Washington Code 48.46.243 – Contract — Participant liability
Current as of: 2023 | Check for updates
|
Other versions
(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 in writing and shall set forth that in the event the health maintenance organization fails to pay for health care services as set forth in the agreement, the enrolled participant shall not be liable to the provider for any sums owed by the health maintenance organization. Every such contract shall provide that this requirement shall survive termination of the contract.
Terms Used In Washington Code 48.46.243
- Commissioner: means the insurance commissioner. See Washington Code 48.46.020
- Contract: A legal written agreement that becomes binding when signed.
- Enrolled participant: means a person who or group of persons which has entered into a contractual arrangement or on whose behalf a contractual arrangement has been entered into with a health maintenance organization to receive health care services. See Washington Code 48.46.020
- Health maintenance organization: means any organization receiving a certificate of registration by the commissioner under this chapter which provides comprehensive health care services to enrolled participants of such organization on a group practice per capita prepayment basis or on a prepaid individual practice plan, except for an enrolled participant's responsibility for copayments and/or deductibles, either directly or through contractual or other arrangements with other institutions, entities, or persons, and which qualifies as a health maintenance organization pursuant to RCW 48. See Washington Code 48.46.020
- Participating provider: means a provider as defined in subsection (21) of this section who contracts with the health maintenance organization or with its contractor or subcontractor and has agreed to provide health care services to enrolled participants with an expectation of receiving payment, other than copayment or deductible, directly or indirectly, from the health maintenance organization. See Washington Code 48.46.020
- Provider: means any health professional, hospital, or other institution, organization, or person that furnishes any health care services and is licensed or otherwise authorized to furnish such services. See Washington Code 48.46.020
- Trustee: A person or institution holding and administering property in trust.
(2) The provisions of subsection (1) of this section shall not apply:
(a) To emergency care from a provider who is not a participating provider;
(b) To out-of-area services;
(c) To the delivery of covered pediatric oral services that are substantially equal to the essential health benefits benchmark plan; or
(d) In exceptional situations approved in advance by the commissioner, if the health maintenance organization is unable to negotiate reasonable and cost-effective participating provider contracts.
(3) No participating provider, or insurance producer, trustee, or assignee thereof, may maintain an action against an enrolled participant to collect sums owed by the health maintenance organization.
NOTES:
Intent—2016 c 122: “It is the intent of the legislature to allow certain provider compensation exhibits to remain confidential by making permanent the provisions of chapter 277, Laws of 2013, which currently expire July 1, 2017, thereby maintaining efficient review and approval of health care plans by the insurance commissioner and fostering innovation in the Washington health insurance market.” [ 2016 c 122 § 1.]
Severability—Effective date—2008 c 217: See notes following RCW 48.03.020.