BP BHEAD INT H

AN ACT Relating to disclosure of information regarding health care services; adding new sections to chapter 48.43 RCW; adding a new section to chapter 70.170 RCW; and creating a new section.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF WASHINGTON:

NEW SECTION. Sec. 1. A new section is added to chapter 48.43 RCW to read as follows:

(1) Unless otherwise specifically provided, the definitions in this section apply throughout this section and sections 2 through 4 of this act.

(a) "Health care facility" or "facility" means hospices licensed under chapter 70.127 RCW, hospitals licensed under chapter 70.41 RCW, rural health care facilities as defined in RCW 70.175.020, psychiatric hospitals licensed under chapter 71.12 RCW, nursing homes licensed under chapter 18.51 RCW, community mental health centers licensed under chapter 71.05 or 71.24 RCW, kidney disease treatment centers licensed under chapter 70.41 RCW, ambulatory diagnostic, treatment, or surgical facilities licensed under chapter 70.41 RCW, drug and alcohol treatment facilities licensed under chapter 70.96A RCW, and home health agencies licensed under chapter 70.127 RCW, and includes such facilities if owned and operated by a political subdivision or instrumentality of the state and such other facilities as required by federal law and implementing regulations.

(b) "Health care provider" or "provider" means:

(i) A person regulated under Title 18 RCW or chapter 70.127 RCW, to practice health or health-related services, or otherwise practicing health care services in this state consistent with state law; or

(ii) An employee or agent of a person described in (b)(i) of this subsection, acting in the course and scope of his or her employment.

(c) "Health care service" means that service offered or provided by health care facilities and health care providers relating to the prevention, cure, or treatment of illness, injury, or disease.

(d) "Health carrier" or "carrier" means a disability insurer regulated under chapter 48.20 or 48.21 RCW, a health care service contractor as defined in RCW 48.44.010, a health maintenance organization as defined in RCW 48.46.020, plans operating under the state health care authority under chapter 41.05 RCW, the state health insurance pool operating under chapter 48.41 RCW, and insuring entities regulated under this chapter.

(e) "Health plan" or "plan" means a health plan as defined in RCW 48.43.005(9).

(f) "Primary health care provider" means a health care provider who is regulated under chapter 18.130 RCW and is identified by a carrier as the provider an enrollee would most often use to receive health care services.

(2) Each health carrier that offers a health plan shall disclose in writing, in a style understandable to a person with an average comprehension of the relevant language, using concise and specific terms, and in a manner prescribed by the insurance commissioner in rule, the following information:

(a) A listing of the plan's primary care providers, including degree and certification, practice specialty, the year first licensed to practice, and, if different, the year initially licensed to practice in Washington state;

(b) Premium costs;

(d) A listing of health care services and other services included in the health plan benefits to which an enrollee is entitled and a listing of health care services excluded from plan benefits;

(e) Names, addresses, telephone numbers, and types of health care facilities and outpatient treatment facilities that are under contract with the health carrier;

(f) Procedures for selecting or changing primary care providers, health care facilities, outpatient treatment facilities, or other covered service delivery entities that are covered under the plan;

(g) Any limitations of the services, kinds of services, benefits, and exclusions that apply to the plan, addressing, at least:

(i) Procedures for nighttime visits, weekend visits, and referrals to specialist providers;

(ii) Health care services that can be received and for which payment will be made outside the plan;

(iii) Procedures an enrollee must follow, if any, to obtain prior authorization for services, including requirements, if any, of repeating prior authorization to continue receiving specialist care;

(iv) Description of and authorization requirements for emergency medical care, specifically addressing twenty-four-hour emergency services;

(v) Circumstances under which the carrier may retroactively deny coverage for emergency medical treatment and nonemergency medical treatment that had prior authorization under the plan's written policies; and

(vi) Requirements, if any, that plan providers must comply with any specified numbers, targeted averages, or maximum durations of patient visits;

(h) Availability and conditions of a point-of-service option;

(i) Cost of carrier operations, to be expressed in terms of:

(i) Total revenue; and

(ii) Percentage of total revenue and ratio to enrollee for the following items: Administrations; advertising and promotional activities; facilities; physician services; nonphysician health provider services; and nonhealth provider services;

(j) Procedures for cost-effectiveness, including methods of utilization review and, if done by an organization other than the carrier, the name, address, and telephone number of the utilization review organization;

(k) Definition and use of the term "medical necessity";

(l) Definition and use of the term "experimental treatment";

(m) Criteria and procedures for selecting and dismissing health care providers;

(n) Grievance procedures for claim or treatment denials, dissatisfaction with care, and access to care issues;

(o) Requirement, if any, that restricts a provider in prescribing drugs from a carrier list or formulary and related reimbursement for costs of a drug that is not on a plan list or plan formulary; and

(p) Descriptions and justifications for provider compensation programs, including any incentives or penalties that are intended to encourage providers to withhold services or minimize or avoid referrals to specialists.

(3) A health carrier shall not disseminate a completed disclosure form until the form is submitted to the insurance commissioner. For purposes of this section, a health carrier is not required to submit to the insurance commissioner its separate roster of plan providers or any roster updates.

(4) Upon request, a health carrier shall provide the information required under subsection (2) of this section to all employers who are considering participating in a health plan that is offered by the health carrier or to an employer that is considering renewal of a plan that is provided by the health carrier.

(5) An employer shall provide to its eligible employees the disclosures required under subsection (2) of this section no later than the initiation of any open enrollment period or at least ten days before any employee enrollment deadline that is not associated with an open enrollment period.

(6) An employer shall not execute a contract with a health carrier until the employer receives the information required under subsection (2) of this section.

NEW SECTION. Sec. 2. A new section is added to chapter 48.43 RCW to read as follows:

(1) No public or private health carrier subject to the jurisdiction of the state of Washington may propose, issue, sign, or renew an agreement of any kind, including an enrollee service agreement, that contains a clause or language whose effect, in any way, is to disclaim liability for the care delivered or not delivered to an enrollee because of a decision of the health carrier as to whether the care was a covered service, medically necessary, economically provided, medically appropriate, or similar consideration.

(2) No public or private health carrier subject to the jurisdiction of the state of Washington may propose, issue, sign, or renew an agreement of any kind, including an enrollee service agreement, that contains a clause or language whose effect, in any way, is to shift liability to the provider or the patient, or both, for the care delivered or not delivered in material part because of a payment or other related decision of the health carrier. A clause is a violation of this subsection if, by way of illustration and not limitation, it says that the decision to obtain care is between the provider and the patient, failing to acknowledge the role of payment in such decisions.

(3) Nothing in this section is to be construed to create new liability on anyone for the health carrier's payment or related decisions. The intent of this section is only to prevent health carriers from disclaiming or shifting any existing liability to either providers or patients, or both.

NEW SECTION. Sec. 3. A new section is added to chapter 48.43 RCW to read as follows:

It is a violation of law for a health carrier, as defined in section 1 of this act, to require as a condition of payment, contract, or reimbursement that a health care provider or health care facility refrain from disclosing to any person in a free and timely manner the following information:

(1) Information set forth in section 1(2) of this act;

(2) Specific directions given by a carrier to a provider or facility regarding the availability of health care services and facility available to a specific enrollee;

(3) Unless specifically prohibited by law, information regarding potential injury or liability as a result of the delivery of a health care service; or

(4) Other information that would contribute to an enrollee's ability to judge the quality of the health plan, health care services, providers, and facilities.

NEW SECTION. Sec. 4. A new section is added to chapter 48.43 RCW to read as follows:

(1) A public or private entity who in good faith prepares a document of any kind that compares health plans or carriers of any kind is immune from civil liability from claims based on the document and the contents of the document.

(2)(a) There is absolute immunity to civil liability from claims based on such a comparison document and its contents if the information was provided by the carrier, was substantially accurately presented, and contained the effective date of the information that the carrier supplied, if any.

(b) In the absence of reckless disregard for the truth proven by clear and convincing evidence, there is immunity from claims based on such a comparison document and its contents if the publisher of the comparison document asked for such information from the carrier, was refused, and relied on any usually reliable source for the information including, but not limited to, carrier enrollees, customers, agents, brokers, or providers. The carrier enrollees, customers, agents, brokers, or providers are likewise immune from civil liability on claims based on information they provided if they believed the information to be accurate and had reasonable grounds for doing so.

NEW SECTION. Sec. 5. A new section is added to chapter 70.170 RCW to read as follows:

Consistent with the data reporting requirements of the department of health, each hospital licensed under chapter 70.41 RCW shall report to the department of health annually with respect to its operations in the preceding fiscal year, in such form as the department requires by rule. The report shall include, but not be limited to: (1) Salaries, by classification for each position in the hospital; (2) total number of full-time equivalent employees employed under each classification; (3) salaries and fringe benefits for the twenty highest paid administrative positions; (4) the name of each corporation related to the hospital; (5) the salaries paid to hospital employees by each related corporation and by the hospital to the employees of related corporations; and (6) a breakdown of facility and subfacility budgets by administrative, supervisory, and direct service categories.

NEW SECTION. Sec. 6. Nothing in this act provides any private right or cause of action to, or on behalf of, any enrollee, prospective enrollee, employer, or other person, whether a resident or nonresident of this state. Except for section 5 of this act, this act provides solely an administrative remedy to the insurance commissioner for any violation of Title 48 RCW or any related rule.