Chapter 48.43 RCW



48.43.007Availability of price and quality informationTransparency tools for membersRequirements.
48.43.008Enrollment in employer-sponsored health planPerson eligible for medical assistance.
48.43.009Health care sharing ministries.
48.43.012Health plansPreexisting conditionsRules.
48.43.01211Health plansEligibilityHealth status-related factorsRules.
48.43.0122Individual health benefit plansOpen enrollment and special enrollment periodsRulesEnforcement.
48.43.0123Health plansRescission of coverageRules.
48.43.0124Health plansCost sharing for essential health benefitsRules.
48.43.0125Essential health benefitsAnnual or lifetime dollar limits.
48.43.0126Summary of benefits and explanation of coverageStandards and requirementsNotice of modificationFinesStandards for definitions of health insurance termsRules.
48.43.0127Group health plansWaiting periodRules.
48.43.0128Nongrandfathered health plans and plans issued or renewed on or after January 1, 2022Prohibited discriminationRules.
48.43.016Utilization management standards and criteriaHealth carrier requirementsDefinitions.
48.43.0161Prior authorization practicesCarrier annual reporting requirementsCommissioner's standardized report.
48.43.021Personally identifiable health informationRestrictions on release.
48.43.022Enrollee identification cardSocial security number restriction.
48.43.023Pharmacy identification cardsRules.
48.43.028Eligibility to purchase certain health benefit plansSmall employers and small groups.
48.43.035Group health benefit plansGuaranteed issue and continuity of coverageExceptions.
48.43.038Individual health plansGuarantee of continuity of coverageExceptions.
48.43.039Grace periodNotification or informationInformation concerning delinquencies or nonpayment of premiumsDefined.
48.43.041Individual health benefit plansMandatory benefits.
48.43.043Colorectal cancer examinations and laboratory testsRequired benefits or coverage.
48.43.045Health plan requirementsAnnual reportsExemptions.
48.43.047Health plansMinimum coverage for preventative servicesNo cost-sharing requirements.
48.43.049Health carrier dataInformation from annual statementFormat prescribed by commissionerPublic availability.
48.43.055Procedures for review and adjudication of health care provider complaintsRequirements.
48.43.059Payments made by a second-party payment processDefinition.
48.43.065Right of individuals to receive servicesRight of providers, carriers, and facilities to refuse to participate in or pay for services for reason of conscience or religionRequirements.
48.43.071Health care informationRequirement to provide free copy to covered person appealing denial of social security benefitsExceptions.
48.43.072Required reproductive health care coverageRestrictions on copayments, deductibles, and other form of cost sharing.
48.43.073Required abortion coverageLimitations.
48.43.074Qualified health plansSingle invoice billingCertification of compliance required in the segregation plan for premium amounts attributable to coverage of abortion services.
48.43.078Digital breast tomosynthesisIntent to ensure women with accessCommissioner's and health care authority's duty to clarify mandates.
48.43.081Anatomic pathology servicesPayment for servicesDefinitions.
48.43.083Chiropractor servicesParticipating provider agreementHealth 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 expenseMental health care practitionerConditionsException.
48.43.091Health carrier coverage of outpatient mental health servicesRequirements.
48.43.093Health carrier coverage of emergency medical servicesRequirementsConditions.
48.43.094Pharmacist provided servicesHealth plan requirements.
48.43.096Medication synchronization policy required for health plans covering prescription drugsRequirementsDefinitions.
48.43.097Filing of financial statementsEvery health carrier.
48.43.105Preparation of documents that compare health carriersImmunityDue diligence.
48.43.115Maternity servicesIntentDefinitionsPatient preferenceClinical sovereignty of providerNotice to policyholdersApplication.
48.43.125Coverage at a long-term care facility following hospitalizationDefinition.
48.43.176Eosinophilic gastrointestinal associated disorderElemental formula.
48.43.180Denturist services.
48.43.185General anesthesia services for dental procedures.
48.43.190Payment of chiropractic servicesParity.
48.43.195Contraceptive drugsTwelve-month refill coverage.
48.43.200Disclosure of certain material transactionsReportInformation is confidential.
48.43.205Material acquisitions or dispositions.
48.43.210Asset acquisitionsAsset dispositions.
48.43.215Report of a material acquisition or disposition of assetsInformation 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 agreementsInformation required.
48.43.290Coverage for prescribed durable medical equipment and mobility enhancing equipmentSales and use taxesDefinitions.
48.43.305Report of RBC levelsDistribution of reportFormula for determinationCommissioner may make adjustments.
48.43.310Company action level eventRequired RBC planCommissioner's reviewNotificationChallenge by carrier.
48.43.315Regulatory action level eventRequired RBC planCommissioner's reviewNotificationChallenge by carrier.
48.43.320Authorized control level eventCommissioner's options.
48.43.325Mandatory control level eventCommissioner's dutyRegulatory control.
48.43.330Carrier's right to hearingRequest by carrierDate set by commissioner.
48.43.335Confidentiality of RBC reports and plansUse of certain comparisons prohibitedCertain information intended solely for use by commissioner.
48.43.340Powers or duties of commissioner not limitedRules.
48.43.345Foreign or alien carriersRequired RBC reportCommissioner may require RBC planMandatory control level event.
48.43.350No liability or cause of action against commissioner or department.
48.43.355Notice by commissioner to carrierWhen effective.
48.43.360Initial RBC reportsCalculation of initial RBC levelsSubsequent reports.
48.43.366Self-funded multiple employer welfare arrangements.
48.43.370RBC standards not applicable to certain carriers.
48.43.400Prescription drug utilization managementDefinitions.
48.43.410Prescription drug utilization managementClinical review criteriaRequirement to be evidence-based and updated regularly.
48.43.420Prescription drug utilization managementException request processConditions, requirements, and time frames for approval or denial of requestsEmergency fill coverageNotice of new policies and procedures.
48.43.430Prescription medicationMaximum charge at point of saleRequirements.
48.43.500IntentPurpose2000 c 5.
48.43.505Enrollee's and protected individual's right to privacy and confidential servicesHealth carrier or insurer dutiesRequests for confidential communicationsRules.
48.43.5051Requests for confidential communicationsMonitoring and ensuring complianceStandardized form for submission of requestsRules.
48.43.510Carrier required to disclose health plan informationMarketing and advertising restrictionsRules.
48.43.515Access to appropriate health servicesEnrollee optionsRules.
48.43.517Enrollment of child participating in medical assistance programEmployer-sponsored health plan.
48.43.520Requirement to maintain a documented utilization review program description and written utilization review criteriaRules.
48.43.525Prohibition against retrospective denial of health plan coverageRules.
48.43.530Requirement for carriers to have comprehensive grievance and appeal processesCarrier's dutiesProceduresAppealsRules.
48.43.535Independent review of health care disputesSystem for using certified independent review organizationsRules.
48.43.537Health care disputesCertifying independent review organizationsApplicationRestrictionsMaximum fee schedule for conducting reviewsRules.
48.43.540Requirement to designate a licensed medical directorExemption.
48.43.545Standard of careLiabilityCauses of actionDefenseException.
48.43.550Delegation of dutiesCarrier accountability.
48.43.600Overpayment recoveryCarrier.
48.43.605Overpayment recoveryHealth care provider.
48.43.650Fixed payment insurance productsCommissioner's annual report.
48.43.670Plan or contract renewalModification of wellness program.
48.43.680Lifetime limit on transplantsDefinition.
48.43.690Assessments under RCW 70.290.040 considered medical expenses.
48.43.700ExchangePlans that a carrier must offerReviewRules.
48.43.705Plans offered outside of exchange.
48.43.710Certification as qualified health plan not an exemption.
48.43.715Individual and small group marketSelection of benchmark planMinimum requirementsCriteriaList of state-mandated health benefits.
48.43.720Reinsurance and risk adjustment programsAffordable care actRules.
48.43.725Exclusion of mandated benefits from health planCarrier requirementsNoticeFeesCommissioner's duties.
48.43.730Carrier must file provider contracts and compensation agreements with commissionerApproval or disapprovalConfidentialityHearingsRulesDefinitions.
48.43.731Health care benefit management contractsCarrier filing requirementsNotice to enrolleesConfidentiality of filings.
48.43.733Rates and forms of group health benefit plansTiming of filingsExceptionsRules.
48.43.734Health carrier rate filingsReview of surplus, capital, and profit levels.
48.43.735Reimbursement of health care services provided through telemedicine or store and forward technologyAudio-only telemedicine.
48.43.740Dental only planEmergency dental conditionsDefinitions.
48.43.743Dental only planAnnual data statementContentsPublic useDefinition.
48.43.750Health care provider credentialing applicationsUse of electronic database by health carriers.
48.43.755Health care provider credentialing applicationsUse of electronic database by providers.
48.43.757Health care provider credentialing applicationsReimbursement requirements.
48.43.760Opioid use disorderCoverage without prior authorization.
48.43.761Withdrawal management servicesSubstance use disorder treatment servicesPrior authorizationUtilization reviewMedical necessity review.
48.43.762Opioid overdose reversal medication bulk purchasing and distribution program.
48.43.765Health carrier network adequacyMental health and substance abuse treatment.
48.43.770Individual market health plan availabilityAnnual report.
48.43.775Qualified health plan participationReimbursement rate for other health plans.
48.43.780Insulin drugsCap on enrollee's required payment amountCost-sharing requirements.
48.43.785COVID-19 personal protective equipment expensesHealth care provider reimbursement.
48.43.790Behavioral servicesNext-day appointments.
48.43.795Qualified health plansAcceptance of premium and cost-sharing assistance.
48.43.902Effective date1996 c 312.
48.43.904ConstructionChapter applicable to state registered domestic partnerships2009 c 521.