AN ACT Relating to mitigating barriers to patient access to care resulting from health insurance contracting practices; 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 48.43 RCW to read as follows:

(1)(a) A health carrier may not:

(i) Impose different prior authorization standards and criteria for a covered service among contracting providers of the same licensed profession in the same health plan; or

(ii) Require prior authorization for the first encounter with a contracting provider in a new episode of care. 

(b) Any prior authorization standards and criteria used by a health plan must be based on generally accepted standards of clinical practice.

(c) A health carrier shall disclose, upon the request of a covered person or contracting provider, any standards, criteria, or information the carrier uses for prior authorization decisions.

(d) A health carrier shall respond to a request for prior authorization for a covered habilitative, rehabilitative, or chiropractic service no later than twenty-four hours after receiving the request. If the health carrier does not respond within twenty-four hours of the request, the prior authorization request is deemed granted.

(2)(a) 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 in Washington and must be actively practicing in the same health field or specialty as the health care provider being reviewed.

(b) If a covered person is being treated by more than one provider, the review shall be completed by a provider who holds a license, certification, or registration, in good standing in Washington and who is actively practicing in the same health field or specialty as the principal prescribing or diagnosing provider, unless otherwise agreed to by the covered person and the carrier. This subsection (2)(b) does not prohibit the carrier from providing additional reviews of other categories of providers.

(3) A health carrier may not:

(a) Require a health care provider to participate in one plan, program, or health care arrangement as a condition for participating in any of the carrier's other plans, programs, or arrangements;

(b) 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; or

(c) Require a covered person's cost sharing, including copayments, for habilitative, rehabilitative, or chiropractic care to exceed the cost-sharing amount the carrier requires for primary care.

(4) A health carrier is responsible for any activities it delegates to a subcontractor regarding denials of, or limitations on, access to covered services. A health carrier that delegates such activities to a subcontractor shall ensure that the subcontractor utilizes the correct standards and criteria applicable to each covered person's health benefit plan. If a subcontractor informs a covered person that he or she is eligible for reimbursement for services that exceed the scope of the covered person's coverage in a manner that favors the covered person, the carrier is bound by the information provided by the subcontractor and must reimburse for the services in question regardless of whether they are covered services.    

(5) For purposes of this section, "new episode of care" means treatment for a new condition or an objective or subjective worsening of an existing condition.

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