Revised Code of Washington
2024 Archive

Chapter 48.43 RCW
INSURANCE REFORM
PDF of Chapter Digest
PDF of Complete Chapter
Sections
48.43.001Intent.
48.43.005Definitions.
48.43.007Availability of price and quality information—Transparency tools for members—Requirements.
48.43.008Enrollment in employer-sponsored health plan—Person eligible for medical assistance.
48.43.009Health care sharing ministries.
48.43.012Health plans—Preexisting conditions—Rules.
48.43.01211Health plans—Eligibility—Health status-related factors—Rules.
48.43.0122Individual health benefit plans—Open enrollment and special enrollment periods—Rules—Enforcement.
48.43.0123Health plans—Rescission of coverage—Rules.
48.43.0124Health plans—Cost sharing for essential health benefits—Rules.
48.43.0125Essential health benefits—Annual or lifetime dollar limits.
48.43.0126Summary of benefits and explanation of coverage—Standards and requirements—Notice of modification—Fines—Standards for definitions of health insurance terms—Rules.
48.43.0127Group health plans—Waiting period—Rules.
48.43.0128Nongrandfathered health plans and plans issued or renewed on or after January 1, 2022—Prohibited discrimination—Rules.
48.43.016Utilization management standards and criteria—Health carrier requirements—Definitions.
48.43.0161Prior authorization practices—Carrier annual reporting requirements—Commissioner's standardized report.
48.43.021Personally identifiable health information—Restrictions on release.
48.43.022Enrollee identification card—Social security number restriction.
48.43.023Pharmacy identification cards—Rules.
48.43.028Eligibility to purchase certain health benefit plans—Small employers and small groups.
48.43.035Group health benefit plans—Guaranteed issue and continuity of coverage—Exceptions.
48.43.038Individual health plans—Guarantee of continuity of coverage—Exceptions.
48.43.039Grace period—Notification or information—Information concerning delinquencies or nonpayment of premiums—Defined.
48.43.041Individual health benefit plans—Mandatory benefits.
48.43.043Colorectal cancer examinations and laboratory tests—Required benefits or coverage.
48.43.045Health plan requirements—Annual reports—Exemptions.
48.43.047Health plans—Minimum coverage for preventive services—No cost-sharing requirements.
48.43.049Health carrier data—Information from annual statement—Format prescribed by commissioner—Public availability.
48.43.055Procedures for review and adjudication of health care provider complaints—Requirements.
48.43.059Payments made by a second-party payment process—Definition.
48.43.065Right of individuals to receive services—Right of providers, carriers, and facilities to refuse to participate in or pay for services for reason of conscience or religion—Requirements.
48.43.071Health care information—Requirement to provide free copy to covered person appealing denial of social security benefits—Exceptions.
48.43.072Required reproductive health care coverage—Restrictions on copayments, deductibles, and other form of cost sharing.
48.43.0725Reproductive health plan coverage—Immediate postpartum contraception devices.
48.43.073Required abortion coverage—Limitations.
48.43.074Qualified health plans—Single invoice billing—Certification of compliance required in the segregation plan for premium amounts attributable to coverage of abortion services.
48.43.076Digital breast examinations—Cost sharing.
48.43.078Digital breast tomosynthesis—Intent to ensure women with access—Commissioner's and health care authority's duty to clarify mandates.
48.43.081Anatomic pathology services—Payment for services—Definitions.
48.43.083Chiropractor services—Participating provider agreement—Health carrier reimbursement.
48.43.085Health carrier may not prohibit its enrollees from contracting for services outside the health care plan.
48.43.087Contracting for services at enrollee's expense—Mental health care practitioner—Conditions—Exception.
48.43.091Health carrier coverage of outpatient mental health services—Requirements.
48.43.093Health carrier coverage of emergency medical services—Requirements—Conditions.
48.43.094Pharmacist provided services—Health plan requirements.
48.43.096Medication synchronization policy required for health plans covering prescription drugs—Requirements—Definitions.
48.43.0961Continuity of coverage for health plans covering prescription drugs for behavioral health.
48.43.097Filing of financial statements—Every health carrier.
48.43.105Preparation of documents that compare health carriers—Immunity—Due diligence.
48.43.115Maternity services—Intent—Definitions—Patient preference—Clinical sovereignty of provider—Notice to policyholders—Application.
48.43.121Ground ambulance services organizations—Coverage.
48.43.125Coverage at a long-term care facility following hospitalization—Definition.
48.43.135Hearing instruments—Coverage.
48.43.176Eosinophilic gastrointestinal associated disorder—Elemental formula.
48.43.180Denturist services.
48.43.185General anesthesia services for dental procedures.
48.43.190Payment of chiropractic services—Parity.
48.43.195Contraceptive drugs—Twelve-month refill coverage.
DISCLOSURE OF MATERIAL TRANSACTIONS
48.43.200Disclosure of certain material transactions—Report—Information is confidential.
48.43.205Material acquisitions or dispositions.
48.43.210Asset acquisitions—Asset dispositions.
48.43.215Report of a material acquisition or disposition of assets—Information required.
48.43.220Material nonrenewals, cancellations, or revisions of ceded reinsurance agreements.
48.43.225Report of a material nonrenewal, cancellation, or revision of ceded reinsurance agreements—Information required.
MISCELLANEOUS
48.43.290Coverage for prescribed durable medical equipment and mobility enhancing equipment—Sales and use taxes—Definitions.
RISK-BASED CAPITAL STANDARDS FOR HEALTH CARRIERS
48.43.300Definitions.
48.43.305Report of RBC levels—Distribution of report—Formula for determination—Commissioner may make adjustments.
48.43.310Company action level event—Required RBC plan—Commissioner's review—Notification—Challenge by carrier.
48.43.315Regulatory action level event—Required RBC plan—Commissioner's review—Notification—Challenge by carrier.
48.43.320Authorized control level event—Commissioner's options.
48.43.325Mandatory control level event—Commissioner's duty—Regulatory control.
48.43.330Carrier's right to hearing—Request by carrier—Date set by commissioner.
48.43.335Confidentiality of RBC reports and plans—Use of certain comparisons prohibited—Certain information intended solely for use by commissioner.
48.43.340Powers or duties of commissioner not limited—Rules.
48.43.345Foreign or alien carriers—Required RBC report—Commissioner may require RBC plan—Mandatory control level event.
48.43.350No liability or cause of action against commissioner or department.
48.43.355Notice by commissioner to carrier—When effective.
48.43.360Initial RBC reports—Calculation of initial RBC levels—Subsequent reports.
48.43.366Self-funded multiple employer welfare arrangements.
48.43.370RBC standards not applicable to certain carriers.
PRESCRIPTION DRUG UTILIZATION MANAGEMENT
48.43.400Prescription drug utilization management—Definitions.
48.43.410Prescription drug utilization management—Clinical review criteria—Requirement to be evidence-based and updated regularly.
48.43.420Prescription drug utilization management—Exception request process—Conditions, requirements, and time frames for approval or denial of requests—Emergency fill coverage—Notice of new policies and procedures.
48.43.430Prescription medication—Maximum charge at point of sale—Requirements.
48.43.435Prescription medication—Cost-sharing calculation—Application—Rules.
48.43.440Human immunodeficiency virus postexposure prophylaxis drugs—Cost sharing and prior authorization.
HEALTH CARE PATIENT PROTECTION
48.43.500Intent—Purpose—2000 c 5.
48.43.505Enrollee's and protected individual's right to privacy and confidential services—Health carrier or insurer duties—Requests for confidential communications—Rules.
48.43.5051Requests for confidential communications—Monitoring and ensuring compliance—Standardized form for submission of requests—Rules.
48.43.510Carrier required to disclose health plan information—Marketing and advertising restrictions—Rules.
48.43.515Access to appropriate health services—Enrollee options—Rules.
48.43.517Enrollment of child participating in medical assistance program—Employer-sponsored health plan.
48.43.520Requirement to maintain a documented utilization review program description and written utilization review criteria—Rules.
48.43.525Prohibition against retrospective denial of health plan coverage—Rules.
48.43.530Requirement for carriers to have comprehensive grievance and appeal processes—Carrier's duties—Procedures—Appeals—Rules.
48.43.535Independent review of health care disputes—System for using certified independent review organizations—Rules.
48.43.537Health care disputes—Certifying independent review organizations—Application—Restrictions—Maximum fee schedule for conducting reviews—Rules.
48.43.540Requirement to designate a licensed medical director—Exemption.
48.43.545Standard of care—Liability—Causes of action—Defense—Exception.
48.43.550Delegation of duties—Carrier accountability.
MISCELLANEOUS
48.43.600Overpayment recovery—Carrier.
48.43.605Overpayment recovery—Health care provider.
48.43.650Fixed payment insurance products—Commissioner's annual report.
48.43.670Plan or contract renewal—Modification of wellness program.
48.43.680Lifetime limit on transplants—Definition.
48.43.690Assessments under RCW 70.290.040 considered medical expenses.
48.43.700Exchange—Plans that a carrier must offer—Review—Rules.
48.43.705Plans offered outside of exchange.
48.43.710Certification as qualified health plan not an exemption.
48.43.715Individual and small group market—Selection of benchmark plan—Minimum requirements—Criteria—List of state-mandated health benefits.
48.43.720Reinsurance and risk adjustment programs—Affordable care act—Rules.
48.43.725Exclusion of mandated benefits from health plan—Carrier requirements—Notice—Fees—Commissioner's duties.
48.43.730Carrier must file provider contracts and compensation agreements with commissioner—Approval or disapproval—Confidentiality—Hearings—Rules—Definitions.
48.43.731Health care benefit management contracts—Carrier filing requirements—Notice to enrollees—Confidentiality of filings.
48.43.733Rates and forms of group health benefit plans—Timing of filings—Exceptions—Rules.
48.43.734Health carrier rate filings—Review of surplus, capital, and profit levels.
48.43.735Reimbursement of health care services provided through telemedicine or store and forward technology—Audio-only telemedicine.
48.43.740Dental only plan—Emergency dental conditions—Definitions.
48.43.743Dental only plan—Annual data statement—Contents—Public use—Definition.
48.43.745Dental only plan—Denturist services.
48.43.750Health care provider credentialing applications—Use of electronic database by health carriers.
48.43.755Health care provider credentialing applications—Use of electronic database by providers.
48.43.757Health care provider credentialing applications—Reimbursement requirements.
48.43.760Opioid use disorder—Coverage without prior authorization.
48.43.761Withdrawal management services—Substance use disorder treatment services—Prior authorization—Utilization review—Medical necessity review.
48.43.762Opioid overdose reversal medication bulk purchasing and distribution program.
48.43.764Standard set of criteria—Authority review.
48.43.765Health carrier network adequacy—Mental health and substance abuse treatment.
48.43.767Behavioral health services—Network access.
48.43.770Individual market health plan availability—Annual report.
48.43.775Qualified health plan participation—Reimbursement rate for other health plans.
48.43.780Cap on enrollee's required payment amount for specific drugs and equipment—Cost-sharing requirements.
48.43.785COVID-19 personal protective equipment expenses—Health care provider reimbursement.
48.43.790Behavioral services—Next-day appointments.
48.43.795Qualified health plans—Acceptance of premium and cost-sharing assistance.
48.43.800Primary care expenditures assessment—Review.
48.43.805Prescription drug upper payment limit—Rules.
48.43.810Biomarker testing—Standards—Construction.
48.43.815Donor human milk—Standards.
48.43.820Consolidated appropriations act enforcement—Implementation of federal regulations.
48.43.825Certified peer specialist services—Network access standards.
48.43.830Prior authorization.
48.43.835Physician assistants—Coverage.
CONSTRUCTION
48.43.902Effective date—1996 c 312.
48.43.904Construction—Chapter applicable to state registered domestic partnerships—2009 c 521.