of mental health and substance use disorder care.
(4)(a) Except as otherwise provided in (c) of this subsection, in conducting utilization reviews relating to service intensity or level of care placement, continued stay, or transfer or discharge, the health carrier shall apply relevant age-appropriate patient placement criteria from nonprofit professional associations and shall authorize placement at the service intensity and level of care consistent with that criteria. The health carrier may not apply conflicting or more restrictive criteria. A carrier may continue to use software-based clinical decision support tools, including those developed by commercial entities, so long as such tools incorporate and apply with fidelity the relevant age-appropriate patient placement criteria consistent with the requirements of this subsection.
(b) If the carrier's application of the relevant age-appropriate patient placement criteria under (a) of this subsection is not consistent with the service intensity or level of care placement requested by the covered person or their provider, any adverse benefit determination notice must include full details of the carrier's assessment under the relevant criteria to the provider and the covered person.
(c) A carrier may use patient placement criteria in addition to the relevant age-appropriate placement criteria under (a) of this subsection only to approve requested services and may not rely on additional patient placement criteria to issue an adverse benefit determination or otherwise deny, restrict, or limit access to requested services.
(d) For utilization review not relating to service intensity or level of care placement, continued stay, or transfer or discharge, a carrier may use clinical review criteria from either for-profit or nonprofit sources provided that the clinical review criteria meet the requirements of subsection (3) of this section.
(e) To ensure appropriate use of all clinical review criteria used by a carrier to conduct utilization reviews, carriers must comply with any oversight measures deemed appropriate by the commissioner.
(5) A health carrier may not limit benefits or coverage for medically necessary mental health and substance use disorder services on the basis that those services should or could be covered by a public entitlement program including, but not limited to, special education or an individualized education program, medicaid, medicare, supplemental security income, or social security disability insurance, and may not include or enforce a contract term that excludes otherwise covered benefits on the basis that those services should or could be covered by a public entitlement program. Nothing in this subsection may be construed to require a carrier to cover benefits that have been authorized and provided for a covered person by a public entitlement program, except as otherwise required by state or federal law.
(6) This section applies to any health care benefit manager, as defined in RCW 48.200.020[,] or contracted provider that performs utilization review functions directly or indirectly on a health carrier's behalf.
(7) A health carrier may not adopt, impose, or enforce terms in its policies or provider agreements, in writing or in operation, in a manner that undermines, alters, or conflicts with the requirements of this section.
(8) If a health carrier provides any benefits for a mental health condition or substance use disorder in any classification of benefits, it shall provide meaningful benefits for that mental health condition or substance use disorder in every classification in which medical or surgical benefits are provided. For purposes of this subsection, whether the benefits provided are considered "meaningful benefits" is determined in comparison to the benefits provided for medical conditions and surgical procedures in the classification and requires, at a minimum, coverage of benefits for that condition or disorder in each classification in which the health carrier provides benefits for one or more medical conditions or surgical procedures. A health carrier does not provide meaningful benefits under this subsection unless it provides benefits for a core treatment for that condition or disorder in each classification in which the health carrier provides benefits for a core treatment for one or more medical conditions or surgical procedures. If there is no core treatment for a covered mental health condition or substance use disorder with respect to a classification, the health carrier is not required to provide benefits for a core treatment for such condition or disorder in that classification, but shall provide benefits for such condition or disorder in every classification in which medical or surgical benefits are provided.
(9) The provisions of 89 Fed. Reg. 77586 et seq., as published on September 23, 2024, and any guidance issued by federal departments of health and human services, labor, and the treasury to implement the rules adopted in September 2024 are incorporated in this section in their entirety.
(10) If, following an adverse benefit determination, a covered person requests one or more nonquantitative treatment limitation parity compliance analyses that the health carrier is required to have completed by 29 U.S.C. Sec. 1185a or 42 U.S.C. Sec. 300gg–26, the health carrier shall provide the requested analyses free of charge within 30 days.
(11) This section does not prohibit a requirement that mental health and substance use disorder services be medically necessary, if a comparable requirement is applicable to medical and surgical services.
[ 2025 c 227 s 2.]
Notes:
Effective date—2025 c 227 ss 1-8: "Sections 1 through 8 of this act take effect January 1, 2027." [ 2025 c 227 s 10.]
Findings—Intent—2025 c 227: "(1) The legislature finds that:
(a) Access to mental health and substance use disorder treatment is critical to the health and well-being of individuals with these conditions and that access to appropriate care is important to reducing preventable emergency department visits, hospitalizations, and physical health care costs associated with significant comorbidities;
(b) Health insurance coverage is essential to ensuring that individuals can access needed mental health and substance use disorder treatment and that health carriers should make medical necessity determinations based on the objective needs of the patient; and
(c) The mental health and substance use disorder workforce faces a number of administrative barriers and undue financial risks with respect to participation in health carriers' provider networks that should be alleviated.
(2) Therefore, it is the intent of the legislature to increase access to mental health and substance use disorder treatment by updating Washington's mental health parity requirements, requiring that medical necessity determinations be consistent with generally accepted standards of care and recommendations from nonprofit health care provider associations, requiring consistent rules for both mental health and substance use disorders, and eliminating harmful barriers to care." [ 2025 c 227 s 1.]
Rules—2025 c 227: "The insurance commissioner may adopt rules necessary to implement this act, including requiring submission of quantitative data to determine in-operation parity compliance." [ 2025 c 227 s 9.]

catchline: Mental health and substance use disorder services—Coverage—Utilization reviews. (Effective January 1, 2027.)


title: RCW 48.43.767

text:
By July 1, 2025, every carrier shall provide access to services provided by behavioral health support specialists in a manner sufficient to meet the network access standards set forth in rules established by the office of the insurance commissioner.
[ 2023 c 270 s 12.]

catchline: Behavioral health services—Network access.


title: RCW 48.43.770

text:
The commissioner shall submit an annual report to the appropriate committees of the legislature on the number of health plans available per county in the individual market.
[ 2019 c 364 s 7.]

catchline: Individual market health plan availability—Annual report.


title: RCW 48.43.775

text:
A carrier may not require a provider or facility participating in a qualified health plan under RCW 41.05.410 to, as a condition of participation in a qualified health plan under RCW 41.05.410, accept a reimbursement rate for other health plans offered by the carrier at the same rate as the provider or facility is reimbursed for a qualified health plan under RCW 41.05.410.
[ 2019 c 364 s 8.]

catchline: Qualified health plan participation—Reimbursement rate for other health plans.


title: RCW 48.43.780

text:
(1)(a) Except as required in (b) of this subsection, a health plan issued or renewed on or after January 1, 2023, that provides coverage for prescription insulin drugs for the treatment of diabetes must cap the total amount that an enrollee is required to pay for a covered insulin drug at an amount not to exceed $35 per 30-day supply of the drug. Prescription insulin drugs must be covered without being subject to a deductible, and any cost sharing paid by an enrollee must be applied toward the enrollee's deductible obligation.
(b) If the federal internal revenue service removes insulin from the list of preventive care services which can be covered by a qualifying health plan for a health savings account before the deductible is satisfied, for a health plan that provides coverage for prescription insulin drugs for the treatment of diabetes and is offered as a qualifying health plan for a health savings account, the carrier must establish the plan's cost sharing for the coverage of prescription insulin for diabetes at the minimum level necessary to preserve the enrollee's ability to claim tax exempt contributions from his or her health savings account under internal revenue service laws and regulations.
(2)(a) Except as provided in (b) of this subsection, a health plan issued or renewed on or after January 1, 2025, that provides coverage for prescription asthma inhalers for the treatment of asthma shall cap the total amount that an enrollee is required to pay for at least one covered inhaled corticosteroid and at least one covered inhaled corticosteroid combination that is federal food and drug administration approved for the treatment of asthma at an amount not to exceed $35 per 30-day supply of the drug. A health plan must ensure that a covered inhaled corticosteroid and a covered inhaled corticosteroid combination is always available to a patient at the amount required by this subsection. Except as provided in (b) of this subsection, prescription asthma inhalers must be covered without being subject to a deductible, and any cost sharing paid by an enrollee must be applied toward the enrollee's deductible obligation.
(b) For a health plan that is offered as a qualifying health plan for a health savings account, the health carrier shall establish the plan's cost sharing for asthma inhalers that are not on the federal internal revenue service's list of preventive care services at the minimum level necessary to preserve the enrollee's ability to claim tax exempt contributions and withdrawals from the enrollee's health savings account under internal revenue service laws and regulations. If the federal internal revenue service removes asthma inhalers from the list of preventive care services which can be covered by a qualifying health plan for a health savings account before the deductible is satisfied, for a health plan that provides coverage for prescription asthma inhalers for the treatment of asthma and is offered as a qualifying health plan for a health savings account, the carrier shall establish the plan's cost sharing for the coverage of prescription asthma inhalers at the minimum level necessary to preserve the enrollee's ability to claim tax exempt contributions from the enrollee's health savings account under internal revenue service laws and regulations.
(3)(a) Except as provided in (b) of this subsection, a health plan issued or renewed on or after January 1, 2025, that provides coverage for prescription epinephrine autoinjectors for the treatment of allergic reaction shall cap the total amount that an enrollee is required to pay for at least one covered epinephrine autoinjector product containing at least two autoinjectors at an amount not to exceed $35. A health plan must ensure that a covered epinephrine autoinjector is always available to a patient at the amount required by this subsection. Except as provided in (b) of this subsection, prescription epinephrine autoinjectors must be covered without being subject to a deductible, and any cost sharing paid by an enrollee must be applied toward the enrollee's deductible obligation.
(b) For a health plan that is offered as a qualifying health plan for a health savings account, the health carrier shall establish the plan's cost sharing for epinephrine autoinjectors at the minimum level necessary to preserve the enrollee's ability to claim tax exempt contributions and withdrawals from the enrollee's health savings account under internal revenue service laws and regulations. If the federal internal revenue service adds epinephrine autoinjectors to the list of preventive care services which can be covered by a qualifying health plan for a health savings account before the deductible is satisfied, coverage must be provided as described in (a) of this subsection without being subject to the deductible.
(4) The office of the insurance commissioner must provide written notice of any changes in internal revenue service guidance regarding any prescription drug covered in this section to affected parties, the chief clerk of the house of representatives, the secretary of the senate, the office of the code reviser, and others as deemed appropriate by the office.
(5) To the extent not prohibited under this section, health plans may apply drug utilization management strategies to prescription drugs covered under subsections (2) and (3) of this section.
[ 2024 c 226 s 1; 2023 c 16 s 1; 2022 c 10 s 1. Prior: 2020 c 346 s 5; 2020 c 245 s 1.]
Notes:
Effective date—2022 c 10 s 1: "Section 1 of this act takes effect January 1, 2023." [ 2022 c 10 s 3.]
Intent—2020 c 346: See note following RCW 70.14.165.

catchline: Cap on enrollee's required payment amount for specific drugs and equipment—Cost-sharing requirements.


title: RCW 48.43.790

text:
Health plans issued or renewed on or after January 1, 2023, must make next-day appointments available to enrollees experiencing urgent, symptomatic behavioral health conditions to receive covered behavioral health services. The appointment may be with a licensed provider other than a licensed behavioral health professional, as long as that provider is acting within their scope of practice, and may be provided through telemedicine consistent with RCW 48.43.735. Need for urgent symptomatic care is associated with the presentation of behavioral health signs or symptoms that require immediate attention, but are not emergent.
[ 2021 c 302 s 106.]
Notes:
Findings—Intent—2021 c 302: See note following RCW 71.24.890.


title: RCW 48.43.795

text:
For qualified health plans offered on the exchange, a carrier shall:
(1) Accept payments for enrollee premiums or cost-sharing assistance under RCW 43.71.110 or as part of a sponsorship program under RCW 43.71.030(4). Nothing in this subsection expands or restricts the types of sponsorship programs authorized under state and federal law;
(2) Clearly communicate premium assistance amounts to enrollees as part of the invoicing and payment process; and
(3) Accept and process enrollment and payment data transferred by the exchange in a timely manner.
[ 2021 c 246 s 4.]

catchline: Qualified health plans—Acceptance of premium and cost-sharing assistance.


title: RCW 48.43.800

text:
(1) The commissioner may require health carriers to annually report primary care expenditures in previous calendar years or anticipated for upcoming calendar years.
(2) The commissioner may determine the form and content of carrier primary care expenditure reporting. In developing the form and content for reporting, the commissioner shall consider the definition of primary care expenditures and any primary care expenditure targets established under RCW 70.390.080 as well as primary care expenditure reporting systems implemented by the health care authority for medical assistance and employee benefits coverage administered under chapter 41.05 or 74.09 RCW.
(3) Primary care expenditure reports submitted by carriers under this section are public information.
[ 2025 c 6 s 1; 2022 c 155 s 2.]

catchline: Primary care expenditures reporting—Review.


title: RCW 48.43.805

text:
(1) For health plans issued or renewed on or after January 1, 2024, if the prescription drug affordability board, as established in chapter 70.405 RCW, establishes an upper payment limit for a prescription drug pursuant to RCW 70.405.050, a carrier must provide sufficient information, as determined by the commissioner, to indicate that reimbursement for a claim for that prescription drug will not exceed the upper payment limit for the drug established by the board.
(2) The commissioner may adopt any rules necessary to implement this section.
[ 2022 c 153 s 10.]

catchline: Prescription drug upper payment limit—Rules.


title: RCW 48.43.810

text:
(1) Health plans issued or renewed on or after January 1, 2023, shall exempt an enrollee from prior authorization requirements for coverage of biomarker testing for either of the following:
(a) Stage 3 or 4 cancer; or
(b) Recurrent, relapsed, refractory, or metastatic cancer.
(2) For purposes of this section, "biomarker test" means a single or multigene diagnostic test of the cancer patient's biospecimen, such as tissue, blood, or other bodily fluids, for DNA, RNA, or protein alterations, including phenotypic characteristics of a malignancy, to identify an individual with a subtype of cancer, in order to guide patient treatment.
(3) For purposes of this section, biomarker testing must be:
(a) Recommended in the latest version of nationally recognized guidelines or biomarker compendia, such as those published by the national comprehensive cancer network;
(b) Approved by the United States food and drug administration or a validated clinical laboratory test performed in a clinical laboratory certified under the clinical laboratory improvement amendments or in an alternative laboratory program approved by the centers for medicare and medicaid services;
(c) A covered service; and
(d) Prescribed by an in-network provider.
(4) This section does not limit, prohibit, or modify an enrollee's rights to biomarker testing as part of an approved clinical trial under chapter 69.77 RCW.
(5) Nothing in this section may be construed to mandate coverage of a health care service.
(6) Nothing in this section prohibits a health plan from requiring a biomarker test prior to approving a drug or treatment.
(7) This section does not limit an enrollee's rights to access individual gene tests.
[ 2022 c 123 s 1.]


title: RCW 48.43.815

text:
(1) For group health plans other than small group health plans issued or renewed on or after January 1, 2023, a health carrier shall provide coverage for medically necessary donor human milk for inpatient use when ordered by a licensed health care provider with prescriptive authority or an international board certified lactation consultant certified by the international board of lactation consultant examiners for an infant who is medically or physically unable to receive maternal human milk or participate in chest feeding or whose parent is medically or physically unable to produce maternal human milk in sufficient quantities or caloric density or participate in chest feeding, if the infant meets at least one of the following criteria:
(a) An infant birth weight of below 2,500 grams;
(b) An infant gestational age equal to or less than 34 weeks;
(c) Infant hypoglycemia;
(d) A high risk for development of necrotizing enterocolitis, bronchopulmonary dysplasia, or retinopathy of prematurity;
(e) A congenital or acquired gastrointestinal condition with long-term feeding or malabsorption complications;
(f) Congenital heart disease requiring surgery in the first year of life;
(g) An organ or bone marrow transplant;
(h) Sepsis;
(i) Congenital hypotonias associated with feeding difficulty or malabsorption;
(j) Renal disease requiring dialysis in the first year of life;
(k) Craniofacial anomalies;
(l) An immunologic deficiency;
(m) Neonatal abstinence syndrome;
(n) Any other serious congenital or acquired condition for which the use of pasteurized donor human milk and donor human milk derived products is medically necessary and supports the treatment and recovery of the child; or
(o) Any baby still inpatient within 72 hours of birth without sufficient human milk available.
(2) Donor human milk covered under this section must be obtained from a milk bank that meets minimum standards adopted by the department of health pursuant to RCW 43.70.645.
(3) For purposes of this section:
(a) "Donor human milk" means human milk that has been contributed to a milk bank by one or more donors.
(b) "Milk bank" means an organization that engages in the procurement, processing, storage, distribution, or use of human milk contributed by donors.
(4) The commissioner may adopt any rules necessary to implement this section.
[ 2022 c 236 s 1.]

catchline: Donor human milk—Standards.


title: RCW 48.43.820

text:
The commissioner is authorized to enforce provisions of P.L. 116-260 (enacted December 27, 2020, as the consolidated appropriations act of 2021) and implementing federal regulations in effect on March 31, 2022, that are applicable to or regulate the conduct of carriers issuing health plans or grandfathered health plans to residents of Washington state on or after January 1, 2022. In addition to the enforcement actions authorized under RCW 48.02.080, the commissioner may impose a civil monetary penalty in an amount not to exceed $100 for each day for each individual with respect to which a failure to comply with these provisions occurs.
[ 2022 c 263 s 5.]
Notes:
Effective date—2022 c 263: See note following RCW 43.371.100.

catchline: Consolidated appropriations act enforcement—Implementation of federal regulations.


title: RCW 48.43.825

text:
By July 1, 2026, each carrier shall provide access to services provided by certified peer support specialists and certified peer support specialist trainees in a manner sufficient to meet the network access standards set forth in rules established by the office of the insurance commissioner.
[ 2025 c 360 s 16; 2023 c 469 s 16.]

catchline: Certified peer support specialist services—Network access standards.


title: RCW 48.43.830

text:
(1) Each carrier offering a health plan issued or renewed on or after January 1, 2024, shall comply with the following standards related to prior authorization for health care services and prescription drugs:
(a) The carrier shall meet the following time frames for prior authorization determinations and notifications to a participating provider or facility that submits the prior authorization request through an electronic prior authorization process, as designated by each carrier:
(i) For electronic standard prior authorization requests, the carrier shall make a decision and notify the provider or facility of the results of the decision within three calendar days, excluding holidays, of submission of an electronic prior authorization request by the provider or facility that contains the necessary information to make a determination. If insufficient information has been provided to the carrier to make a decision, the carrier shall request any additional information from the provider or facility within one calendar day of submission of the electronic prior authorization request.
(ii) For electronic expedited prior authorization requests, the carrier shall make a decision and notify the provider or facility of the results of the decision within one calendar day of submission of an electronic prior authorization request by the provider or facility that contains the necessary information to make a determination. If insufficient information has been provided to the carrier to make a decision, the carrier shall request any additional information from the provider or facility within one calendar day of submission of the electronic prior authorization request.
(b) The carrier shall meet the following time frames for prior authorization determinations and notifications to a participating provider or facility that submits the prior authorization request through a process other than an electronic prior authorization process:
(i) For nonelectronic standard prior authorization requests, the carrier shall make a decision and notify the provider or facility of the results of the decision within five calendar days of submission of a nonelectronic prior authorization request by the provider or facility that contains the necessary information to make a determination. If insufficient information has been provided to the carrier to make a decision, the carrier shall request any additional information from the provider or facility within five calendar days of submission of the nonelectronic prior authorization request.
(ii) For nonelectronic expedited prior authorization requests, the carrier shall make a decision and notify the provider or facility of the results of the decision within two calendar days of submission of a nonelectronic prior authorization request by the provider or facility that contains the necessary information to make a determination. If insufficient information has been provided to the carrier to make a decision, the carrier shall request any additional information from the provider or facility within one calendar day of submission of the nonelectronic prior authorization request.
(c) In any instance in which a carrier has determined that a provider or facility has not provided sufficient information for making a determination under (a) and (b) of this subsection, a carrier may establish a specific reasonable time frame for submission of the additional information. This time frame must be communicated to the provider and enrollee with a carrier's request for additional information.
(d) The carrier's prior authorization requirements must be described in detail and written in easily understandable language. The carrier shall make its most current prior authorization requirements and restrictions, including the written clinical review criteria, available to providers and facilities in an electronic format upon request. The prior authorization requirements must be based on peer-reviewed clinical review criteria. The clinical review criteria must be evidence-based criteria and must accommodate new and emerging information related to the appropriateness of clinical criteria with respect to black and indigenous people, other people of color, gender, and underserved populations. The clinical review criteria must be evaluated and updated, if necessary, at least annually.
(e) When denying a prior authorization determination, the carrier shall include the credentials, board certifications, and areas of specialty of the provider who had clinical oversight over the determination in any notification sent to the health plan enrollee and provider requesting or referring the service.
(2) Carriers must post any adjustments to policies and procedures that impact the applicability of their prior authorization requirements for health care services or prescription drugs, including new applications of prior authorization, in a single location on the carrier's website. After December 30, 2030, any new application of prior authorization for health care services must be available to providers on the electronic prior authorization system or application programming interface system referenced in subsection (4) of this section.
(3)(a) Only a licensed physician or a licensed health professional working within their scope of practice may deny a prior authorization request based on medical necessity. The licensed physician or licensed health professional shall evaluate the specific clinical issues involved in the health care services requested by the requesting provider by reviewing and considering the requesting provider's recommendation, the enrollee's medical or other clinical history, as applicable, and individual clinical circumstances. Artificial intelligence shall not be the sole means used to deny, delay, or modify health care services. Algorithms may be used to process and approve prior authorization requests, but may not be used without human review to deny care based on a determination of medical necessity.
(b) A carrier that uses artificial intelligence for the purpose of prior authorization or prior authorization functions, based in whole or in part on medical necessity, or that contracts with or otherwise works through an entity that uses artificial intelligence for the purpose of prior authorization or prior authorization functions, based in whole or in part on medical necessity, shall ensure all of the following:
(i) The artificial intelligence bases its determination on the following information, as applicable:
(A) An enrollee's medical or other clinical history, including demographic data; and
(B) Individual clinical circumstances as presented by the requesting provider;
(ii) The artificial intelligence does not base its determination solely on a group data set;
(iii) The artificial intelligence's criteria and guidelines comply with this chapter and applicable state and federal law;
(iv) The use of the artificial intelligence does not discriminate, directly or indirectly, against an enrollee in violation of state or federal law;
(v) The artificial intelligence is fairly and equitably applied, including in accordance with any applicable regulations and guidance issued by the federal department of health and human services;
(vi) The policies and procedures for using artificial intelligence are open to audit by the office of the insurance commissioner under chapter 48.37 RCW;
(vii) The artificial intelligence's performance, use, and outcomes are periodically reviewed by the carrier to maximize accuracy and reliability; and
(viii) Patient data is not used beyond its intended and stated purpose, consistent with chapter 70.02 RCW and the federal health insurance portability and accountability act of 1996, 42 U.S.C. Sec. 1320d et al., as applicable.
(4)(a) Each carrier shall establish and maintain a prior authorization application programming interface that is consistent with final rules issued by the federal centers for medicare and medicaid services and published in the federal register, and that indicates that a prior authorization denial or authorization of a service less intensive than that included in the original request is an adverse benefit determination and is subject to the carrier's grievance and appeal process under RCW 48.43.535.
(b) Each carrier shall establish and maintain an interoperable electronic process or application programming interface that automates the process for in-network providers to determine whether a prior authorization is required for a covered prescription drug. The interoperable electronic process or application programming interface must support the exchange of prior authorization requests and determinations for prescription drugs, including information on covered alternative prescription drugs, beginning January 1, 2027, and must:
(i) Allow providers to identify prior authorization information and documentation requirements;
(ii) Facilitate the exchange of prior authorization requests and determinations from its electronic health records or practice management system; and
(iii) Indicate that a prior authorization denial or authorization of a drug other than the one included in the original prior authorization request is an adverse benefit determination and is subject to the carrier's grievance and appeal process under RCW 48.43.535.
(c) Regardless of whether federal rules related to standards for using an application programming interface to communicate prior authorization status to providers are revoked, delayed, suspended, or not finalized by the federal centers for medicare and medicaid services after February 8, 2024, the requirements of (a) of this subsection shall be enforced beginning January 1, 2027.
(d) By September 13, 2023, and at least every six months thereafter until September 13, 2026, the commissioner shall provide an update to the health care policy committees of the legislature on the development of rules and implementation guidance from the federal centers for medicare and medicaid services regarding the standards for development of application programming interfaces and interoperable electronic processes related to prior authorization functions. The updates should include recommendations, as appropriate, on whether the status of the federal rule development aligns with the provisions of chapter 382, Laws of 2023. The commissioner also shall report on any actions by the federal centers for medicare and medicaid services to exercise enforcement discretion related to the implementation and maintenance of an application programming interface for prior authorization functions. The commissioner shall consult with the health care authority, carriers, providers, and consumers on the development of these updates and any recommendations.
(5) Nothing in this section applies to prior authorization determinations made pursuant to RCW 48.43.761.
(6) This section applies to prior authorization functions carried out by health care benefit managers, as defined in RCW 48.200.020, under direct or indirect contract with a carrier.
(7) The commissioner may adopt any rules necessary to implement this section.
(8) For the purposes of this section:
(a) "Artificial intelligence" means the use of machine learning and related technologies that use data to train statistical models for the purpose of enabling computer systems to perform tasks normally associated with human intelligence or perception, such as computer vision, speech or natural language processing, and content generation. "Artificial intelligence" includes generative artificial intelligence.
(b) "Expedited prior authorization request" means a request by a provider or facility for approval of a health care service or prescription drug where:
(i) The passage of time:
(A) Could seriously jeopardize the life or health of the enrollee;
(B) Could seriously jeopardize the enrollee's ability to regain maximum function; or
(C) In the opinion of a provider or facility with knowledge of the enrollee's medical condition, would subject the enrollee to severe pain that cannot be adequately managed without the health care service or prescription drug that is the subject of the request; or
(ii) The enrollee is undergoing a current course of treatment using a nonformulary drug.
(c) "Generative artificial intelligence" means an artificial intelligence system that generates novel data or content based on a foundation model.
(d) "Machine learning" means the process by which artificial intelligence is developed using data and algorithms to draw inferences therefrom to automatically adapt or improve its accuracy without explicit programming.
(e) "Standard prior authorization request" means a request by a provider or facility for approval of a health care service or prescription drug where the request is made in advance of the enrollee obtaining a health care service or prescription drug that is not required to be expedited.
[ 2026 c 157 s 2; 2025 c 25 s 1; 2023 c 382 s 1.]
Notes:
Expiration date—2026 c 157 ss 2 and 6: "Sections 2 and 6 of this act expire January 1, 2027." [ 2026 c 157 s 9.]
Finding—Intent—2026 c 157: "(1) The legislature finds that health carriers are the decision makers for the type and level of care covered for an enrollee's health care benefits and are not responsible for determining or altering an enrollee's diagnosis or treatment plan. It is not always transparent who the decision maker is or how decisions are made in determining enrollee coverage for treatment, prescription drugs, or services. Artificial intelligence is being increasingly utilized by health carriers to make or aid in decisions about medical necessity and coverage of provider-recommended treatment.
(2) It is the intent of the legislature to increase transparency in the prior authorization process for health care coverage decisions and to ensure licensed physicians and licensed health professionals remain responsible for making determinations regarding treatments, prescription drugs, and other health care services. If artificial intelligence is used to aid in the decision-making process, standards must be put in place to ensure artificial intelligence is not used to make inappropriate determinations that could impact the health of an enrollee.
(3) It is the intent of the legislature to update the protections of this act for enrollees to include managed care organizations as soon as feasible, recognizing that low-income, publicly insured Washingtonians deserve the same patient protections as higher-income, commercially insured Washingtonians." [ 2026 c 157 s 1.]
PDF
RCW 48.43.830
Prior authorization—Standards—Denials—Application—Rules. (Effective January 1, 2027.)
(1) Each carrier offering a health plan issued or renewed on or after January 1, 2024, shall comply with the following standards related to prior authorization for health care services and prescription drugs:
(a) The carrier shall meet the following time frames for prior authorization determinations and notifications to a participating provider or facility that submits the prior authorization request through an electronic prior authorization process, as designated by each carrier:
(i) For electronic standard prior authorization requests, the carrier shall make a decision and notify the provider or facility of the results of the decision within three calendar days, excluding holidays, of submission of an electronic prior authorization request by the provider or facility that contains the necessary information to make a determination. If insufficient information has been provided to the carrier to make a decision, the carrier shall request any additional information from the provider or facility within one calendar day of submission of the electronic prior authorization request.
(ii) For electronic expedited prior authorization requests, the carrier shall make a decision and notify the provider or facility of the results of the decision within one calendar day of submission of an electronic prior authorization request by the provider or facility that contains the necessary information to make a determination. If insufficient information has been provided to the carrier to make a decision, the carrier shall request any additional information from the provider or facility within one calendar day of submission of the electronic prior authorization request.
(b) The carrier shall meet the following time frames for prior authorization determinations and notifications to a participating provider or facility that submits the prior authorization request through a process other than an electronic prior authorization process:
(i) For nonelectronic standard prior authorization requests, the carrier shall make a decision and notify the provider or facility of the results of the decision within five calendar days of submission of a nonelectronic prior authorization request by the provider or facility that contains the necessary information to make a determination. If insufficient information has been provided to the carrier to make a decision, the carrier shall request any additional information from the provider or facility within five calendar days of submission of the nonelectronic prior authorization request.
(ii) For nonelectronic expedited prior authorization requests, the carrier shall make a decision and notify the provider or facility of the results of the decision within two calendar days of submission of a nonelectronic prior authorization request by the provider or facility that contains the necessary information to make a determination. If insufficient information has been provided to the carrier to make a decision, the carrier shall request any additional information from the provider or facility within one calendar day of submission of the nonelectronic prior authorization request.
(c) In any instance in which a carrier has determined that a provider or facility has not provided sufficient information for making a determination under (a) and (b) of this subsection, a carrier may establish a specific reasonable time frame for submission of the additional information. This time frame must be communicated to the provider and enrollee with a carrier's request for additional information.
(d) The carrier's prior authorization requirements must be described in detail and written in easily understandable language. The carrier shall make its most current prior authorization requirements and restrictions, including the written clinical review criteria, available to providers and facilities in an electronic format upon request. The prior authorization requirements must be based on peer-reviewed clinical review criteria. The clinical review criteria must be evidence-based criteria and must accommodate new and emerging information related to the appropriateness of clinical criteria with respect to black and indigenous people, other people of color, gender, and underserved populations. The clinical review criteria must be evaluated and updated, if necessary, at least annually. Clinical review criteria used for purposes of reviewing and decided upon prior authorization requests related to mental health and substance use disorder services, as defined in RCW 48.43.766, must meet the requirements of RCW 48.43.766.
(e) When denying a prior authorization determination, the carrier shall include the credentials, board certifications, and areas of specialty of the provider who had clinical oversight over the determination in any notification sent to the health plan enrollee and provider requesting or referring the service.
(2) Carriers must post any adjustments to policies and procedures that impact the applicability of their prior authorization requirements for health care services or prescription drugs, including new applications of prior authorization, in a single location on the carrier's website. After December 30, 2030, any new application of prior authorization for health care services must be available to providers on the electronic prior authorization system or application programming interface system.
(3)(a) Only a licensed physician or a licensed health professional working within their scope of practice may deny a prior authorization request based on medical necessity. The licensed physician or licensed health professional shall evaluate the specific clinical issues involved in the health care services requested by the requesting provider by reviewing and considering the requesting provider's recommendation, the enrollee's medical or other clinical history, as applicable, and individual clinical circumstances. Artificial intelligence shall not be the sole means used to deny, delay, or modify health care services. Algorithms may be used to process and approve prior authorization requests, but may not be used without human review to deny care based on a determination of medical necessity.
(b) A carrier that uses artificial intelligence for the purpose of prior authorization or prior authorization functions, based in whole or in part on medical necessity, or that contracts with or otherwise works through an entity that uses artificial intelligence for the purpose of prior authorization or prior authorization functions, based in whole or in part on medical necessity, shall ensure all of the following:
(i) The artificial intelligence bases its determination on the following information, as applicable:
(A) An enrollee's medical or other clinical history, including demographic data; and
(B) Individual clinical circumstances as presented by the requesting provider;
(ii) The artificial intelligence does not base its determination solely on a group data set;
(iii) The artificial intelligence's criteria and guidelines comply with this chapter and applicable state and federal law;
(iv) The use of the artificial intelligence does not discriminate, directly or indirectly, against an enrollee in violation of state or federal law;
(v) The artificial intelligence is fairly and equitably applied, including in accordance with any applicable regulations and guidance issued by the federal department of health and human services;
(vi) The policies and procedures for using artificial intelligence are open to audit by the office of the insurance commissioner under chapter 48.37 RCW;
(vii) The artificial intelligence's performance, use, and outcomes are periodically reviewed by the carrier to maximize accuracy and reliability; and
(viii) Patient data is not used beyond its intended and stated purpose, consistent with chapter 70.02 RCW and the federal health insurance portability and accountability act of 1996, 42 U.S.C. Sec. 1320d et al., as applicable.
(4)(a) Each carrier shall establish and maintain a prior authorization application programming interface that is consistent with final rules issued by the federal centers for medicare and medicaid services and published in the federal register, and that indicates that a prior authorization denial or authorization of a service less intensive than that included in the original request is an adverse benefit determination and is subject to the carrier's grievance and appeal process under RCW 48.43.535.
(b) Each carrier shall establish and maintain an interoperable electronic process or application programming interface that automates the process for in-network providers to determine whether a prior authorization is required for a covered prescription drug. The interoperable electronic process or application programming interface must support the exchange of prior authorization requests and determinations for prescription drugs, including information on covered alternative prescription drugs, beginning January 1, 2027, and must:
(i) Allow providers to identify prior authorization information and documentation requirements;
(ii) Facilitate the exchange of prior authorization requests and determinations from its electronic health records or practice management system; and
(iii) Indicate that a prior authorization denial or authorization of a drug other than the one included in the original prior authorization request is an adverse benefit determination and is subject to the carrier's grievance and appeal process under RCW 48.43.535.
(c) Regardless of whether federal rules related to standards for using an application programming interface to communicate prior authorization status to providers are revoked, delayed, suspended, or not finalized by the federal centers for medicare and medicaid services after February 8, 2024, the requirements of (a) of this subsection shall be enforced beginning January 1, 2027.
(d) By September 13, 2023, and at least every six months thereafter until September 13, 2026, the commissioner shall provide an update to the health care policy committees of the legislature on the development of rules and implementation guidance from the federal centers for medicare and medicaid services regarding the standards for development of application programming interfaces and interoperable electronic processes related to prior authorization functions. The updates should include recommendations, as appropriate, on whether the status of the federal rule development aligns with the provisions of chapter 382, Laws of 2023. The commissioner also shall report on any actions by the federal centers for medicare and medicaid services to exercise enforcement discretion related to the implementation and maintenance of an application programming interface for prior authorization functions. The commissioner shall consult with the health care authority, carriers, providers, and consumers on the development of these updates and any recommendations.
(5) Nothing in this section applies to prior authorization determinations made pursuant to RCW 48.43.761.
(6) This section applies to prior authorization functions carried out by health care benefit managers, as defined in RCW 48.200.020, under direct or indirect contract with a carrier.
(7) The commissioner may adopt any rules necessary to implement this section.
(8) For the purposes of this section:
(a) "Artificial intelligence" means the use of machine learning and related technologies that use data to train statistical models for the purpose of enabling computer systems to perform tasks normally associated with human intelligence or perception, such as computer vision, speech or natural language processing, and content generation. "Artificial intelligence" includes generative artificial intelligence.
(b) "Expedited prior authorization request" means a request by a provider or facility for approval of a health care service or prescription drug where:
(i) The passage of time:
(A) Could seriously jeopardize the life or health of the enrollee;
(B) Could seriously jeopardize the enrollee's ability to regain maximum function; or
(C) In the opinion of a provider or facility with knowledge of the enrollee's medical condition, would subject the enrollee to severe pain that cannot be adequately managed without the health care service or prescription drug that is the subject of the request; or
(ii) The enrollee is undergoing a current course of treatment using a nonformulary drug.
(c) "Generative artificial intelligence" means an artificial intelligence system that generates novel data or content based on a foundation model.
(d) "Machine learning" means the process by which artificial intelligence is developed using data and algorithms to draw inferences therefrom to automatically adapt or improve its accuracy without explicit programming.
(e) "Standard prior authorization request" means a request by a provider or facility for approval of a health care service or prescription drug where the request is made in advance of the enrollee obtaining a health care service or prescription drug that is not required to be expedited.
[ 2026 c 157 s 3. Prior: 2025 c 227 s 8; 2025 c 25 s 1; 2023 c 382 s 1.]
Notes:
Effective date—2026 c 157 ss 3 and 7: "Sections 3 and 7 of this act take effect January 1, 2027." [ 2026 c 157 s 10.]
Finding—Intent—2026 c 157: See note following RCW 48.43.830.
Effective date—2025 c 227 ss 1-8: See note following RCW 48.43.766.
Findings—Intent—Rules—2025 c 227: See notes following RCW 48.43.766.

catchline: Prior authorization—Standards—Denials—Application—Rules. (Effective until January 1, 2027.)


title: RCW 48.43.835

text:
This chapter authorizes carriers to reimburse employers of physician assistants for covered services rendered by licensed physician assistants. Payment for services within the physician assistant's scope of practice must be made when ordered or performed by a physician assistant if the same services would have been covered if ordered or performed by a physician. Physician assistants or their employers, who are billing on behalf of the physician assistant, are authorized to bill for and receive direct payment for the services delivered by physician assistants. A carrier may not impose a practice, education, or collaboration requirement that is inconsistent with or more restrictive than state laws or regulations governing physician assistants.
[ 2024 c 62 s 11.]
Notes:
Effective date—2024 c 62 ss 1-8, 10-18, 20-26, 28, and 30-32: See note following RCW 18.71A.010.
Intent—2024 c 62: See note following RCW 18.71A.020.

catchline: Physician assistants—Coverage.


title: RCW 48.43.840

text:
(1) Except as provided in subsection (9) of this section, a health plan offered in the large group or small group market that is issued or renewed on or after January 1, 2026, must include coverage for one or more prostheses per limb and custom orthotic braces per limb when medically necessary for the enrollee to participate in any of the following:
(a) Completing activities of daily living or essential job-related activities; and
(b) Performing physical activities, including but not limited to running, biking, swimming, and strength training, for maximizing the enrollee's lower limb function, upper limb function, or both.
(2) The coverage required under this section must also include coverage for:
(a) Materials, components, and related services necessary to use the devices for their intended purposes;
(b) Instruction to the enrollee on using the devices; and
(c) Reasonable repair or replacement of the devices.
(3)(a) Coverage under this section includes coverage for the replacement or repair of a prosthetic limb or custom orthotic brace or for the replacement or repair of any part of such devices, without regard to continuous use or useful lifetime restrictions, if medically necessary because:
(i) Of a change in the physiological condition of the patient;
(ii) Of an irreparable change in the condition of the device or a part of the device; or
(iii) The device, or any part of the device, requires repairs and the cost of such repairs would be more than 60 percent of the cost of a replacement device or of the part being replaced.
(b) Confirmation from the prescribing health care provider may be required if the prosthetic limb or custom orthotic brace or part being replaced is less than three years old.
(4) A health plan offered in the large group or small group market may not deny coverage for a prosthetic limb or custom orthotic brace for an enrollee with a disability if health care services would otherwise be covered for a nondisabled person seeking medical or surgical intervention to restore or maintain the ability to perform the same physical activity.
(5) For coverage under this section, a health plan offered in the large group or small group market may apply normal utilization management and prior authorization practices. Any denial of coverage must be issued in writing with an explanation for determining coverage was not medically necessary.
(6) A health plan offered in the large group or small group market shall provide payment for coverage under this section that is at least equal to the payment and coverage for prosthetic limbs and custom orthotic braces provided under federal laws and regulations for the aged and disabled pursuant to 42 U.S.C. Sec. 1395k, 1395l, and 1395m and 42 C.F.R. Sec. 414.202, 414.210, 414.228, and 410.100.
(7) No later than July 1, 2028, each carrier that issues a health plan subject to this section shall report to the office of the insurance commissioner, in a form and manner determined by the commissioner, the number of claims and the total amount of claims paid in the state for the services required by this section for plan years 2026 and 2027. The commissioner shall aggregate this data by plan year in a report and submit the report to the relevant committees of the legislature by December 1, 2028.
(8) For the purposes of this section:
(a) "Prosthetic limb" or "prosthesis" means an external medical device that is used to replace or restore a missing limb or portion of a limb and is deemed medically necessary for an individual with a mobility impairing health condition or disability.
(b) "Custom orthotic brace" means an external medical device that is custom-fabricated or custom-fitted to support, correct, or alleviate neuromuscular or musculoskeletal dysfunction, disease, injury, or deformity, is needed to improve the safety and efficiency of functional mobility, is patient-specific based on the patient's unique physical condition, and is deemed medically necessary for individuals with a mobility impairing health condition or disability.
(9) This section does not apply to health plans offered in the individual market or to self-insured or fully insured large group health plans offered to public employees and school employees under chapter 41.05 RCW.
[ 2025 c 96 s 1.]

catchline: Prosthetic limbs and custom orthotic braces—Coverage—Reporting.


title: RCW 48.43.845

text:
(1) A health plan issued or renewed on or after January 1, 2026, that includes coverage for prescription hormone therapy must provide reimbursement for a 12-month refill of covered prescription hormone therapy obtained at one time by the enrollee, unless the enrollee requests a smaller supply, the prescribing provider instructs that the enrollee must receive a smaller supply, or the prescription hormone therapy is a controlled substance. The 12-month refill requirement only applies to prescription hormone therapy that is able to be safely stored at room temperature without refrigeration. If the prescription hormone therapy is a controlled substance, the health plan must provide reimbursement for the maximum refill allowed under state and federal law to be obtained at one time by the enrollee. Any dispensing practices required by the health plan must follow clinical guidelines for appropriate prescribing and dispensing to ensure the health of the patient while maximizing access to effective prescription hormone therapy.
(2) Nothing in this section prohibits a health plan from limiting refills that may be obtained in the last quarter of the plan year if a 12-month supply of the prescription hormone therapy has already been dispensed during the plan year.
(3) Nothing in this section prohibits a prescribing provider from temporarily limiting refills that may be obtained to a 90-day supply at one time if the prescription hormone therapy is experiencing an acute dispensing shortage during the plan year provided limits must be rescinded at first opportunity of a regularly reinstated, sustainable supply.
(4) To the extent not otherwise prohibited under this section or state or federal law, health plans may apply drug utilization management strategies to prescription drugs covered under subsection (1) of this section.
(5) For purposes of this section, "prescription hormone therapy" means all drugs approved by the United States food and drug administration that are used to medically suppress, increase, or replace hormones that the body is not producing at intended levels. Prescription hormone therapy does not include glucagon-like peptide-1 and glucagon-like peptide-1 receptor agonists.
[ 2025 c 171 s 1.]

catchline: Prescription hormone therapy—Coverage.


title: RCW 48.43.850

text:
(1) For health plans issued or renewed on or after January 1, 2027, except as provided in subsection (2) of this section, a health carrier shall provide coverage for all federal food and drug administration approved HIV antiviral drugs without prior authorization, step therapy, or any other utilization management protocols.
(2) If the United States food and drug administration has approved one or more therapeutic equivalents of a drug, device, or product for the prevention or treatment of HIV, this section does not require a health plan to cover all of the therapeutically equivalent versions without prior authorization, step therapy, or any other utilization management protocols, if at least one therapeutically equivalent version is covered without prior authorization, step therapy, or any other utilization management protocols.
[ 2026 c 48 s 1.]

catchline: HIV antiviral drugs—Prior authorization.


title: RCW 48.43.902

text:
This act shall take effect July 1, 1996.
[ 1996 c 312 s 8.]

catchline: Effective date—1996 c 312.


title: RCW 48.43.904

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 125.]

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


title: RCW 48.44.010

text:
For the purposes of this chapter:
(1) "Carrier" means a health maintenance organization, an insurer, a health care service contractor, or other entity responsible for the payment of benefits or provision of services under a group or individual contract.
(2) "Census date" means the date upon which a health care services contractor offering coverage to a small employer must base rate calculations. For a small employer applying for a health benefit plan through a contractor other than its current contractor, the census date is the date that final group composition is received by the contractor. For a small employer that is renewing its health benefit plan through its existing contractor, the census date is ninety days prior to the effective date of the renewal.
(3) "Commissioner" means the insurance commissioner.
(4) "Copayment" means an amount specified in a group or individual contract which is an obligation of an enrolled participant for a specific service which is not fully prepaid.
(5) "Deductible" means the amount an enrolled participant is responsible to pay before the health care service contractor begins to pay the costs associated with treatment.
(6) "Enrolled participant" means a person or group of persons who have entered into a contractual arrangement or on whose behalf a contractual arrangement has been entered into with a health care service contractor to receive health care services.
(7) "Fully subordinated debt" means those debts that meet the requirements of RCW 48.44.037(3) and are recorded as equity.
(8) "Group contract" means a contract for health care services which by its terms limits eligibility to members of a specific group. The group contract may include coverage for dependents.
(9) "Health care service contractor" means any corporation, cooperative group, or association, which is sponsored by or otherwise intimately connected with a provider or group of providers, who or which not otherwise being engaged in the insurance business, accepts prepayment for health care services from or for the benefit of persons or groups of persons as consideration for providing such persons with any health care services. "Health care service contractor" does not include direct patient-provider primary care practices as defined in RCW 48.150.010.
(10) "Health care services" means and includes medical, surgical, dental, chiropractic, hospital, optometric, podiatric, pharmaceutical, ambulance, custodial, mental health, and other therapeutic services.
(11) "Individual contract" means a contract for health care services issued to and covering an individual. An individual contract may include dependents.
(12) "Insolvent" or "insolvency" means that the organization has been declared insolvent and is placed under an order of liquidation by a court of competent jurisdiction.
(13) "Net worth" means the excess of total admitted assets as defined in RCW 48.12.010 over total liabilities but the liabilities shall not include fully subordinated debt.
(14) "Participating provider" means a provider, who or which has contracted in writing with a health care service contractor to accept payment from and to look solely to such contractor according to the terms of the subscriber contract for any health care services rendered to a person who has previously paid, or on whose behalf prepayment has been made, to such contractor for such services.
(15) "Provider" means any health professional, hospital, or other institution, organization, or person that furnishes health care services and is licensed to furnish such services.
(16) "Replacement coverage" means the benefits provided by a succeeding carrier.
(17) "Uncovered expenditures" means the costs to the health care service contractor for health care services that are the obligation of the health care service contractor for which an enrolled participant would also be liable in the event of the health care service contractor's insolvency and for which no alternative arrangements have been made as provided herein. The term does not include expenditures for covered services when a provider has agreed not to bill the enrolled participant even though the provider is not paid by the health care service contractor, or for services that are guaranteed, insured or assumed by a person or organization other than the health care service contractor.
[ 2010 c 292 s 3; 2007 c 267 s 2; 1990 c 120 s 1; 1986 c 223 s 1. Prior: 1983 c 286 s 3; 1983 c 154 s 3; 1980 c 102 s 10; 1965 c 87 s 1; 1961 c 197 s 1; 1947 c 268 s 1; Rem. Supp. 1947 s 6131-10.]
Notes:
Reviser's note: The definitions in this section have been alphabetized pursuant to RCW 1.08.015(2)(k).
Application—2010 c 292: See note following RCW 48.43.005.
Severability—1983 c 286: See note following RCW 48.44.309.
Severability—1983 c 154: See note following RCW 48.44.299.

catchline: Definitions.


title: RCW 48.44.011

text:
(1) Insurance producer, as used in this chapter, means any person appointed or authorized by a health care service contractor to solicit applications for health care service contracts on its behalf.
(2) No person shall act as or hold himself or herself out to be an appointed insurance producer of a health care service contractor unless licensed as a disability insurance producer by this state and appointed by the health care service contractor on whose behalf solicitations are to be made.
(3) Applications, appointments, and qualifications for licenses, the renewal thereof, the fees and issuance of a license, and the renewal thereof shall be in accordance with the provisions of chapter 48.17 RCW that are applicable to a disability insurance producer.
(4) The commissioner may revoke, suspend, or refuse to issue or renew any insurance producer's license, or levy a fine upon the licensee, in accordance with those provisions of chapter 48.17 RCW that are applicable to a disability insurance producer.
[ 2008 c 217 s 50; 1983 c 202 s 1; 1969 c 115 s 7.]
Notes:
Severability—Effective date—2008 c 217: See notes following RCW 48.03.020.

catchline: Insurance producer—Definition—License required—Application, issuance, renewal, fees—Penalties involving license.


title: RCW 48.44.013

text:
Health care service contractors and limited health care service contractors shall send a copy specifically for the office of the insurance commissioner to the secretary of state of any corporate document required to be filed in the office of the secretary of state, including articles of incorporation and bylaws, and any amendments thereto. The copy specifically provided for the office of the insurance commissioner shall be in addition to the copies required by the secretary of state and shall clearly indicate on the copy that it is for delivery to the office of the insurance commissioner.
[ 1998 c 23 s 16.]

catchline: Filings with secretary of state—Copy for commissioner.


title: RCW 48.44.015

text:
(1) A person may not in this state, by mail or otherwise, act as or hold himself or herself out to be a health care service contractor, as defined in RCW 48.44.010 without first being registered with the commissioner.
(2) The issuance, sale, or offer for sale in this state of securities of its own issue by any health care service contractor domiciled in this state other than the memberships and bonds of a nonprofit corporation shall be subject to the provisions of chapter 48.06 RCW relating to obtaining solicitation permits the same as if health care service contractors were domestic insurers.
(3) Any person violating any provision of subsection (2) of this section is guilty of a gross misdemeanor and will, upon conviction, be fined not more than one thousand dollars or imprisoned for not more than six months, or both, for each violation.
[ 2003 c 250 s 7; 1983 c 202 s 2; 1969 c 115 s 6.]
Notes:
Severability—2003 c 250: See note following RCW 48.01.080.

catchline: Registration by health care service contractors required—Penalty.


title: RCW 48.44.016

text:
(1) As used in this section, "person" has the same meaning as in RCW 48.01.070.
(2) For the purpose of this section, an act is committed in this state if it is committed, in whole or in part, in the state of Washington, or affects persons or property within the state and relates to or involves a health care services contract.
(3) Any person who knowingly violates RCW 48.44.015(1) is guilty of a class B felony punishable under chapter 9A.20 RCW.
(4) Any criminal penalty imposed under this section is in addition to, and not in lieu of, any other civil or administrative penalty or sanction otherwise authorized under state law.
(5)(a) If the commissioner has cause to believe that any person has violated the provisions of RCW 48.44.015(1), the commissioner may:
(i) Issue and enforce a cease and desist order in accordance with the provisions of RCW 48.02.080; and/or
(ii) Assess a civil penalty of not more than twenty-five thousand dollars for each violation, after providing notice and an opportunity for a hearing in accordance with chapters 34.05 and 48.04 RCW.
(b) Upon failure to pay a civil penalty when due, the attorney general may bring a civil action on behalf of the commissioner to recover the unpaid penalty. Any amounts collected by the commissioner must be paid to the state treasurer for the account of the general fund.
[ 2003 c 250 s 8.]
Notes:
Severability—2003 c 250: See note following RCW 48.01.080.

catchline: Unregistered activities—Acts committed in this state—Sanctions.


title: RCW 48.44.017

text:
(1) The definitions in this subsection apply throughout this section unless the context clearly requires otherwise.
(a) "Claims" means the cost to the health care service contractor of health care services, as defined in RCW 48.43.005, provided to a contract holder or paid to or on behalf of a contract holder in accordance with the terms of a health benefit plan, as defined in RCW 48.43.005. This includes capitation payments or other similar payments made to providers for the purpose of paying for health care services for an enrollee.
(b) "Claims reserves" means: (i) The liability for claims which have been reported but not paid; (ii) the liability for claims which have not been reported but which may reasonably be expected; (iii) active life reserves; and (iv) additional claims reserves whether for a specific liability purpose or not.
(c) "Declination rate" for a health care service contractor means the percentage of the total number of applicants for individual health benefit plans received by that health care service contractor in the aggregate in the applicable year which are not accepted for enrollment by that health care service contractor based on the results of the standard health questionnaire administered pursuant to *RCW 48.43.018(2)(a).
(d) "Earned premiums" means premiums, as defined in RCW 48.43.005, plus any rate credits or recoupments less any refunds, for the applicable period, whether received before, during, or after the applicable period.
(e) "Incurred claims expense" means claims paid during the applicable period plus any increase, or less any decrease, in the claims reserves.
(f) "Loss ratio" means incurred claims expense as a percentage of earned premiums.
(g) "Reserves" means: (i) Active life reserves; and (ii) additional reserves whether for a specific liability purpose or not.
(2) A health care service contractor must file supporting documentation of its method of determining the rates charged for its individual contracts. At a minimum, the health care service contractor must provide the following supporting documentation:
(a) A description of the health care service contractor's rate-making methodology;
(b) An actuarially determined estimate of incurred claims which includes the experience data, assumptions, and justifications of the health care service contractor's projection;
(c) The percentage of premium attributable in aggregate for nonclaims expenses used to determine the adjusted community rates charged; and
(d) A certification by a member of the American academy of actuaries, or other person approved by the commissioner, that the adjusted community rate charged can be reasonably expected to result in a loss ratio that meets or exceeds the loss ratio standard of seventy-four percent, minus the premium tax rate applicable to the carrier's individual health benefit plans under RCW 48.14.0201.
[ 2011 c 314 s 11; 2008 c 303 s 5; 2001 c 196 s 11; 2000 c 79 s 29.]
Notes:
*Reviser's note: RCW 48.43.018 was repealed by 2019 c 33 s 7.
Effective date—2011 c 314 ss 10-12: See note following RCW 48.20.025.
Effective date—2001 c 196: See note following RCW 48.20.025.
Effective date—Severability—2000 c 79: See notes following RCW 48.04.010.

catchline: Schedule of rates for individual contracts—Loss ratio—Definitions.


title: RCW 48.44.020

text:
(1) Any health care service contractor may enter into contracts with or for the benefit of persons or groups of persons which require prepayment for health care services by or for such persons in consideration of such health care service contractor providing one or more health care services to such persons and such activity shall not be subject to the laws relating to insurance if the health care services are rendered by the health care service contractor or by a participating provider.
(2) The commissioner may on examination, subject to the right of the health care service contractor to demand and receive a hearing under chapters 48.04 and 34.05 RCW, disapprove any individual or group contract form for any of the following grounds:
(a) If it contains or incorporates by reference any inconsistent, ambiguous or misleading clauses, or exceptions and conditions which unreasonably or deceptively affect the risk purported to be assumed in the general coverage of the contract; or
(b) If it has any title, heading, or other indication of its provisions which is misleading; or
(c) If purchase of health care services thereunder is being solicited by deceptive advertising; or
(d) If it contains unreasonable restrictions on the treatment of patients; or
(e) If it violates any provision of this chapter; or
(f) If it fails to conform to minimum provisions or standards required by regulation made by the commissioner pursuant to chapter 34.05 RCW; or
(g) If any contract for health care services with any state agency, division, subdivision, board, or commission or with any political subdivision, municipal corporation, or quasi-municipal corporation fails to comply with state law.
(3) In addition to the grounds listed in subsection (2) of this section, the commissioner may disapprove any contract if the benefits provided therein are unreasonable in relation to the amount charged for the contract. Rates, or any modification of rates effective on or after July 1, 2008, for individual health benefit plans may not be used until sixty days after they are filed with the commissioner. If the commissioner does not disapprove a rate filing within sixty days after the health care service contractor has filed the documents required in RCW 48.44.017(2) and any rules adopted pursuant thereto, the filing shall be deemed approved.
(4)(a) Every contract between a health care service contractor and a participating provider of health care services shall be in writing and shall state that in the event the health care service contractor fails to pay for health care services as provided in the contract, the enrolled participant shall not be liable to the provider for sums owed by the health care service contractor. Every such contract shall provide that this requirement shall survive termination of the contract.
(b) No participating provider, insurance producer, trustee, or assignee may maintain any action against an enrolled participant to collect sums owed by the health care service contractor.
[ 2008 c 303 s 2; 2008 c 217 s 51; 2000 c 79 s 28; 1990 c 120 s 5; 1986 c 223 s 2; 1985 c 283 s 1; 1983 c 286 s 4; 1973 1st ex.s. c 65 s 1; 1969 c 115 s 1; 1961 c 197 s 2; 1947 c 268 s 2; Rem. Supp. 1947 s 6131-11.]
Notes:
Reviser's note: This section was amended by 2008 c 217 s 51 and by 2008 c 303 s 2, 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).
Severability—Effective date—2008 c 217: See notes following RCW 48.03.020.
Effective date—Severability—2000 c 79: See notes following RCW 48.04.010.
Severability—1983 c 286: See note following RCW 48.44.309.

catchline: Contracts for services—Examination of contract forms by commissioner—Grounds for disapproval—Liability of participant.