Revised Code of Washington - RCW Title 48 Insurance - Chapter 48.46 Health Maintenance Organizations

48.46.010 Legislative declaration -- Purpose
In affirmation of the declared principle that health care is a right of every citizen of the state, the legislature expresses its concern that the ...

48.46.012 Filings with secretary of state -- Copy for commissioner
Health maintenance organizations shall send a copy specifically for the office of the insurance commissioner to the secretary of state of any corporate document required ...

48.46.020 Definitions
As used in this chapter, the terms defined in this section shall have the meanings indicated unless the context indicates otherwise. (1) "Health maintenance organization" ...

48.46.023 Agent -- Definition -- License required -- Application, issuance, renewal, fees -- Penalties involving license
(1) Agent, as used in this chapter, means any person appointed or authorized by a health maintenance organization to solicit applications for health care service ...

48.46.027 Registration, required -- Issuance of securities -- Penalty
(1) A person may not in this state, by mail or otherwise, act as or hold himself or herself out to be a health maintenance ...

48.46.030 Eligibility requirements for certificate of registration -- Application requirements, information
Any corporation, cooperative group, partnership, individual, association, or groups of health professionals licensed by the state of Washington, public hospital district, or public institutions of ...

48.46.033 Unregistered activities -- Acts committed in this state -- Sanctions
(1) As used in this section, "person" has the same meaning as in RCW 48.01.070. (2) For the purpose of this section, an act is ...

48.46.040 Certificate of registration -- Issuance -- Grounds for refusal -- Name restrictions -- Inspection and review of facilities
The commissioner shall issue a certificate of registration to the applicant within sixty days of such filing unless he notifies the applicant within such time ...

48.46.045 Catastrophic health plans permitted
Notwithstanding the provisions of this chapter, a health maintenance organization may offer catastrophic health plans as defined in RCW 48.43.005.[2000 c 79 § 27.]Notes: Effective ...

48.46.060 Prepayment agreements -- Standards for forms and documents -- Grounds for disapproval -- Cancellation or failure to renew -- Filing of agreement forms
(1) Any health maintenance organization may enter into agreements with or for the benefit of persons or groups of persons, which require prepayment for health ...

48.46.062 Schedule of rates for individual agreements -- Loss ratio -- Remittance of premiums -- Definitions
(1) The definitions in this subsection apply throughout this section unless the context clearly requires otherwise. (a) "Claims" means the cost to the health maintenance ...

48.46.063 Calculation of premiums -- Members of a purchasing pool--Adjusted community rating method -- Definitions
(1) Premiums for health benefit plans for individuals who purchase the plan as a member of a purchasing pool: (a) Consisting of five hundred or ...

48.46.064 Calculation of premiums -- Adjusted community rate -- Definitions
(1) Except for health benefit plans covered under RCW 48.46.063, premium rates for health benefit plans for individuals shall be subject to the following provisions: ...

48.46.066 Health plan benefits for small employers -- Coverage -- Exemption from statutory requirements -- Premium rates -- Requirements for providing coverage for small employers
(1)(a) A health maintenance organization offering any health benefit plan to a small employer, either directly or through an association or member-governed group formed specifically ...

48.46.068 Requirements for plans offered to small employers -- Definitions
(1) A health maintenance organization may not offer any health benefit plan to any small employer without complying with RCW 48.46.066(3). (2) Employers purchasing health ...

48.46.070 Governing body
(1) The members of the governing body of a health maintenance organization shall be nominated by the voting members or by the enrolled participants and ...

48.46.080 Annual statement -- Filings -- Contents -- Fee -- Penalty for failure to file -- Accuracy required
(1) Every domestic health maintenance organization shall annually, on or before the first day of March, file with the commissioner a statement verified by at ...

48.46.090 Standard of services provided
A health maintenance organization, and the health care facilities and providers with which such organization has entered into contracts to provide health care services to ...

48.46.100 Grievance procedure
A health maintenance organization shall establish and maintain a grievance procedure, approved by the commissioner, to provide reasonable and effective resolution of complaints initiated by ...

48.46.110 Name restrictions -- Discrimination -- Recovery of costs of health care services participant not entitled to
(1) No health maintenance organization may refer to itself in its name or advertising with any of the words: "insurance", "casualty", "surety", "mutual", or any ...

48.46.120 Examination of health maintenance organizations -- Duties of organizations, powers of commissioner -- Independent audit reports
(1) The commissioner may make an examination of the operations of any health maintenance organization as often as he deems necessary in order to carry ...

48.46.130 Investigation of violations -- Hearing -- Findings -- Penalties -- Order requiring compliance, etc. -- Suspension or revocation of certificate, effect -- Application to courts
(1) The commissioner may, consistent with the provisions of the administrative procedure act, chapter 34.05 RCW, initiate proceedings to determine whether a health maintenance organization ...

48.46.135 Fine in addition to or in lieu of suspension, revocation, or refusal
After hearing or upon stipulation by the registrant and in addition to or in lieu of the suspension, revocation, or refusal to renew any registration ...

48.46.140 Fees
Every organization subject to this chapter shall pay to the commissioner the following fees: (1) For filing a copy of its application for a certificate ...

48.46.170 Effect of chapter as to other laws -- Construction
(1) Solicitation of enrolled participants by a health maintenance organization granted a certificate of registration, or its agents or representatives, does not violate any provision ...

48.46.180 Duty of employer to inform and make available to employees option of enrolling in health maintenance organization
(1) The state government, or any political subdivision thereof, which offers its employees a health benefits plan shall make available to and inform its employees ...

48.46.190 Payroll deductions for capitation payments to health maintenance organizations
See RCW 41.04.233. ...

48.46.200 Rules and regulations
The commissioner may, in accordance with the provisions of the administrative procedure act, chapter 34.05 RCW, promulgate rules and regulations as necessary or proper to ...

48.46.210 Compliance with federal funding requirements -- Construction
Nothing in this chapter shall prohibit any health maintenance organization from meeting the requirements of any federal law which would authorize such health maintenance organization ...

48.46.220 Review of administrative action
Any party aggrieved by a decision, order, or regulation made under this chapter by the commissioner shall have the right to have such reviewed pursuant ...

48.46.225 Financial failure -- Supervision of commissioner -- Priority of distribution of assets
(1) Any rehabilitation, liquidation, or conservation of a health maintenance organization is the same as the rehabilitation, liquidation, or conservation of an insurance company and ...

48.46.235 Minimum net worth -- Requirement to maintain -- Determination of amount
(1) Except as provided in subsection (2) of this section, every health maintenance organization must have and maintain a minimum net worth equal to the ...

48.46.237 Minimum net worth -- Domestic or foreign health maintenance organization
(1) For purposes of this section: (a) "Domestic health maintenance organization" means a health maintenance organization formed under the laws of this state; and (b) ...

48.46.240 Funded reserve requirements
(1) Each health maintenance organization obtaining a certificate of registration from the commissioner shall provide and maintain a funded reserve of one hundred fifty thousand ...

48.46.243 Contract -- Participant liability -- Commissioner's review
(1) Subject to subsection (2) of this section, every contract between a health maintenance organization and its participating providers of health care services shall be ...

48.46.245 Plan for handling insolvency -- Commissioner's review
Each health maintenance organization shall have a plan for handling insolvency which allows for continuation of benefits for the duration of the agreement period for ...

48.46.247 Insolvency -- Commissioner's duties -- Participants' options -- Allocation of coverage
(1)(a) In the event of insolvency of a health care service contractor or health maintenance organization and upon order of the commissioner, all other carriers ...

48.46.250 Coverage of dependent children -- Newborn infants, congenital anomalies -- Notification period
(1) Any health maintenance agreement under this chapter which provides coverage for dependent children of the enrolled participant shall provide the same coverage for newborn ...

48.46.260 Individual health maintenance agreement -- Return within ten days of delivery -- Refunds -- Void from beginning
Every subscriber of an individual health maintenance agreement may return the agreement to the health maintenance organization or the agent through whom it was purchased ...

48.46.270 Financial interests of health maintenance organization authorities, restricted -- Exceptions, regulations
(1) No person having any authority in the investment or disposition of the funds of a health maintenance organization and no officer or director of ...

48.46.272 Diabetes coverage -- Definitions
The legislature finds that diabetes imposes a significant health risk and tremendous financial burden on the citizens and government of the state of Washington, and ...

48.46.275 Mammograms -- Insurance coverage
Each health maintenance agreement issued or renewed after January 1, 1990, that provides benefits for hospital or medical care shall provide benefits for screening or ...

48.46.277 Prostate cancer screening
(1) Each health maintenance agreement issued or renewed after December 31, 2006, that provides coverage for hospital or medical expenses shall provide coverage for prostate ...

48.46.280 Reconstructive breast surgery
(1) Any health care service plan issued, amended, or renewed after July 24, 1983, shall provide coverage for reconstructive breast surgery resulting from a mastectomy ...

48.46.285 Mastectomy, lumpectomy
No health maintenance organization under this chapter may refuse coverage or cancel or decline coverage solely because of a mastectomy or lumpectomy performed on the ...

48.46.291 Mental health services -- Health plans -- Definition -- Coverage required, when
(1) For the purposes of this section, "mental health services" means medically necessary outpatient and inpatient services provided to treat mental disorders covered by the ...

48.46.292 Mental health treatment -- Waiver of preauthorization for persons involuntarily committed
A health maintenance organization providing services or benefits for hospital or medical care coverage in this state shall waive a preauthorization from the health maintenance ...

48.46.300 Future dividends or refunds, restricted -- Issuance or sale of securities regulated
(1) No health maintenance organization nor any individual acting in behalf thereof may guarantee or agree to the payment of future dividends or future refunds ...

48.46.310 Registration not endorsement
The granting of a certificate of registration to a health maintenance organization is permissive only, and does not constitute an endorsement by the insurance commissioner ...

48.46.320 Dependent children, termination of coverage, conditions
Any health maintenance agreement which provides that coverage of a dependent child shall terminate upon attainment of the limiting age for dependent children specified in ...

48.46.325 Option to cover dependents under age twenty-five
(1) Any individual health maintenance agreement that provides coverage for a subscriber's dependent must offer the option of covering any unmarried dependent under the age ...

48.46.340 Return of agreement within ten days
Every subscriber of an individual health maintenance agreement may return the agreement to the health maintenance organization or the agent through whom it was purchased ...

48.46.350 Chemical dependency treatment
Each group agreement for health care services that is delivered or issued for delivery or renewed on or after January 1, 1988, must contain provisions ...

48.46.355 "Chemical dependency" defined
For the purposes of RCW 48.46.350, "chemical dependency" means an illness characterized by a physiological of psychological dependency, or both, on a controlled substance regulated ...

48.46.360 Payment of cost of agreement directly to holder during labor dispute -- Changes restricted -- Notice to employee
Any employee whose compensation includes a health maintenance agreement, the cost of which is paid in full or in part by an employer including the ...

48.46.370 Coverage not denied for handicap
No health maintenance organization may deny coverage to a person solely on account of the presence of any sensory, mental, or physical handicap. Nothing in ...

48.46.375 Benefits for prenatal diagnosis of congenital disorders -- Agreements entered into or renewed on or after January 1, 1990
On or after January 1, 1990, every group health maintenance agreement entered into or renewed that covers hospital, medical, or surgical expenses and which provides ...

48.46.380 Notice of reason for cancellation, denial, or refusal to renew agreement
Every authorized health maintenance organization, upon canceling, denying, or refusing to renew any individual health maintenance agreement, shall, upon written request, directly notify in writing ...

48.46.390 Providing information on cancellation or refusal -- No liability for insurance commissioner or health maintenance organization
With respect to the provisions of health maintenance agreements as set forth in RCW 48.46.380, there shall be no liability on the part of, and ...

48.46.400 False or misleading advertising prohibited
No person may knowingly make, publish, or disseminate any false, deceptive, or misleading representation or advertising in the conduct of the business of a health ...

48.46.410 Misrepresentations to induce termination or retention of agreement prohibited
No health maintenance organization nor any person representing a health maintenance organization may by misrepresentation or misleading comparisons induce or attempt to induce any member ...

48.46.420 Penalty for violations
(1) Except as otherwise provided in this chapter, any health maintenance organization which, or person who, violates any provision of this chapter is guilty of ...

48.46.430 Enforcement authority of commissioner
For the purposes of this chapter, the insurance commissioner shall have the same powers and duties of enforcement as are provided in RCW 48.02.080.[1983 c ...

48.46.440 Continuation option to be offered
Every health maintenance organization that issues agreements providing group coverage for hospital or medical care shall offer the agreement holder an option to include an ...

48.46.450 Conversion agreement to be offered -- Exceptions, conditions
(1) Except as otherwise provided by this section, any group health maintenance agreement entered into or renewed on or after January 1, 1985, that provides ...

48.46.460 Conversion agreement -- Restrictions and requirements
(1) A health maintenance organization must offer a conversion agreement for comprehensive health care services and shall not require proof of insurability as a condition ...

48.46.470 Endorsement of modifications
If an individual health care service agreement is issued on any basis other than as applied for, an endorsement setting forth such modification must accompany ...

48.46.480 Continuation of coverage of former family members
Every health care service agreement issued, amended, or renewed after January 1, 1986, for an individual and his or her dependents shall contain provisions to ...

48.46.490 Coverage for adopted children
(1) Any health maintenance agreement under this chapter which provides coverage for dependent children, as defined in the agreement of the enrolled participant, shall cover ...

48.46.500 Cancellation of rider
Upon application by an enrollee, a rider shall be canceled if at least five years after its issuance, no health care services have been received ...

48.46.510 Phenylketonuria
(1) The legislature finds that: (a) Phenylketonuria is a rare inherited genetic disorder. (b) Children with phenylketonuria are unable to metabolize an essential amino acid, ...

48.46.520 Neurodevelopmental therapies -- Employer-sponsored group contracts
(1) Each employer-sponsored group contract for comprehensive health care service which is entered into, or renewed, on or after twelve months after July 23, 1989, ...

48.46.530 Temporomandibular joint disorders -- Insurance coverage
(1) Except as provided in this section, a health maintenance agreement entered into or renewed after December 31, 1989, shall offer optional coverage for the ...

48.46.535 Prescriptions -- Preapproval of individual claims -- Subsequent rejection prohibited -- Written record required
Health maintenance organizations who through an authorized representative have first approved, by any means, an individual prescription claim as eligible may not reject that claim ...

48.46.540 Nonresident pharmacies
For the purposes of this chapter, a nonresident pharmacy is defined as any pharmacy located outside this state that ships, mails, or delivers, in any ...

48.46.565 Foot care services
Except to the extent that a health maintenance organization contracts with a group medical practice which only treats that organization's patients, a health maintenance organization ...

48.46.570 Denturist services
Notwithstanding any provision of any health maintenance organization agreement covering dental care as provided for in this chapter, effective January 1, 1995, benefits shall not ...

48.46.575 Doctor of osteopathic medicine and surgery -- Discrimination based on board certification is prohibited
A health maintenance organization that provides health care services to the general public may not discriminate against a qualified doctor of osteopathic medicine and surgery ...

48.46.580 When injury caused by intoxication or use of narcotics
A health maintenance organization may not deny coverage for the treatment of an injury solely because the injury was sustained as a consequence of the ...

48.46.600 Disclosure of certain material transactions -- Report -- Information is confidential
(1) Every health maintenance organization domiciled in this state shall file a report with the commissioner disclosing material acquisitions and dispositions of assets or material ...

48.46.605 Material acquisitions or dispositions
No acquisitions or dispositions of assets need be reported pursuant to RCW 48.46.600 if the acquisitions or dispositions are not material. For purposes of RCW ...

48.46.610 Asset acquisitions -- Asset dispositions
(1) Asset acquisitions subject to RCW 48.46.600 through 48.46.625 include every purchase, lease, exchange, merger, consolidation, succession, or other acquisition other than the construction or ...

48.46.615 Report of a material acquisition or disposition of assets -- Information required
The following information is required to be disclosed in any report of a material acquisition or disposition of assets: (1) Date of the transaction; (2) ...

48.46.620 Material nonrenewals, cancellations, or revisions of ceded reinsurance agreements
(1) No nonrenewals, cancellations, or revisions of ceded reinsurance agreements need be reported under RCW 48.46.600 if the nonrenewals, cancellations, or revisions are not material. ...

48.46.625 Report of a material nonrenewal, cancellation, or revision of ceded reinsurance agreements -- Information required
The following is required to be disclosed in any report of a material nonrenewal, cancellation, or revision of ceded reinsurance agreements: (1) The effective date ...

48.46.900 Liberal construction
It is intended that the provisions of this chapter shall be liberally construed to accomplish the purposes provided for and authorized herein.[1975 1st ex.s. c ...

48.46.910 Severability -- 1975 1st ex.s. c 290
If any provision of this 1975 amendatory act, or its application to any person or circumstance is held invalid, the remainder of the act, or ...

48.46.920 Short title
This 1975 amendatory act may be known and cited as "The Washington Health Maintenance Organization Act of 1975".[1975 1st ex.s. c 290 § 27.] ...