S-1862.1 _______________________________________________
SENATE BILL 5999
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State of Washington 54th Legislature 1995 Regular Session
By Senator Sheldon
Read first time 02/22/95. Referred to Committee on Health & Long‑Term Care.
AN ACT Relating to payment for pharmacy providers when health maintenance organizations fail to make payment; and amending RCW 48.46.243 and 48.46.245.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF WASHINGTON:
Sec. 1. RCW 48.46.243 and 1990 c 119 s 7 are each amended to read as follows:
(1) Subject to subsection (2) of this section, every contract between a health maintenance organization and its participating providers of health care services shall be in writing and shall set forth that in the event the health maintenance organization fails to pay for health care services as set forth in the agreement, the enrolled participant shall not be liable to the provider, except pharmacy providers, for any sums owed by the health maintenance organization. Every such contract shall provide that this requirement shall survive termination of the contract.
(2) The provisions of subsection (1) of this section shall not apply to emergency care from a provider who is not a participating provider, to out-of-area services or, in exceptional situations approved in advance by the commissioner, if the health maintenance organization is unable to negotiate reasonable and cost-effective participating provider contracts.
(3)(a) Each participating provider contract form shall be filed with the commissioner fifteen days before it is used.
(b) Any contract form not affirmatively disapproved within fifteen days of filing shall be deemed approved, except that the commissioner may extend the approval period an additional fifteen days upon giving notice before the expiration of the initial fifteen-day period. The commissioner may approve such a contract form for immediate use at any time. Approval may be subsequently withdrawn for cause.
(c) Subject to the right of the health maintenance organization to demand and receive a hearing under chapters 48.04 and 34.05 RCW, the commissioner may disapprove such a contract form if it is in any respect in violation of this chapter or if it fails to conform to minimum provisions or standards required by the commissioner by rule under chapter 34.05 RCW.
(4) No participating provider, or agent, trustee, or assignee thereof, may maintain an action against an enrolled participant to collect sums owed by the health maintenance organization.
Sec. 2. RCW 48.46.245 and 1990 c 119 s 8 are each amended to read as follows:
Each health maintenance organization shall have a plan for handling insolvency which allows for continuation of benefits for the duration of the agreement period for which premiums have been paid and continuation of benefits to members who are confined on the date of insolvency in an inpatient facility until their discharge or expiration of benefits. The commissioner shall approve such a plan if it includes:
(1) Insurance to cover the expenses to be paid for continued benefits after insolvency;
(2) Except for pharmacy providers, provisions in provider contracts that obligate the provider to provide services for the duration of the period after the health maintenance organization's insolvency for which premium payment has been made and until the enrolled participants' discharge from inpatient facilities;
(3) Use of insolvency reserves established under RCW 48.46.240;
(4) Acceptable letters of credit or approved surety bonds; or
(5) Any other arrangements the commissioner and the organization mutually agree are appropriate to assure that benefits are continued.
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