Chapter 284-170 WAC

Last Update: 11/30/23

HEALTH BENEFIT PLAN MANAGEMENT

WAC Sections

SUBCHAPTER A
GENERAL PROVISIONS
HTMLPDF284-170-110Purpose.
HTMLPDF284-170-120Applicability and scope.
HTMLPDF284-170-125Compliance with state and federal laws.
HTMLPDF284-170-130Definitions.
SUBCHAPTER B
HEALTH CARE NETWORKS
HTMLPDF284-170-200Network access—General standards.
HTMLPDF284-170-210Alternate access delivery request.
HTMLPDF284-170-220Amended alternate access delivery request for services subject to the Balance Billing Protection Act.
HTMLPDF284-170-230Maintenance of sufficient provider networks.
HTMLPDF284-170-240Use of subcontracted networks.
HTMLPDF284-170-260Provider directories.
HTMLPDF284-170-270Every category of health care providers.
HTMLPDF284-170-280Network reports—Format.
HTMLPDF284-170-285Mental health and substance use disorder web page model format and required content.
HTMLPDF284-170-300Essential community providers for exchange plans—Definition.
HTMLPDF284-170-310Essential community providers for exchange plans—Network access.
HTMLPDF284-170-320Issuer recordkeeping—Provider networks.
HTMLPDF284-170-330Tiered provider networks.
HTMLPDF284-170-340Assessment of access.
HTMLPDF284-170-350Issuer standards for women's right to directly access certain health care practitioners for women's health care services.
HTMLPDF284-170-360Enrollee's access to providers.
HTMLPDF284-170-370Hospital emergency service departments and practice groups.
HTMLPDF284-170-380Standards for temporary substitution of contracted network providers—"Locum tenens" providers.
HTMLPDF284-170-390Rule concerning contracted network providers called to active duty military service.
SUBCHAPTER C
PROVIDER CONTRACTS AND PAYMENT
HTMLPDF284-170-401Provider and facility contracts with issuers—Generally.
HTMLPDF284-170-411Selection of participating providers—Credentialing and unfair discrimination.
HTMLPDF284-170-421Provider contracts—Standards—Hold harmless provisions.
HTMLPDF284-170-431Provider contracts—Terms and conditions of payment.
HTMLPDF284-170-433Provider contracts—Telemedicine.
HTMLPDF284-170-440Provider contracts—Dispute resolution process.
HTMLPDF284-170-450Pharmacy identification cards.
HTMLPDF284-170-460Provider contracts—Audit guidelines.
HTMLPDF284-170-470Pharmacy claims—Rejections, notifications and disclosures.
HTMLPDF284-170-480Participating provider—Filing and approval.
HTMLPDF284-170-490Effective date.
DISPOSITION OF SECTIONS FORMERLY CODIFIED IN THIS TITLE
284-170-001Transitional reinsurance program. [Statutory Authority: RCW 48.02.060, 48.43.720. WSR 13-05-024 (Matter No. R 2012-09), § 284-170-001, filed 2/11/13, effective 3/14/13.] Decodified by WSR 16-01-081, filed 12/14/15, effective 12/14/15. Recodified as § 284-43-0210.
284-170-002Risk adjustment program. [Statutory Authority: RCW 48.02.060, 48.43.720. WSR 13-05-025 (Matter No. R 2012-12), § 284-170-002, filed 2/11/13, effective 3/14/13.] Decodified by WSR 16-01-081, filed 12/14/15, effective 12/14/15. Recodified as § 284-43-0230.
284-170-250Geographic rating area factor development. [Statutory Authority: RCW 48.02.060, 48.44.050, 48.46.200, and 45 C.F.R. 147.102. WSR 13-11-003 (Matter No. R 2013-01), § 284-170-250, filed 5/1/13, effective 6/1/13.] Decodified by WSR 16-01-081, filed 12/14/15, effective 12/14/15. Recodified as § 284-43-6200.
284-170-252Geographic rating area designation. [Statutory Authority: RCW 48.02.060, 48.44.050, 48.46.200, and 45 C.F.R. 147.102. WSR 13-11-003 (Matter No. R 2013-01), § 284-170-252, filed 5/1/13, effective 6/1/13.] Decodified by WSR 16-01-081, filed 12/14/15, effective 12/14/15. Recodified as § 284-43-6220.
284-170-400Preexisting condition limitations. [Statutory Authority: RCW 48.02.060, 48.18.120(2), 48.20.450, 48.43.0211, 48.43.720(3), 48.44.050, 48.46.200, 45 C.F.R. §§ 147.104, 147.106, 155.420, and 155.725. WSR 14-01-042 (Matter No. R 2013-02), § 284-170-400, filed 12/11/13, effective 1/1/14.] Decodified by WSR 16-01-081, filed 12/14/15, effective 12/14/15. Recodified as § 284-43-5000.
284-170-410Special enrollment requirements for small group plans. [Statutory Authority: RCW 48.02.060, 48.18.120(2), 48.20.450, 48.43.0211, 48.43.720(3), 48.44.050, 48.46.200, 45 C.F.R. §§ 147.104, 147.106, 155.420, and 155.725. WSR 14-01-042 (Matter No. R 2013-02), § 284-170-410, filed 12/11/13, effective 1/1/14.] Decodified by WSR 16-01-081, filed 12/14/15, effective 12/14/15. Recodified as § 284-43-1020.
284-170-412Special enrollment periods for small group qualified health plans. [Statutory Authority: RCW 48.02.060, 48.18.120(2), 48.20.450, 48.43.0211, 48.43.720(3), 48.44.050, 48.46.200, 45 C.F.R. §§ 147.104, 147.106, 155.420, and 155.725. WSR 14-01-042 (Matter No. R 2013-02), § 284-170-412, filed 12/11/13, effective 1/1/14.] Decodified by WSR 16-01-081, filed 12/14/15, effective 12/14/15. Recodified as § 284-43-1040.
284-170-415Duration and effective dates of small group special enrollment periods. [Statutory Authority: RCW 48.02.060, 48.18.120(2), 48.20.450, 48.43.0211, 48.43.720(3), 48.44.050, 48.46.200, 45 C.F.R. §§ 147.104, 147.106, 155.420, and 155.725. WSR 14-01-042 (Matter No. R 2013-02), § 284-170-415, filed 12/11/13, effective 1/1/14.] Decodified by WSR 16-01-081, filed 12/14/15, effective 12/14/15. Recodified as § 284-43-1060.
284-170-420Individual market open enrollment requirements. [Statutory Authority: RCW 48.02.060, 48.18.120(2), 48.44.050, 48.46.200 and 45 C.F.R. Parts 144, 146 and 147. WSR 14-08-036 (Matter No. R 2014-01), § 284-170-420, filed 3/26/14, effective 4/26/14. Statutory Authority: RCW 48.02.060, 48.18.120(2), 48.20.450, 48.43.0211, 48.43.720(3), 48.44.050, 48.46.200, 45 C.F.R. §§ 147.104, 147.106, 155.420, and 155.725. WSR 14-01-042 (Matter No. R 2013-02), § 284-170-420, filed 12/11/13, effective 1/1/14.] Decodified by WSR 16-01-081, filed 12/14/15, effective 12/14/15. Recodified as § 284-43-1080.
284-170-425Individual market special enrollment requirements. [Statutory Authority: RCW 48.02.060, 48.18.120(2), 48.20.450, 48.43.0211, 48.43.720(3), 48.44.050, 48.46.200, 45 C.F.R. §§ 147.104, 147.106, 155.420, and 155.725. WSR 14-01-042 (Matter No. R 2013-02), § 284-170-425, filed 12/11/13, effective 1/1/14.] Decodified by WSR 16-01-081, filed 12/14/15, effective 12/14/15. Recodified as § 284-43-1100.
284-170-430Individual market special enrollment period requirements for qualified health plans. [Statutory Authority: RCW 48.02.060, 48.18.120(2), 48.20.450, 48.43.0211, 48.43.720(3), 48.44.050, 48.46.200, 45 C.F.R. §§ 147.104, 147.106, 155.420, and 155.725. WSR 14-01-042 (Matter No. R 2013-02), § 284-170-430, filed 12/11/13, effective 1/1/14.] Decodified by WSR 16-01-081, filed 12/14/15, effective 12/14/15. Recodified as § 284-43-1120.
284-170-435Duration, notice requirements and effective dates of coverage for individual market special enrollment periods. [Statutory Authority: RCW 48.02.060, 48.18.120(2), 48.20.450, 48.43.0211, 48.43.720(3), 48.44.050, 48.46.200, 45 C.F.R. §§ 147.104, 147.106, 155.420, and 155.725. WSR 14-01-042 (Matter No. R 2013-02), § 284-170-435, filed 12/11/13, effective 1/1/14.] Decodified by WSR 16-01-081, filed 12/14/15, effective 12/14/15. Recodified as § 284-43-1140.
284-170-800Purpose and scope—Pediatric dental benefits for health benefit plans sold outside of the health benefit exchange. [Statutory Authority: RCW 48.02.060 and 48.43.715. WSR 14-09-080 (Matter No. R 2013-19), § 284-170-800, filed 4/18/14, effective 5/19/14.] Decodified by WSR 16-01-081, filed 12/14/15, effective 12/14/15. Recodified as § 284-43-5720.
284-170-805Definitions. [Statutory Authority: RCW 48.02.060 and 48.43.715. WSR 14-09-080 (Matter No. R 2013-19), § 284-170-805, filed 4/18/14, effective 5/19/14.] Decodified by WSR 16-01-081, filed 12/14/15, effective 12/14/15. Recodified as § 284-43-5740.
284-170-810Pediatric dental benefits design—Methods of satisfying requirements. [Statutory Authority: RCW 48.02.060 and 48.43.715. WSR 14-09-080 (Matter No. R 2013-19), § 284-170-810, filed 4/18/14, effective 5/19/14.] Decodified by WSR 16-01-081, filed 12/14/15, effective 12/14/15. Recodified as § 284-43-5760.
284-170-870Deadline for filing individual health plans, small group health plans, and stand-alone dental plans. [Statutory Authority: RCW 48.02.060, 48.18.100, 48.43.340, 48.43.715, 48.44.050, and 48.46.200. WSR 14-07-047 (Matter No. R 2013-27), § 284-170-870, filed 3/13/14, effective 4/13/14.] Decodified by WSR 16-01-081, filed 12/14/15, effective 12/14/15. Recodified as § 284-43-0200.
284-170-950Grandfathered health plan status. [Statutory Authority: RCW 48.02.060, 48.43.700, 48.43.715, 48.44.050, 48.46.200, and 45 C.F.R. 150.101(2). WSR 14-01-039 (Matter No. R 2013-13), § 284-170-950, filed 12/11/13, effective 1/11/14.] Decodified by WSR 16-01-081, filed 12/14/15, effective 12/14/15. Recodified as § 284-43-0250.
284-170-952Market conduct requirements related to grandfathered status. [Statutory Authority: RCW 48.02.060, 48.43.700, 48.43.715, 48.44.050, 48.46.200, and 45 C.F.R. 150.101(2). WSR 14-01-039 (Matter No. R 2013-13), § 284-170-952, filed 12/11/13, effective 1/11/14.] Decodified by WSR 16-01-081, filed 12/14/15, effective 12/14/15. Recodified as § 284-43-0270.
284-170-954Small group coverage market transition requirements. [Statutory Authority: RCW 48.02.060, 48.43.700, 48.43.715, 48.44.050, 48.46.200, and 45 C.F.R. 150.101(2). WSR 14-01-039 (Matter No. R 2013-13), § 284-170-954, filed 12/11/13, effective 1/11/14.] Decodified by WSR 16-01-081, filed 12/14/15, effective 12/14/15. Recodified as § 284-43-0290.
284-170-955Association health plan compliance with statutory or regulatory changes. [Statutory Authority: RCW 48.02.060, 48.43.700, 48.43.715, 48.44.050, 48.46.200, and 45 C.F.R. 150.101(2). WSR 14-01-039 (Matter No. R 2013-13), § 284-170-955, filed 12/11/13, effective 1/11/14.] Decodified by WSR 16-01-081, filed 12/14/15, effective 12/14/15. Recodified as § 284-43-0310.
284-170-958Transition of plans purchased by association members. [Statutory Authority: RCW 48.02.060, 48.43.700, 48.43.715, 48.44.050, 48.46.200, and 45 C.F.R. 150.101(2). WSR 14-01-039 (Matter No. R 2013-13), § 284-170-958, filed 12/11/13, effective 1/11/14.] Decodified by WSR 16-01-081, filed 12/14/15, effective 12/14/15. Recodified as § 284-43-0330.
284-170-959Individual coverage market transition requirements. [Statutory Authority: RCW 48.02.060, 48.43.700, 48.43.715, 48.44.050, 48.46.200, and 45 C.F.R. 150.101(2). WSR 14-01-039 (Matter No. R 2013-13), § 284-170-959, filed 12/11/13, effective 1/11/14.] Decodified by WSR 16-01-081, filed 12/14/15, effective 12/14/15. Recodified as § 284-43-0350.