State Provider Contract Requirements.
Health carriers must file all provider contracts and provider compensation agreements with the Office of the Insurance Commissioner (OIC) 30 calendar days before use. When a carrier and provider negotiate an agreement that deviates from a filed agreement, the specific contract must be filed 30 days prior to use. Any provider contract or provider compensation agreements not affirmatively disapproved by the OIC are deemed approved, except the OIC may extend the approval date an additional 15 days with notice before the initial 30-day period expires. Changes to the previously filed agreements that modify the compensation or related terms, must be filed and are deemed approved upon filing if no other changes are made to the previously approved agreement. The OIC may not base a disapproval of the agreement on the amount of the compensation or other financial arrangements between the carrier and provider, unless the compensation amount causes the underlying health benefit plan to be in violation of state or federal law.
The OIC rules require a health carrier and contracting health care provider or facility to provide at least 60 days' written notice to each other before terminating the contract without cause. Whether the termination was for cause, or without cause, the carrier must make a good faith effort to ensure written notice of a termination is provided at least 30 days before the effective date of the termination, or immediately for a termination for cause that results in less than 30 days' notice, to all enrollees who are patients seen on a regular basis by a specialist, by a provider for whom they have a standing referral, or by a primary care provider. The OIC must approve the notices sent by carriers to enrollees.
Health Profession's Discipline.
The Uniform Disciplinary Act (UDA) governs credentialed health professionals credentialed by the Department of Health (DOH) or one of the health professions' boards or commissions, such as the Medical Commission. Depending on the profession, the disciplining authority may be the Secretary of Health or a board or commission. Under the UDA, a disciplining authority may take action against a license holder for a variety of reasons, including misrepresentation or fraud, unlicensed practice, and the mental or physical inability to practice skillfully or safely. A disciplining authority may initiate disciplinary action after receiving a complaint or if the disciplining authority has reason to believe that the licensee engaged in unprofessional conduct.
Among other acts and conditions, unprofessional conduct is defined under the UDA to include: suspension, revocation, or restriction of an individual's license to practice any health care profession in any jurisdiction; violation of any state or federal statute or administrative rule regulating the profession in question; and violations of rules established by any health agency.
Federal No Surprises Act Continuity of Care Requirements.
Under the federal No Surprises Act, if a provider or facility ceases to be an in-network provider because of a contract termination, certain continuity of care protections apply to an individual who meets the definition of a continuing care patient. For the continuing care patient whose provider's or facility's contract termination leads to a change in network status, the carrier must:
Continuing care patients are defined as individuals who, with respect to a provider or facility, are:
The continued care election may last until the earlier of 90 days or the date on which such individual is no longer a continuing care patient with the provider or facility. A continuing care patient's treating provider or health care facility must: accept payment from the carrier and cost sharing from the individual for items and services as payment in full; and continue to adhere to all policies, procedures, and quality standards imposed by the carrier for an individual as if the termination had not occurred.
For a provider contract that is expiring by its own terms or for which one party has given notice to the other party of intended termination without cause according to the contract terms, the health care facility, provider, or any health care provider employed by, contracted with, or affiliated with the facility, and the health carrier may not make public statements, including communications with impacted enrollees or patients, regarding the expiration or termination of the contract until 45 days before the termination date, unless the disclosure is required by law or the expiration or termination has already been disclosed because of a legal obligation. Communications exclusively with the Governor, legislators, or state agency staff regarding a potential or intended contract termination does not constitute a public statement.
Public statements and communications with enrollees or patients may not occur before the carrier, facility, or provider gives written notice of the termination to the other party, unless agreed upon by the parties.
By December 1, 2025, the Insurance Commissioner (Commissioner), in consultation with carriers, providers, facilities, and consumers, must develop standard template language for notices sent to health plan enrollees and patients, which must be posted on the Commissioner's website. The notices must include:
Notices sent to enrollees or patients that solely utilize the template language developed pursuant to this section are not subject to review or approval. Notices that alter or do not use the template language in full must be reviewed and approved by the Commissioner before use.
By January 1, 2026, these requirements must be included in all provider contracts. The Commissioner must develop template language for inclusion in provider contracts by rule.
The Commissioner may enforce the requirements that are related to carriers on or after January 1, 2026. In addition to the Commissioner's existing enforcement authority, the Commissioner may impose a civil penalty of up to $100 for each day that a notice has been sent to enrollees in advance of the 45-day period for each enrollee to whom the notice has been sent. If the Commissioner has cause to believe that any provider or facility has violated these requirements, the Commissioner may submit information to the Department of Health (DOH), another appropriate health care facility licensing entity, or the appropriate disciplining authority for action. Prior to submitting information to the DOH, another appropriate health care facility licensing entity, or a disciplining authority, the Commissioner may provide the facility or provider an opportunity to explain why the actions in question did not violate the prohibitions. The DOH, another appropriate health care facility licensing entity, or appropriate disciplining authority may levy a fine or cost recovery upon a provider or facility that has engaged in a pattern of unresolved violations and must notify the Commissioner of the results of any review and enforcement actions taken against a provider or facility.
Violation of the notice provisions by a health care provider constitutes unprofessional conduct for purposes of the Uniform Disciplinary Act. For hospitals, behavioral health providers, ambulatory surgical facilities, and medical test sites, the DOH may levy a fine of up to $1,000 per violation and take other formal or informal disciplinary action as authorized. For birthing centers, in-home services agencies, and private establishments, the DOH may take enforcement actions as authorized for any violations of the notice requirements.
The amended bill:
(In support) Current rules require insurers to give notice to enrollees at least 30 days before termination, unless for cause. These contract disputes are almost always resolved before the termination date. While carriers typically wait until the 30-day mark to send out notices, there is no regulation on providers or facilities regarding notices sent to the public. Between June 2023 and January 2025, the OIC received 27 notices of potential contract terminations between health insurers and hospitals or health systems. When consumers see these notices, it causes uncertainty and anxiety even when an agreement is reached, which happens often. This bill would create more consistent requirements for all parties.
This is an issue that has been around for several years, and the parties have all been brought together to work on this bill. This bill would establish consistent policies on communications to enrollees to hopefully tamp down any anxiety that a potential termination of a contract may bring. Many have heard from constituents about these disputes, and they do not want to be put in the middle anymore. This bill is intended to set some guidelines for all parties to operate within the same timeline and with consistent language.
Stakeholders have worked together on this bill. This bill is a step in the right direction to make health care more affordable and limit the current behavior seen in contract negotiations with large hospital systems that put consumers in the middle of negotiations. Health plans negotiate hundreds of contracts each year and do so with the goal of reaching not only an agreement that fairly compensates providers but also ensures consumers have access to affordable and quality care. The media should be kept out of contract negotiations, but that has been a new strategy in the last few years to put the consumers in the middle by contacting the media. Public outcry is used as a tool to get higher rates. This bill aims to eliminate this practice.
(Opposed) None.
Nico Janssen, Office of the Insurance Commissioner; Lisa Thatcher, Washington State Hospital Association; Christine Brewer, Premera Blue Cross; and Jennifer Muhm, Regence BlueShield.