Revised Code of Washington - RCW Title 48 Insurance - Chapter 48.43 Insurance Reform

48.43.001 Intent
It is the intent of the legislature to ensure that all enrollees in managed care settings have access to adequate information regarding health care services ...

48.43.005 Definitions
Unless otherwise specifically provided, the definitions in this section apply throughout this chapter. (1) "Adjusted community rate" means the rating method used to establish the ...

48.43.008 Enrollment in employer-sponsored health plan -- Person eligible for medical assistance
When the department of social and health services determines that it is cost-effective to enroll a person eligible for medical assistance under chapter 74.09 RCW ...

48.43.012 Individual health benefit plans -- Preexisting conditions
(1) No carrier may reject an individual for an individual health benefit plan based upon preexisting conditions of the individual except as provided in RCW ...

48.43.015 Health benefit plans -- Preexisting conditions
(1) For a health benefit plan offered to a group, every health carrier shall reduce any preexisting condition exclusion, limitation, or waiting period in the ...

48.43.018 Requirement to complete the standard health questionnaire -- Exemptions -- Results (as amended by 2007 c 80)
(1) Except as provided in (a) through ((~~(e)~~)) (d) of this subsection, a health carrier may require any person applying for an individual health benefit ...

48.43.018 Requirement to complete the standard health questionnaire -- Exemptions -- Results (as amended by 2007 c 259)
(1) Except as provided in (a) through ((~~(e)~~)) (d) of this subsection, a health carrier may require any person applying for an individual health benefit ...

48.43.021 Personally identifiable health information -- Restrictions on release
Except as otherwise required by statute or rule, a carrier and the Washington state health insurance pool, and persons acting at the direction of or ...

48.43.022 Enrollee identification card -- Social security number restriction
After December 31, 2005, a health carrier that issues a card identifying a person as an enrollee, and requires the person to present the card ...

48.43.023 Pharmacy identification cards--Rules
(1) A health carrier that provides coverage for prescription drugs provided on an outpatient basis and issues a card or other technology for claims processing, ...

48.43.025 Group health benefit plans -- Preexisting conditions
(1) For group health benefit plans for groups other than small groups, no carrier may reject an individual for health plan coverage based upon preexisting ...

48.43.028 Eligibility to purchase certain health benefit plans -- Small employers and small groups
To the extent required of the federal health insurance portability and accountability act of 1996, the eligibility of an employer or group to purchase a ...

48.43.035 Group health benefit plans -- Guaranteed issue and continuity of coverage -- Exceptions -- Group of one
For group health benefit plans, the following shall apply: (1) All health carriers shall accept for enrollment any state resident within the group to whom ...

48.43.038 Individual health plans -- Guarantee of continuity of coverage--Exceptions
(1) Except as provided in subsection (4) of this section, all individual health plans shall contain or incorporate by endorsement a guarantee of the continuity ...

48.43.041 Individual health benefit plans -- Mandatory benefits
(1) All individual health benefit plans, other than catastrophic health plans, offered or renewed on or after October 1, 2000, shall include benefits described in ...

48.43.043 Colorectal cancer examinations and laboratory tests -- Required benefits or coverage
(1) Health plans issued or renewed on or after July 1, 2008, must provide benefits or coverage for colorectal cancer examinations and laboratory tests consistent ...

48.43.045 Health plan requirements -- Annual reports -- Exemptions
(1) Every health plan delivered, issued for delivery, or renewed by a health carrier on and after January 1, 1996, shall: (a) Permit every category ...

48.43.049 Health carrier data -- Information from annual statement -- Format prescribed by commissioner -- Public availability
(1) Each health carrier offering a health benefit plan shall submit to the commissioner on or before April 1st of each year as part of ...

48.43.055 Procedures for review and adjudication of health care provider complaints -- Requirements
Each health carrier as defined under RCW 48.43.005 shall file with the commissioner its procedures for review and adjudication of complaints initiated by health care ...

48.43.065 Right 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
(1) The legislature recognizes that every individual possesses a fundamental right to exercise their religious beliefs and conscience. The legislature further recognizes that in developing ...

48.43.083 Chiropractor services -- Participating provider agreement -- Health carrier reimbursement
(1) A health carrier must reimburse a chiropractor who has signed a participating provider agreement for services determined by the carrier to be medically necessary ...

48.43.085 Health carrier may not prohibit its enrollees from contracting for services outside the health care plan
Notwithstanding any other provision of law, no health carrier subject to the jurisdiction of the state of Washington may prohibit directly or indirectly its enrollees ...

48.43.087 Contracting for services at enrollee's expense -- Mental health care practitioner -- Conditions -- Exception
(1) For purposes of this section: (a) "Health carrier" includes disability insurers regulated under chapter 48.20 or 48.21 RCW, health care services contractors regulated under ...

48.43.091 Health carrier coverage of outpatient mental health services -- Requirements
Every health carrier that provides coverage for any outpatient mental health service shall comply with the following requirements: (1) In performing a utilization review of ...

48.43.093 Health carrier coverage of emergency medical services -- Requirements -- Conditions
(1) When conducting a review of the necessity and appropriateness of emergency services or making a benefit determination for emergency services: (a) A health carrier ...

48.43.097 Filing of financial statements -- Every health carrier
Every health carrier holding a registration from the commissioner shall file its financial statements as required by this code and by the commissioner in accordance ...

48.43.105 Preparation of documents that compare health carriers -- Immunity -- Due diligence
(1) A public or private entity who exercises due diligence in preparing a document of any kind that compares health carriers of any kind is ...

48.43.115 Maternity services -- Intent -- Definitions -- Patient preference -- Clinical sovereignty of provider -- Notice to policyholders -- Application
(1) The legislature recognizes the role of health care providers as the appropriate authority to determine and establish the delivery of quality health care services ...

48.43.125 Coverage at a long-term care facility following hospitalization -- Definition
(1) A carrier that provides coverage for a person at a long-term care facility following the person's hospitalization shall, upon the request of the person ...

48.43.180 Denturist services
Notwithstanding any provision of any certified health plan covering dental care as provided for in this chapter, effective January 1, 1995, benefits shall not be ...

48.43.185 General anesthesia services for dental procedures
(1) Each group health benefit plan that provides coverage for hospital, medical, or ambulatory surgery center services must cover general anesthesia services and related facility ...

48.43.190 Payment of chiropractic services -- Parity
(1)(a) A health carrier may not pay a chiropractor less for a service or procedure identified under a particular physical medicine and rehabilitation code or ...

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

48.43.205 Material acquisitions or dispositions
No acquisitions or dispositions of assets need be reported pursuant to RCW 48.43.200 if the acquisitions or dispositions are not material. For purposes of RCW ...

48.43.210 Asset acquisitions -- Asset dispositions
(1) Asset acquisitions subject to RCW 48.43.200 through 48.43.225 include every purchase, lease, exchange, merger, consolidation, succession, or other acquisition other than the construction or ...

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

48.43.220 Material nonrenewals, cancellations, or revisions of ceded reinsurance agreements
(1) No nonrenewals, cancellations, or revisions of ceded reinsurance agreements need be reported under RCW 48.43.200 if the nonrenewals, cancellations, or revisions are not material. ...

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

48.43.300 Definitions
The definitions in this section apply throughout RCW 48.43.300 through 48.43.370 unless the context clearly requires otherwise. (1) "Adjusted RBC report" means an RBC report ...

48.43.305 Report of RBC levels -- Distribution of report -- Formula for determination -- Commissioner may make adjustments
(1) Every domestic carrier shall, on or prior to the filing date of March 1st, prepare and submit to the commissioner a report of its ...

48.43.310 Company action level event -- Required RBC plan -- Commissioner's review -- Notification -- Challenge by carrier
(1) "Company action level event" means any of the following events: (a) The filing of an RBC report by a carrier which indicates that: (i) ...

48.43.315 Regulatory action level event -- Required RBC plan -- Commissioner's review -- Notification -- Challenge by carrier
(1) "Regulatory action level event" means, with respect to any carrier, any of the following events: (a) The filing of an RBC report by the ...

48.43.320 Authorized control level event -- Commissioner's options
(1) "Authorized control level event" means any of the following events: (a) The filing of an RBC report by the carrier which indicates that the ...

48.43.325 Mandatory control level event -- Commissioner's duty -- Regulatory control
(1) "Mandatory control level event" means any of the following events: (a) The filing of an RBC report which indicates that the carrier's total adjusted ...

48.43.330 Carrier's right to hearing -- Request by carrier -- Date set by commissioner
(1) Upon notification to a carrier by the commissioner of any of the following, the carrier shall have the right to a hearing, in accordance ...

48.43.335 Confidentiality of RBC reports and plans -- Use of certain comparisons prohibited -- Certain information intended solely for use by commissioner
(1) All RBC reports, to the extent the information therein is not required to be set forth in a publicly available annual statement schedule, and ...

48.43.340 Powers or duties of commissioner not limited -- Rules
(1) The provisions of RCW 48.43.300 through 48.43.370 are supplemental to any other provisions of the laws and rules of this state, and shall not ...

48.43.345 Foreign or alien carriers -- Required RBC report -- Commissioner may require RBC plan -- Mandatory control level event
(1) Any foreign or alien carrier shall, upon the written request of the commissioner, submit to the commissioner an RBC report as of the end ...

48.43.350 No liability or cause of action against commissioner or department
There is no liability on the part of, and no cause of action shall arise against, the commissioner or insurance department or its employees or ...

48.43.355 Notice by commissioner to carrier -- When effective
All notices by the commissioner to a carrier that may result in regulatory action are effective upon dispatch if transmitted by registered or certified mail, ...

48.43.360 Initial RBC reports -- Calculation of initial RBC levels -- Subsequent reports
For RBC reports to be filed by carriers commencing operations after June 11, 1998, those carriers shall calculate the initial RBC levels using financial projections, ...

48.43.366 Self-funded multiple employer welfare arrangements
A self-funded multiple employer welfare arrangement, as defined in RCW 48.125.010, is subject to the same RBC reporting requirements as a domestic carrier under RCW ...

48.43.370 RBC standards not applicable to certain carriers
RCW 48.43.300 through 48.43.370 shall not apply to a carrier which is subject to the provisions of RCW 48.05.430 through *48.05.490.[1998 c 241 § 15.]Notes: ...

48.43.500 Intent -- Purpose -- 2000 c 5
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 ...

48.43.505 Requirement to protect enrollee's right to privacy or confidential services -- Rules
(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 ...

48.43.510 Carrier required to disclose health plan information -- Marketing and advertising restrictions -- Rules
(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, ...

48.43.515 Access to appropriate health services -- Enrollee options -- Rules
(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 ...

48.43.517 Enrollment of child participating in medical assistance program -- Employer-sponsored health plan
When the department of social and health services has determined that it is cost-effective to enroll a child participating in a medical assistance program under ...

48.43.520 Requirement to maintain a documented utilization review program description and written utilization review criteria -- Rules
(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. ...

48.43.525 Prohibition against retrospective denial of health plan coverage -- Rules
(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 ...

48.43.530 Requirement for carriers to have a comprehensive grievance process -- Carrier's duties -- Procedures -- Appeals -- Rules
(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 ...

48.43.535 Independent review of health care disputes -- System for using certified independent review organizations -- Rules
(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 ...

48.43.540 Requirement to designate a licensed medical director -- Exemption
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 ...

48.43.545 Standard of care -- Liability -- Causes of action -- Defense -- Exception
(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 ...

48.43.550 Delegation of duties -- Carrier accountability
Each carrier is accountable for and must oversee any activities required by chapter 5, Laws of 2000 that it delegates to any subcontractor. No contract ...

48.43.600 Overpayment recovery -- Carrier
(1) Except in the case of fraud, or as provided in subsections (2) and (3) of this section, a carrier may not: (a) Request a ...

48.43.605 Overpayment recovery -- Health care provider
(1) Except in the case of fraud, or as provided in subsection (2) of this section, a health care provider may not: (a) Request additional ...

48.43.650 Fixed payment insurance products -- Commissioner's annual report
The commissioner shall collect information from insurers offering fixed payment insurance products, and report aggregated data for each calendar year, including the number of groups ...

48.43.901 Captions not law -- 1996 c 312
Captions used in this act do not constitute part of the law.[1996 c 312 § 6.] ...

48.43.902 Effective date -- 1996 c 312
This act shall take effect July 1, 1996.[1996 c 312 § 8.] ...

48.43.903 Severability -- 1998 c 241
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 ...