AN
ACT Relating to health care patient protection; amending RCW 70.02.110,
70.02.900, 51.04.020, 74.09.050, and 70.47.130; adding new sections to chapter
48.43 RCW; adding a new section to chapter 70.02 RCW; adding a new section to
chapter 43.70 RCW; adding new sections to chapter 41.05 RCW; creating new
sections; repealing RCW 48.43.075 and 48.43.095; and providing effective dates.
BE IT
ENACTED BY THE LEGISLATURE OF THE STATE OF WASHINGTON:
NEW
SECTION. Sec. 1.
PATIENT RIGHTS. It is the intent of the legislature that
enrollees covered by health plans receive quality health care designed to
maintain and improve their health. The purpose of this act is to ensure that
health plan enrollees:
(1)
Have improved access to information regarding their health plans;
(2)
Have sufficient and timely access to appropriate health care services, and
choice among health care providers;
(3)
Are assured that health care decisions are made by appropriate medical
personnel;
(4)
Have access to a quick and impartial process for appealing plan decisions;
(5)
Are protected from unnecessary invasions of health care privacy; and
(6)
Are assured that personal health care information will be used only as
necessary to obtain and pay for health care or to improve the quality of care.
NEW
SECTION. Sec. 2. A
new section is added to chapter 70.02 RCW to read as follows:
HEALTH
INFORMATION PRIVACY. Third-party payors shall not release health care
information disclosed under this chapter, except to the extent that health care
providers are authorized to do so under RCW 70.02.050.
Sec.
3. RCW
70.02.110 and 1991 c 335 s 402 are each amended to read as follows:
HEALTH
INFORMATION PRIVACY. (1) In making a correction or amendment, the health care
provider shall:
(a)
Add the amending information as a part of the health record; and
(b)
Mark the challenged entries as corrected or amended entries and indicate the
place in the record where the corrected or amended information is located, in a
manner practicable under the circumstances.
(2)
If the health care provider maintaining the record of the patient's health care
information refuses to make the patient's proposed correction or amendment, the
provider shall:
(a)
Permit the patient to file as a part of the record of the patient's health care
information a concise statement of the correction or amendment requested and
the reasons therefor; and
(b)
Mark the challenged entry to indicate that the patient claims the entry is
inaccurate or incomplete and indicate the place in the record where the
statement of disagreement is located, in a manner practicable under the
circumstances.
(3)
A health care provider who receives a request from a patient to amend or
correct the patient's health care information, as provided in RCW 70.02.100,
shall forward any changes made in the patient's health care information or
health record, including any statement of disagreement, to any third-party
payor or insurer to which the health care provider has disclosed the health
care information that is the subject of the request.
Sec.
4. RCW
70.02.900 and 1991 c 335 s 901 are each amended to read as follows:
HEALTH
INFORMATION PRIVACY. (1) This chapter does not restrict a health care provider,
a third-party payor, or an insurer regulated under Title 48 RCW from
complying with obligations imposed by federal or state health care payment
programs or federal or state law.
(2)
This chapter does not modify the terms and conditions of disclosure under Title
51 RCW and chapters 13.50, 26.09, 70.24, 70.39, 70.96A, 71.05, and 71.34 RCW
and rules adopted under these provisions.
NEW
SECTION. Sec. 5. HEALTH
INFORMATION PRIVACY. (1) Health carriers and insurers shall adopt policies and
procedures that conform administrative, business, and operational practices to
protect an enrollee's right to privacy or right to confidential health care
services granted under state or federal laws.
(2)
The commissioner may adopt rules to implement this section after considering
relevant standards adopted by national managed care accreditation organizations
and the national association of insurance commissioners, and after considering
the effect of those standards on the ability of carriers to undertake enrollee
care management and disease management programs.
NEW
SECTION. Sec. 6.
INFORMATION DISCLOSURE. (1) A carrier that offers a health plan may not offer
to sell a health plan to an enrollee or to any group representative, agent,
employer, or enrollee representative without first offering to provide, and
providing upon request, the following information before purchase or selection:
(a)
A listing of covered benefits, including prescription drug benefits, if any, a
copy of the current formulary, if any is used, definitions of terms such as
generic versus brand name, and policies regarding coverage of drugs, such as
how they become approved or taken off the formulary, and how consumers may be
involved in decisions about benefits;
(b)
A listing of exclusions, reductions, and limitations to covered benefits, and
any definition of medical necessity or other coverage criteria upon which they
may be based;
(c)
A statement of the carrier's policies for protecting the confidentiality of
health information;
(d)
A statement of the cost of premiums and any enrollee cost-sharing requirements;
(e)
A summary explanation of the carrier's grievance process;
(f)
A statement regarding the availability of a point-of-service option, if any,
and how the option operates; and
(g)
A convenient means of obtaining lists of participating primary care and
specialty care providers, including disclosure of network arrangements that
restrict access to providers within any plan network. The offer to provide the
information referenced in this subsection (1) must be clearly and prominently
displayed on any information provided to any prospective enrollee or to any prospective
group representative, agent, employer, or enrollee representative.
(2)
Upon the request of any person, including a current enrollee, prospective
enrollee, or the insurance commissioner, a carrier must provide written
information regarding any health care plan it offers, that includes the
following written information:
(a)
Any documents, instruments, or other information referred to in the medical
coverage agreement;
(b)
A full description of the procedures to be followed by an enrollee for consulting
a provider other than the primary care provider and whether the enrollee's
primary care provider, the carrier's medical director, or another entity must
authorize the referral;
(c)
Procedures, if any, that an enrollee must first follow for obtaining prior
authorization for health care services;
(d)
A written description of any reimbursement or payment arrangements, including,
but not limited to, capitation provisions, fee-for-service provisions, and
health care delivery efficiency provisions, between a carrier and a provider or
network;
(e)
Descriptions and justifications for provider compensation programs, including
any incentives or penalties that are intended to encourage providers to
withhold services or minimize or avoid referrals to specialists;
(f)
An annual accounting of all payments made by the carrier which have been
counted against any payment limitations, visit limitations, or other overall
limitations on a person's coverage under a plan;
(g)
A copy of the carrier's grievance process for claim or service denial and for
dissatisfaction with care; and
(h)
Accreditation status with one or more national managed care accreditation
organizations, and whether the carrier tracks its health care effectiveness
performance using the health employer data information set (HEDIS), whether it
publicly reports its HEDIS data, and how interested persons can access its
HEDIS data.
(3)
Each carrier shall provide to all enrollees and prospective enrollees a list of
available disclosure items.
(4)
Nothing in this section requires a carrier or a health care provider to divulge
proprietary information to an enrollee, including the specific contractual
terms and conditions between a carrier and a provider.
(5)
No carrier may advertise or market any health plan to the public as a plan that
covers services that help prevent illness or promote the health of enrollees
unless it:
(a)
Provides all clinical preventive health services provided by the basic health
plan, authorized by chapter 70.47 RCW;
(b)
Monitors and reports annually to enrollees on standardized measures of health
care and satisfaction of all enrollees in the health plan. The state
department of health shall recommend appropriate standardized measures for this
purpose, after consideration of national standardized measurement systems
adopted by national managed care accreditation organizations and state agencies
that purchase managed health care services; and
(c)
Makes available upon request to enrollees its integrated plan to identify and
manage the most prevalent diseases within its enrolled population, including
cancer, heart disease, and stroke.
(6)
No carrier may preclude or discourage its providers from informing an enrollee
of the care he or she requires, including various treatment options, and
whether in the providers' view such care is consistent with the plan's health
coverage criteria, or otherwise covered by the enrollee's medical coverage
agreement with the carrier. No carrier may prohibit, discourage, or penalize a
provider otherwise practicing in compliance with the law from advocating on
behalf of an enrollee with a carrier. Nothing in this section shall be
construed to authorize a provider to bind a carrier to pay for any service.
(7)
No carrier may preclude or discourage enrollees or those paying for their
coverage from discussing the comparative merits of different carriers with
their providers. This prohibition specifically includes prohibiting or
limiting providers participating in those discussions even if critical of a
carrier.
(8)
Each carrier must communicate enrollee information required in this act by
means that ensure that a substantial portion of the enrollee population can
make use of the information.
(9)
The commissioner may adopt rules to implement this section. In developing
rules to implement this section, the commissioner shall consider relevant
standards adopted by national managed care accreditation organizations and
state agencies that purchase managed health care services.
NEW
SECTION. Sec. 7.
ACCESS TO APPROPRIATE HEALTH SERVICES. (1) Each enrollee in a health plan must
have adequate choice among health care providers.
(2)
Each carrier must allow an enrollee to choose a primary care provider who is
accepting new enrollees from a list of participating providers. Enrollees also
must be permitted to change primary care providers at any time with the change
becoming effective no later than the beginning of the month following the
enrollee's request for the change.
(3)
Each carrier must have a process whereby an enrollee with a complex or serious
medical or psychiatric condition may receive a standing referral to a participating
specialist for an extended period of time.
(4)
Each carrier must provide for appropriate and timely referral of enrollees to a
choice of specialists within the plan if specialty care is warranted. If the
type of medical specialist needed for a specific condition is not represented
on the specialty panel, enrollees must have access to nonparticipating
specialty health care providers.
(5)
Each carrier shall provide enrollees with direct access to the participating
chiropractor of the enrollee's choice for covered chiropractic health care
without the necessity of prior referral. Nothing in this subsection shall
prevent carriers from restricting enrollees to seeing only providers who have
signed participating provider agreements or from utilizing other managed care
and cost containment techniques and processes. For purposes of this
subsection, "covered chiropractic health care" means covered benefits
and limitations related to chiropractic health services as stated in the plan's
medical coverage agreement, with the exception of any provisions related to
prior referral for services.
(6)
Each carrier must provide, upon the request of an enrollee, access by the
enrollee to a second opinion regarding any medical diagnosis or treatment plan
from a qualified participating provider of the enrollee's choice.
(7)
Each carrier must cover services of a primary care provider whose contract with
the plan or whose contract with a subcontractor is being terminated by the plan
or subcontractor without cause under the terms of that contract for at least
sixty days following notice of termination to the enrollees or, in group
coverage arrangements involving periods of open enrollment, only until the end
of the next open enrollment period. The provider's relationship with the
carrier or subcontractor must be continued on the same terms and conditions as
those of the contract the plan or subcontractor is terminating, except for any
provision requiring that the carrier assign new enrollees to the terminated
provider.
(8)
Every carrier shall meet the standards set forth in this section and any rules
adopted by the commissioner to implement this section. In developing rules to
implement this section, the commissioner shall consider relevant standards
adopted by national managed care accreditation organizations and state agencies
that purchase managed health care services.
NEW
SECTION. Sec. 8.
HEALTH CARE DECISIONS. (1) Carriers that offer a health plan shall maintain a
documented utilization review program description and written utilization
review criteria based on reasonable medical evidence. The program must include
a method for reviewing and updating criteria. Carriers shall make clinical
protocols, medical management standards, and other review criteria available
upon request to participating providers.
(2)
The commissioner shall adopt, in rule, standards for this section after
considering relevant standards adopted by national managed care accreditation
organizations and state agencies that purchase managed health care services.
(3)
A carrier shall not be required to use medical evidence or standards in its
utilization review of religious nonmedical treatment or religious nonmedical
nursing care.
NEW
SECTION. Sec. 9.
RETROSPECTIVE DENIAL OF SERVICES. (1) A health carrier that offers a health
plan shall not retrospectively deny coverage for emergency and nonemergency
care that had prior authorization under the plan's written policies at the time
the care was rendered.
(2)
The commissioner shall adopt, in rule, standards for this section after
considering relevant standards adopted by national managed care accreditation
organizations and state agencies that purchase managed health care services.
NEW
SECTION. Sec. 10.
GRIEVANCE PROCESS. (1) Each carrier that offers a health plan must have a
fully operational, comprehensive grievance process that complies with the
requirements of this section and any rules adopted by the commissioner to
implement this section. For the purposes of this section, the commissioner
shall consider grievance process standards adopted by national managed care
accreditation organizations and state agencies that purchase managed health
care services.
(2)
Each carrier must process as a complaint an enrollee's expression of
dissatisfaction about customer service or the quality or availability of a
health service. Each carrier must implement procedures for registering and
responding to oral and written complaints in a timely and thorough manner.
(3)
Each carrier must provide written notice to an enrollee or the enrollee's
designated representative, and the enrollee's provider, of its decision to
deny, modify, reduce, or terminate payment, coverage, authorization, or
provision of health care services or benefits, including the admission to or
continued stay in a health care facility.
(4)
Each carrier must process as an appeal an enrollee's written or oral request
that the carrier reconsider: (a) Its resolution of a complaint made by an
enrollee; or (b) its decision to deny, modify, reduce, or terminate payment,
coverage, authorization, or provision of health care services or benefits,
including the admission to, or continued stay in, a health care facility. A
carrier must not require that an enrollee file a complaint prior to seeking
appeal of a decision under (b) of this subsection.
(5)
To process an appeal, each carrier must:
(a)
Provide written notice to the enrollee when the appeal is received;
(b)
Assist the enrollee with the appeal process;
(c)
Make its decision regarding the appeal within thirty days of the date the
appeal is received. An appeal must be expedited if the enrollee's provider or
the carrier's medical director reasonably determines that following the appeal
process response timelines could seriously jeopardize the enrollee's life,
health, or ability to regain maximum function. The decision regarding an
expedited appeal must be made within seventy-two hours of the date the appeal is
received;
(d)
Cooperate with a representative authorized in writing by the enrollee;
(e)
Consider information submitted by the enrollee;
(f)
Investigate and resolve the appeal; and
(g)
Provide written notice of its resolution of the appeal to the enrollee and,
with the permission of the enrollee, to the enrollee's providers. The written
notice must explain the carrier's decision and the supporting coverage or
clinical reasons and the enrollee's right to request independent review of the
carrier's decision under section 11 of this act.
(6)
Written notice required by subsection (3) of this section must explain:
(a)
The carrier's decision and the supporting coverage or clinical reasons; and
(b)
The carrier's appeal process, including information, as appropriate, about how
to exercise the enrollee's rights to obtain a second opinion, and how to
continue receiving services as provided in this section.
(7)
When an enrollee requests that the carrier reconsider its decision to modify,
reduce, or terminate an otherwise covered health service that an enrollee is
receiving through the health plan and the carrier's decision is based upon a
finding that the health service, or level of health service, is no longer
medically necessary or appropriate, the carrier must continue to provide that
health service until the appeal is resolved. If the resolution of the appeal
or any review sought by the enrollee under section 11 of this act affirms the
carrier's decision, the enrollee may be responsible for the cost of this
continued health service.
(8)
Each carrier must provide a clear explanation of the grievance process upon
request, upon enrollment to new enrollees, and annually to enrollees and
subcontractors.
(9)
Each carrier must ensure that the grievance process is accessible to enrollees
who are limited English speakers, who have literacy problems, or who have
physical or mental disabilities that impede their ability to file a grievance.
(10)
Each carrier must: Track each appeal until final resolution; maintain, and
make accessible to the commissioner for a period of three years, a log of all
appeals; and identify and evaluate trends in appeals.
NEW
SECTION. Sec. 11.
INDEPENDENT REVIEW OF HEALTH CARE DISPUTES. (1) There is a need for a process
for the fair consideration of disputes relating to decisions by carriers that
offer a health plan to deny, modify, reduce, or terminate coverage of or
payment for health care services for an enrollee.
(2)
An enrollee may seek review by a certified independent review organization of a
carrier's decision to deny, modify, reduce, or terminate coverage of or payment
for a health care service, after exhausting the carrier's grievance process
and receiving a decision that is unfavorable to the enrollee, or after the
carrier has exceeded the timelines for grievances provided in section 10 of
this act, without good cause and without reaching a decision.
(3)
The commissioner must establish and use a rotational registry system for the
assignment of a certified independent review organization to each dispute. The
system should be flexible enough to ensure that an independent review
organization has the expertise necessary to review the particular medical
condition or service at issue in the dispute.
(4)
Carriers must provide to the appropriate certified independent review
organization, not later than the third business day after the date the carrier
receives a request for review, a copy of:
(a)
Any medical records of the enrollee that are relevant to the review;
(b)
Any documents used by the carrier in making the determination to be reviewed by
the certified independent review organization;
(c)
Any documentation and written information submitted to the carrier in support
of the appeal; and
(d)
A list of each physician or health care provider who has provided care to the
enrollee and who may have medical records relevant to the appeal. Health
information or other confidential or proprietary information in the custody of
a carrier may be provided to an independent review organization, subject to
rules adopted by the commissioner.
(5)
The medical reviewers from a certified independent review organization will
make determinations regarding the medical necessity or appropriateness of, and
the application of health plan coverage provisions to, health care services for
an enrollee. The medical reviewers' determinations must be based upon their
expert medical judgment, after consideration of relevant medical, scientific,
and cost-effectiveness evidence, and medical standards of practice in the state
of Washington. Except as provided in this subsection, the certified
independent review organization must ensure that determinations are consistent
with the scope of covered benefits as outlined in the medical coverage
agreement. Medical reviewers may override the health plan's medical necessity
or appropriateness standards if the standards are determined upon review to be
unreasonable or inconsistent with sound, evidence-based medical practice.
(6)
Once a request for an independent review determination has been made, the
independent review organization must proceed to a final determination, unless
requested otherwise by both the carrier and the enrollee or the enrollee's
representative.
(7)
Carriers must timely implement the certified independent review organization's
determination, and must pay the certified independent review organization's
charges.
(8)
When an enrollee requests independent review of a dispute under this section,
and the dispute involves a carrier's decision to modify, reduce, or terminate
an otherwise covered health service that an enrollee is receiving at the time
the request for review is submitted and the carrier's decision is based upon a
finding that the health service, or level of health service, is no longer
medically necessary or appropriate, the carrier must continue to provide the
health service if requested by the enrollee until a determination is made under
this section. If the determination affirms the carrier's decision, the
enrollee may be responsible for the cost of the continued health service.
(9)
A certified independent review organization may notify the office of the
insurance commissioner if, based upon its review of disputes under this
section, it finds a pattern of substandard or egregious conduct by a carrier.
(10)(a)
The commissioner shall adopt rules to implement this section after considering
relevant standards adopted by national managed care accreditation
organizations.
(b)
This section is not intended to supplant any existing authority of the office
of the insurance commissioner under this title to oversee and enforce carrier
compliance with applicable statutes and rules.
NEW
SECTION. Sec. 12. A
new section is added to chapter 43.70 RCW to read as follows:
INDEPENDENT
REVIEW ORGANIZATIONS. (1) The department shall adopt rules providing a
procedure and criteria for certifying one or more organizations to perform
independent review of health care disputes described in section 11 of this act.
(2)
The rules must require that the organization ensure:
(a)
The confidentiality of medical records transmitted to an independent review
organization for use in independent reviews;
(b)
That each health care provider, physician, or contract specialist making review
determinations for an independent review organization is qualified.
Physicians, other health care providers, and, if applicable, contract
specialists must be appropriately licensed, certified, or registered as
required in Washington state or in at least one state with standards
substantially comparable to Washington state. Reviewers may be drawn from
nationally recognized centers of excellence, academic institutions, and
recognized leading practice sites. Expert medical reviewers should have
substantial, recent clinical experience dealing with the same or similar health
conditions. The organization must have demonstrated expertise and a history of
reviewing health care in terms of medical necessity, appropriateness, and the
application of other health plan coverage provisions;
(c)
That any physician, health care provider, or contract specialist making a
review determination in a specific review is free of any actual or potential
conflict of interest or bias. Neither the expert reviewer, nor the independent
review organization, nor any officer, director, or management employee of the
independent review organization may have any material professional, familial,
or financial affiliation with any of the following: The health carrier;
professional associations of carriers and providers; the provider; the
provider's medical or practice group; the health facility at which the service
would be provided; the developer or manufacturer of a drug or device under
review; or the enrollee;
(d)
The fairness of the procedures used by the independent review organization in
making the determinations;
(e)
That each independent review organization make its determination:
(i)
Not later than the earlier of:
(A)
The fifteenth day after the date the independent review organization receives
the information necessary to make the determination; or
(B)
The twentieth day after the date the independent review organization receives
the request that the determination be made. In exceptional circumstances, when
the independent review organization has not obtained information necessary to
make a determination, a determination may be made by the twenty-fifth day after
the date the organization received the request for the determination; and
(ii)
In cases of a condition that could seriously jeopardize the enrollee's health
or ability to regain maximum function, not later than the earlier of:
(A)
Seventy-two hours after the date the independent review organization receives
the information necessary to make the determination; or
(B)
The eighth day after the date the independent review organization receives the
request that the determination be made;
(f)
That timely notice is provided to enrollees of the results of the independent
review, including the clinical basis for the determination;
(g)
That the independent review organization has a quality assurance mechanism in
place that ensures the timeliness and quality of review and communication of
determinations to enrollees and carriers, and the qualifications, impartiality,
and freedom from conflict of interest of the organization, its staff, and
expert reviewers; and
(h)
That the independent review organization meets any other reasonable
requirements of the department directly related to the functions the
organization is to perform under this section and section 11 of this act.
(3)
To be certified as an independent review organization under this chapter, an organization
must submit to the department an application in the form required by the
department. The application must include:
(a)
For an applicant that is publicly held, the name of each stockholder or owner
of more than five percent of any stock or options;
(b)
The name of any holder of bonds or notes of the applicant that exceed one
hundred thousand dollars;
(c)
The name and type of business of each corporation or other organization that
the applicant controls or is affiliated with and the nature and extent of the
affiliation or control;
(d)
The name and a biographical sketch of each director, officer, and executive of
the applicant and any entity listed under (c) of this subsection and a
description of any relationship the named individual has with:
(i)
A carrier;
(ii)
A utilization review agent;
(iii)
A nonprofit or for-profit health corporation;
(iv)
A health care provider;
(v)
A drug or device manufacturer; or
(vi)
A group representing any of the entities described by (d)(i) through (v) of this
subsection;
(e)
The percentage of the applicant's revenues that are anticipated to be derived
from reviews conducted under section 11 of this act;
(f)
A description of the areas of expertise of the health care professionals and
contract specialists making review determinations for the applicant; and
(g)
The procedures to be used by the independent review organization in making
review determinations regarding reviews conducted under section 11 of this act.
(4)
If at any time there is a material change in the information included in the
application under subsection (3) of this section, the independent review
organization shall submit updated information to the department.
(5)
An independent review organization may not be a subsidiary of, or in any way owned
or controlled by, a carrier or a trade or professional association of health
care providers or carriers.
(6)
An independent review organization, and individuals acting on its behalf, are
immune from suit in a civil action when performing functions under this act.
However, this immunity does not apply to an act or omission made in bad faith
or that involves gross negligence.
(7)
Independent review organizations must be free from interference by state
government in its functioning except as provided in subsection (8) of this
section.
(8)
The rules adopted under this section shall include provisions for terminating
the certification of an independent review organization for failure to comply
with the requirements for certification. The department may review the
operation and performance of an independent review organization in response to
complaints or other concerns about compliance.
(9)
In adopting rules for this section, the department shall take into
consideration standards for independent review organizations adopted by
national accreditation organizations. The department may accept national
accreditation or certification by another state as evidence that an
organization satisfies some or all of the requirements for certification by the
department as an independent review organization.
NEW
SECTION. Sec. 13.
CARRIER MEDICAL DIRECTOR. Any carrier that offers a health plan and any
self-insured health plan subject to the jurisdiction of Washington state shall
designate a medical director who is licensed under chapter 18.57 or 18.71 RCW.
However, a naturopathic or complementary alternative health plan, which
provides solely complementary alternative health care to individuals, groups,
or health plans, may have a medical director licensed under chapter 18.36A
RCW. A health plan or self-insured health plan that offers only religious
nonmedical treatment or religious nonmedical nursing care shall not be required
to have a medical director.
Sec.
14. RCW
51.04.020 and 1994 c 164 s 24 are each amended to read as follows:
The
director shall:
(1)
Establish and adopt rules governing the administration of this title;
(2)
Ascertain and establish the amounts to be paid into and out of the accident fund;
(3)
Regulate the proof of accident and extent thereof, the proof of death and the
proof of relationship and the extent of dependency;
(4)
Supervise the medical, surgical, and hospital treatment to the intent that it
may be in all cases efficient and up to the recognized standard of modern
surgery;
(5)
Issue proper receipts for moneys received and certificates for benefits accrued
or accruing;
(6)
Investigate the cause of all serious injuries and report to the governor from
time to time any violations or laxity in performance of protective statutes or
regulations coming under the observation of the department;
(7)
Compile statistics which will afford reliable information upon which to base
operations of all divisions under the department;
(8)
Make an annual report to the governor of the workings of the department;
(9)
Be empowered to enter into agreements with the appropriate agencies of other
states relating to conflicts of jurisdiction where the contract of employment
is in one state and injuries are received in the other state, and insofar as
permitted by the Constitution and laws of the United States, to enter into
similar agreements with the provinces of Canada; and
(10)
Designate a medical director who is licensed under chapter 18.57 or 18.71 RCW.
Sec.
15. RCW
74.09.050 and 1979 c 141 s 335 are each amended to read as follows:
The
secretary shall appoint such professional personnel and other assistants and
employees, including professional medical screeners, as may be reasonably
necessary to carry out the provisions of this chapter. The medical screeners
shall be supervised by one or more physicians who shall be appointed by the
secretary or his or her designee. The secretary shall appoint a
medical director who is licensed under chapter 18.57 or 18.71 RCW.
NEW
SECTION. Sec. 16. A
new section is added to chapter 41.05 RCW to read as follows:
HEALTH
CARE AUTHORITY MEDICAL DIRECTOR. The administrator shall designate a medical
director who is licensed under chapter 18.57 or 18.71 RCW.
NEW
SECTION. Sec. 17.
CARRIER LIABILITY. (1)(a) A health carrier shall adhere to the accepted
standard of care for health care providers under chapter 7.70 RCW when
arranging for the provision of medically necessary health care services to its
enrollees. A health carrier shall be liable for any and all harm proximately
caused by its failure to follow that standard of care when the failure resulted
in the denial, delay, or modification of the health care service recommended
for, or furnished to, an enrollee.
(b)
A health carrier is also liable for damages under (a) of this subsection for
harm to an enrollee proximately caused by health care treatment decisions that
result from a failure to follow the accepted standard of care made by its:
(i)
Employees;
(ii)
Agents; or
(iii)
Ostensible agents who are acting on its behalf and over whom it has the right
to exercise influence or control or has actually exercised influence or
control.
(2)
The provisions of this section may not be waived, shifted, or modified by
contract or agreement and responsibility for the provisions shall be a duty
that cannot be delegated. Any effort to waive, modify, delegate, or shift
liability for a breach of the duty established by this section, through a
contract for indemnification or otherwise, is invalid.
(3)
This section does not create any new cause of action, or eliminate any
presently existing cause of action, with respect to health care providers and
health care facilities that are included in and subject to the provisions of
chapter 7.70 RCW.
(4)
It is a defense to any action or liability asserted under this section against
a health carrier that:
(a)
The health care service in question is not a benefit provided under the plan or
the service is subject to limitations under the plan that have been exhausted;
(b)
Neither the health carrier, nor any employee, agent, or ostensible agent for
whose conduct the health carrier is liable under subsection (1)(b) of this
section, controlled, influenced, or participated in the health care decision;
or
(c)
The health carrier did not deny or unreasonably delay payment for treatment
prescribed or recommended by a participating health care provider for the
enrollee.
(5)
This section does not create any liability on the part of an employer, an
employer group purchasing organization that purchases coverage or assumes risk
on behalf of its employers, or a governmental agency that purchases coverage on
behalf of individuals and families. The governmental entity established to offer
and provide health insurance to public employees, public retirees, and their
covered dependents under RCW 41.05.140 is subject to liability under this
section.
(6)
Nothing in any law of this state prohibiting a health carrier from practicing
medicine or being licensed to practice medicine may be asserted as a defense by
the health carrier in an action brought against it under this section.
(7)(a)
A person may not maintain a cause of action under this section against a health
carrier unless:
(i)
The affected enrollee has suffered substantial harm. As used in this
subsection, "substantial harm" means loss of life, loss or
significant impairment of limb, bodily or cognitive function, significant
disfigurement, or severe or chronic physical pain; and
(ii)
The affected enrollee or the enrollee's representative has exercised the
opportunity established in section 11 of this act to seek independent review of
the health care treatment decision.
(b)
This subsection (7) does not prohibit an enrollee from pursuing other
appropriate remedies, including injunctive relief, a declaratory judgment, or
other relief available under law, if its requirements place the enrollee's
health in serious jeopardy.
(8)
In an action against a health carrier, a finding that a health care provider is
an employee, agent, or ostensible agent of such a health carrier shall not be
based solely on proof that the person's name appears in a listing of approved
physicians or health care providers made available to enrollees under a health
plan.
(9)
Any action under this section shall be commenced within three years of the
completion of the independent review process.
(10)
This section does not apply to workers' compensation insurance under Title 51
RCW.
NEW
SECTION. Sec. 18.
DELEGATION OF DUTIES. Each carrier is accountable for and must oversee any
activities required by this act that it delegates to any subcontractor. No
contract with a subcontractor executed by the health carrier or the
subcontractor may relieve the health carrier of its obligations to any enrollee
for the provision of health care services or of its responsibility for
compliance with statutes or rules.
NEW
SECTION. Sec. 19.
APPLICATION. This act applies to: Health plans as defined in RCW 48.43.005
offered, renewed, or issued by a carrier; medical assistance provided under RCW
74.09.522; the basic health plan offered under chapter 70.47 RCW; and health
benefits provided under chapter 41.05 RCW.
NEW
SECTION. Sec. 20. A
new section is added to chapter 41.05 RCW to read as follows:
Each
health plan that provides medical insurance offered under this chapter,
including plans created by insuring entities, plans not subject to the provisions
of Title 48 RCW, and plans created under RCW 41.05.140, are subject to the
provisions of sections 1, 2, 5 through 12, 17, 18, and RCW 70.02.110 and
70.02.900.
Sec.
21. RCW
70.47.130 and 1997 c 337 s 8 are each amended to read as follows:
(1)
The activities and operations of the Washington basic health plan under this
chapter, including those of managed health care systems to the extent of their
participation in the plan, are exempt from the provisions and requirements of Title
48 RCW except:
(a)
Benefits as provided in RCW 70.47.070;
(b)
Managed health care systems are subject to the provisions of sections 1, 2,
5 through 12, 17, 18, and RCW 70.02.110 and 70.02.900;
(c)
Persons appointed or authorized to solicit applications for enrollment in the
basic health plan, including employees of the health care authority, must
comply with chapter 48.17 RCW. For purposes of this subsection (1)(((b)))
(c), "solicit" does not include distributing information and
applications for the basic health plan and responding to questions; and
(((c)))
(d) Amounts paid to a managed health care system by the basic health
plan for participating in the basic health plan and providing health care
services for nonsubsidized enrollees in the basic health plan must comply with
RCW 48.14.0201.
(2)
The purpose of the 1994 amendatory language to this section in chapter 309,
Laws of 1994 is to clarify the intent of the legislature that premiums paid on behalf
of nonsubsidized enrollees in the basic health plan are subject to the premium
and prepayment tax. The legislature does not consider this clarifying language
to either raise existing taxes nor to impose a tax that did not exist
previously.
NEW
SECTION. Sec. 22. This
act may be known and cited as the health care patient bill of rights.
NEW
SECTION. Sec. 23. If
specific funding for the purposes of this act, referencing this act by bill or
chapter number, is not provided by June 30, 2000, in the omnibus appropriations
act, this act is null and void.
NEW
SECTION. Sec. 24.
Captions used in this act are not any part of the law.
NEW
SECTION. Sec. 25.
Sections 1, 5 through 11, 13, 17, and 18 of this act are each added to chapter
48.43 RCW.
NEW
SECTION. Sec. 26. To
the extent permitted by law, if any provision of this act conflicts with state
or federal law, such provision must be construed in a manner most favorable to
the enrollee.
NEW
SECTION. Sec. 27. If
any provision of this act or its application to any person or circumstance is
held invalid, the remainder of the act or the application of the provision to
other persons or circumstances is not affected.
NEW
SECTION. Sec. 28.
EFFECTIVE DATE. (1) Except as provided in subsections (2) and
(3) of this section, this act applies to contracts entered into or renewing
after June 30, 2001.
(2)
Sections 13, 14, 15, and 16 of this act take effect January 1, 2001.
(3)
Section 29 of this act takes effect July 1, 2001.
NEW
SECTION. Sec. 29. The
following acts or parts of acts are each repealed:
(1) RCW
48.43.075 (Informing patients about their care--Health carriers
may not preclude or discourage) and 1996 c 312 s 2; and
(2) RCW
48.43.095 (Information provided to an enrollee or a prospective
enrollee) and 1996 c 312 s 4.
