41.05.400  <<  41.05.410 >>   41.05.413

Qualified health plansContract forRequirements.

(1) The authority, in consultation with the health benefit exchange, must contract with one or more health carriers to offer qualified health plans on the Washington health benefit exchange for plan years beginning in 2021. A health carrier contracting with the authority under this section must offer at least one bronze, one silver, and one gold qualified health plan in a single county or in multiple counties. The goal of the procurement conducted under this section is to have a choice of qualified health plans under this section offered in every county in the state. The authority may not execute a contract with an apparently successful bidder under this section until after the insurance commissioner has given final approval of the health carrier's rates and forms pertaining to the health plan to be offered under this section and certification of the health plan under RCW 43.71.065.
(2) A qualified health plan offered under this section must meet the following criteria:
(a) The qualified health plan must be a standardized health plan established under RCW 43.71.095;
(b) The qualified health plan must meet all requirements for qualified health plan certification under RCW 43.71.065 including, but not limited to, requirements relating to rate review and network adequacy;
(c) The qualified health plan must incorporate recommendations of the Robert Bree collaborative and the health technology assessment program;
(d) The qualified health plan may use an integrated delivery system or a managed care model that includes care coordination or care management to enrollees as appropriate;
(e) The qualified health plan must meet additional participation requirements to reduce barriers to maintaining and improving health and align to state agency value-based purchasing. These requirements may include, but are not limited to, standards for population health management; high-value, proven care; health equity; primary care; care coordination and chronic disease management; wellness and prevention; prevention of wasteful and harmful care; and patient engagement;
(f) To reduce administrative burden and increase transparency, the qualified health plan's utilization review processes must:
(i) Be focused on care that has high variation, high cost, or low evidence of clinical effectiveness; and
(ii) Meet national accreditation standards;
(g)(i) The total amount the qualified health plan reimburses providers and facilities for all covered benefits in the statewide aggregate, excluding pharmacy benefits, may not exceed one hundred sixty percent of the total amount medicare would have reimbursed providers and facilities for the same or similar services in the statewide aggregate;
(ii) Beginning in calendar year 2023, if the authority determines that selective contracting will result in actuarially sound premium rates that are no greater than the qualified health plan's previous plan year rates adjusted for inflation using the consumer price index, the director may, in consultation with the health benefit exchange, waive (g)(i) of this subsection as a requirement of the contracting process under this section;
(h) For services provided by rural hospitals certified by the centers for medicare and medicaid services as critical access hospitals or sole community hospitals, the rates may not be less than one hundred one percent of allowable costs as defined by the United States centers for medicare and medicaid services for purposes of medicare cost reporting;
(i) Reimbursement for primary care services, as defined by the authority, provided by a physician with a primary specialty designation of family medicine, general internal medicine, or pediatric medicine, may not be less than one hundred thirty-five percent of the amount that would have been reimbursed under the medicare program for the same or similar services; and
(j) The qualified health plan must comply with any requirements established by the authority to address amounts expended on pharmacy benefits including, but not limited to, increasing generic utilization and use of evidence-based formularies.
(3) Nothing in this section prohibits a health carrier offering qualified health plans under this section from offering other health plans in the individual market.

NOTES:

Report and recommendations2019 c 364 § 3: "(1) The health care authority, in consultation with the insurance commissioner and the Washington health benefit exchange, must submit a report and recommendations to the legislature by December 1, 2022, regarding:
(a) The impact on qualified health plan choice, affordability, and market stability of linking offering a qualified health plan under RCW 41.05.410 with participation in programs administered by the public employees' benefits board, the school employees' benefits board, or the health care authority;
(b) The impact on qualified health plan choice, qualified health plan provider networks, affordability, and market stability of linking provider participation in the provider networks of qualified health plans offered under RCW 41.05.410 with provider participation in provider networks of programs administered by the public employees' benefits board, the school employees' benefits board, or the health care authority;
(c) Whether the utilization review processes employed by a health carrier offering a qualified health plan under RCW 41.05.410 should align with clinical criteria published by the health care authority; and
(d) Other issues the health care authority deems relevant to the successful implementation of chapter 364, Laws of 2019.
(2) This section expires January 1, 2023." [ 2019 c 364 § 5.]
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