Background: The 1995 Legislature created the requirement for all health plans to permit every category of health care provider to provide health services included in the Basic Health Plan services. The health care services must be within the scope of practice for the provider and the providers must agree to health plan standards on such areas as the provision of care, utilization review, cost containment, management and administrative procedures, and the provision of cost-effective and clinically efficacious care.

In general, pharmacists have not been included in health plan networks while health plans have contracted with pharmacies or pharmacy benefit managers. A 2013 Attorney General Opinion confirmed that pharmacists are health care providers and must be compensated for services included in the Basic Health Plan and within their scope of practice if the pharmacist agrees to the stated standards of the health plan. Pharmacists are regulated under RCW Chapter 18.64 and are permitted to provide health care services such as drug therapy management and other services beyond the dispensing of drugs or devices.

The Basic Health Plan was a state-sponsored health program that was discontinued with the Medicaid expansion. The covered services included physician services, inpatient and outpatient hospital services, prescription drugs and medications, chemical dependency services, mental health services, organ transplant services, all services necessary for prenatal, postnatal, and well-child care, and wellness, smoking cessation, and chronic disease management.

The federal Affordable Care Act established requirements for individual and small group health plans to cover essential health benefits, which reflect ten general categories of care: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance abuse disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services including oral and vision care.

Summary: Health plans issued or renewed on or after January 1, 2017, must not deny any health care service performed by a pharmacist if the service is within the pharmacist scope of practice, the plan would have provided benefits if the service had been performed by a physician, advanced registered nurse practitioner, or physician assistant, and the pharmacist is included in the plan's network of participating providers.

Health plans must include an adequate number of pharmacists in the network of participating providers. The participation of pharmacies in the plan network's drug benefit does not satisfy the requirement that plans include pharmacists in their networks.

For the 2016 benefit year only, health plans that delegate credentialing agreements to contracted health care facilities must accept credentialing for pharmacists employed or contracted by those facilities. Health plans must reimburse facilities for covered services performed by network pharmacists within their scope of practice per negotiations with the facility.

Health plans must permit every category of health provider to provide services included in the ten categories of care required in the essential health benefits benchmark plan, if the provider agrees to the health plan standards and if the plan covers such services or care in the essential health benefits benchmark plan. The reference to the essential health benefits does not create a mandate to cover a service that is otherwise not a covered benefit.

Votes on Final Passage:

Senate	48	0
House	93	4	(House amended)
Senate	47	0	(Senate concurred)