AN ACT Relating to mitigating barriers to patient access to care resulting from health insurance contracting practices; adding a new section to chapter 41.05 RCW; adding a new section to chapter 48.43 RCW; and providing an effective date.

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

NEW SECTION.  Sec. 1.  A new section is added to chapter 41.05 RCW to read as follows:

(1) A health plan offered to public employees and their covered dependents under this chapter that imposes different prior authorization standards and criteria for a covered service among tiers of contracting providers of the same licensed profession in the same health plan shall, upon request, inform an enrollee which tier an individual provider or group of providers is in.

(2) The health plan may not require prior authorization for an evaluation and management visit or an initial treatment visit with a contracting provider in a new episode of habilitative, rehabilitative, East Asian medicine, or chiropractic care.

(3) Any prior authorization standards and criteria used by the health plan must be based on the plan's medical necessity standards.

(4) The health care authority shall post on its web site and provide upon the request of a covered person or contracting provider any standards, criteria, or information the health plan uses for prior authorization decisions.

(5) A health care provider with whom the administrator of the health plan consults regarding a decision to deny, limit, or terminate a person's covered health care services must hold a license, certification, or registration, in good standing and must be in the same or related health field as the health care provider being reviewed.

(6) The health plan may not require a provider to provide a discount from usual and customary rates for health care services not covered under the health plan, policy, or other agreement, to which the provider is a party.

(7) In addition to the requirements of RCW 48.43.525, the health plan must honor a representation by its subcontractor that a health care service will be covered by the health plan.

(8)(a) A rental network must give a contracted health care provider sixty days' notice prior to adding a new product to its contract with the provider. The rental network may not require the contracted provider to accept the additional product as a condition for continued participation in the in-force contract.

(b) For purposes of this subsection (8):

(i) "Rental network" means any entity that sells access to a network of health care providers to other entities.

(ii) "Product" means an entity purchasing access to a rental network.

(c) This subsection (8) does not apply to entities within the same insurance holding company system as defined in RCW 48.31B.005.

(9) A health plan offered to employees and their covered dependents under this chapter may not require a covered person's cost sharing, including copayments, for habilitative, rehabilitative, East Asian medicine, or chiropractic care to exceed the cost-sharing amount the plan requires for primary care.

(10) For purposes of this section, "new episode of care" means treatment for a new condition.

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

(1) A health carrier that imposes different prior authorization standards and criteria for a covered service among tiers of contracting providers of the same licensed profession in the same health plan shall, upon request, inform an enrollee which tier an individual provider or group of providers is in.

(2) A health carrier may not require prior authorization for an evaluation and management visit or an initial treatment visit with a contracting provider in a new episode of habilitative, rehabilitative, East Asian medicine, or chiropractic care.

(3) Any prior authorization standards and criteria used by a health plan must be based on the carrier's medical necessity standards.

(4) A health carrier shall post on its web site and provide upon the request of a covered person or contracting provider any standards, criteria, or information the carrier uses for prior authorization decisions.

(5) A health care provider with whom a health carrier consults regarding a decision to deny, limit, or terminate a person's covered health care services must hold a license, certification, or registration, in good standing and must be in the same or related health field as the health care provider being reviewed.

(6) A health carrier may not require a provider to provide a discount from usual and customary rates for health care services not covered under a health plan, policy, or other agreement, to which the provider is a party.

(7) In addition to the requirements of RCW 48.43.525, a health carrier must honor a representation by its subcontractor that a health care service will be covered by the carrier's health plan.

(8)(a) A rental network must give a contracted health care provider sixty days' notice prior to adding a new product to its contract with the provider. The rental network may not require the contracted provider to accept the additional product as a condition for continued participation in the in-force contract.

(b) For purposes of this subsection (8):

(i) "Rental network" means any entity that sells access to a network of health care providers to other entities.

(ii) "Product" means an entity purchasing access to a rental network.

(c) This subsection (8) does not apply to entities within the same insurance holding company system as defined in RCW 48.31B.005.

(9) A health carrier may not require a covered person's cost sharing, including copayments, for habilitative, rehabilitative, East Asian medicine, or chiropractic care to exceed the cost-sharing amount the carrier requires for primary care.

(10) For purposes of this section, "new episode of care" means treatment for a new condition.

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