S-1987.1  _______________________________________________

                    SUBSTITUTE SENATE BILL 5813

          _______________________________________________

State of Washington      56th Legislature     1999 Regular Session

By Senate Committee on Health & Long‑Term Care (originally sponsored by Senators Thibaudeau, Deccio, Costa and Winsley)

Read first time 03/03/1999.

Requiring third-party payors to designate a licensed medical director for its coverage decisions.

    AN ACT Relating to health plan medical director licensure and accountability; adding a new section to chapter 48.43 RCW; and adding a new section to chapter 18.130 RCW.

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) Every health insurer shall designate a medical director who is licensed under chapter 18.57 or 18.71 RCW, who shall be subject to section 2 of this act.

    (2) For purposes of this section "health insurer" means a carrier, the department of labor and industries, the health care authority, the medical assistance administration of the department of social and health services, and any self-insured health plan subject to the jurisdiction of Washington state.

NEW SECTION. Sec. 2.  A new section is added to chapter 18.130 RCW to read as follows:

    (1) For purposes of applying this chapter, any decision by a health insurer to deny or limit payment for services because the services are not medically necessary shall be deemed to be the decision of the medical director designated in section 1 of this act.

    (2) The definitions in this subsection apply throughout this section, unless the context clearly requires otherwise.

    (a) "Health insurer" has the same meaning as provided in section 1 of this act.

    (b) "Services" means medical care or items from a person licensed under chapter 18.57, 18.57A, 18.71, or 18.71A RCW, or as defined in RCW 18.79.050.

    (3) The medical quality assurance commission and the state board of osteopathic medicine and surgery may adopt rules to implement this section.

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