§ 48.43.001 Intent
§ 48.43.005 Definitions
§ 48.43.007 Availability of price and quality information — Transparency tools for members — Requirements
§ 48.43.008 Enrollment in employer-sponsored health plan — Person eligible for medical assistance
§ 48.43.009 Health care sharing ministries
§ 48.43.012 Health plans — Preexisting conditions — Rules
§ 48.43.01211 Health plans — Eligibility — Health status-related factors — Rules
§ 48.43.0122 Individual health benefit plans — Open enrollment and special enrollment periods — Rules — Enforcement
§ 48.43.0123 Health plans — Rescission of coverage — Rules
§ 48.43.0124 Health plans — Cost sharing for essential health benefits — Rules
§ 48.43.0125 Essential health benefits — Annual or lifetime dollar limits
§ 48.43.0126 Summary of benefits and explanation of coverage — Standards and requirements — Notice of modification — Fines — Standards for definitions of health insurance terms — Rules
§ 48.43.0127 Group health plans — Waiting period — Rules
§ 48.43.0128 Nongrandfathered health plans and plans issued or renewed on or after January 1, 2022 — Prohibited discrimination — Rules
§ 48.43.016 Utilization management standards and criteria — Health carrier requirements — Definitions
§ 48.43.0161 Prior authorization practices — Carrier annual reporting requirements — Commissioner’s standardized report
§ 48.43.021 Personally identifiable health information — Restrictions on release
§ 48.43.022 Enrollee identification card — Social security number restriction
§ 48.43.023 Pharmacy identification cards — Rules
§ 48.43.028 Eligibility to purchase certain health benefit plans — Small employers and small groups
§ 48.43.035 Group health benefit plans — Guaranteed issue and continuity of coverage — Exceptions
§ 48.43.038 Individual health plans — Guarantee of continuity of coverage — Exceptions
§ 48.43.039 Grace period — Notification or information — Information concerning delinquencies or nonpayment of premiums — Defined
§ 48.43.041 Individual health benefit plans — Mandatory benefits
§ 48.43.043 Colorectal cancer examinations and laboratory tests — Required benefits or coverage
§ 48.43.045 Health plan requirements — Annual reports — Exemptions
§ 48.43.047 Health plans — Minimum coverage for preventative services — No cost-sharing requirements
§ 48.43.049 Health carrier data — Information from annual statement — Format prescribed by commissioner — Public availability
§ 48.43.055 Procedures for review and adjudication of health care provider complaints — Requirements
§ 48.43.059 Payments made by a second-party payment process — Definition
§ 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
§ 48.43.071 Health care information — Requirement to provide free copy to covered person appealing denial of social security benefits — Exceptions
§ 48.43.072 Required reproductive health care coverage — Restrictions on copayments, deductibles, and other form of cost sharing
§ 48.43.0725 Reproductive health plan coverage — Immediate postpartum contraception devices
§ 48.43.073 Required abortion coverage — Limitations
§ 48.43.074 Qualified health plans — Single invoice billing — Certification of compliance required in the segregation plan for premium amounts attributable to coverage of abortion services
§ 48.43.076 Digital breast examinations — Cost sharing
§ 48.43.078 Digital breast tomosynthesis — Intent to ensure women with access — Commissioner’s and health care authority’s duty to clarify mandates
§ 48.43.081 Anatomic pathology services — Payment for services — Definitions
§ 48.43.083 Chiropractor services — Participating provider agreement — Health carrier reimbursement
§ 48.43.085 Health carrier may not prohibit its enrollees from contracting for services outside the health care plan
§ 48.43.087 Contracting for services at enrollee’s expense — Mental health care practitioner — Conditions — Exception
§ 48.43.091 Health carrier coverage of outpatient mental health services — Requirements
§ 48.43.093 Health carrier coverage of emergency medical services — Requirements — Conditions
§ 48.43.094 Pharmacist provided services — Health plan requirements
§ 48.43.096 Medication synchronization policy required for health plans covering prescription drugs — Requirements — Definitions
§ 48.43.0961 Continuity of coverage for health plans covering prescription drugs for behavioral health
§ 48.43.097 Filing of financial statements — Every health carrier
§ 48.43.105 Preparation of documents that compare health carriers — Immunity — Due diligence
§ 48.43.115 Maternity services — Intent — Definitions — Patient preference — Clinical sovereignty of provider — Notice to policyholders — Application
§ 48.43.125 Coverage at a long-term care facility following hospitalization — Definition
§ 48.43.135 Hearing instruments — Coverage
§ 48.43.176 Eosinophilic gastrointestinal associated disorder — Elemental formula
§ 48.43.180 Denturist services
§ 48.43.185 General anesthesia services for dental procedures
§ 48.43.190 Payment of chiropractic services — Parity
§ 48.43.195 Contraceptive drugs — Twelve-month refill coverage
§ 48.43.200 Disclosure of certain material transactions — Report — Information is confidential
§ 48.43.205 Material acquisitions or dispositions
§ 48.43.210 Asset acquisitions — Asset dispositions
§ 48.43.215 Report of a material acquisition or disposition of assets — Information required
§ 48.43.220 Material nonrenewals, cancellations, or revisions of ceded reinsurance agreements
§ 48.43.225 Report of a material nonrenewal, cancellation, or revision of ceded reinsurance agreements — Information required
§ 48.43.290 Coverage for prescribed durable medical equipment and mobility enhancing equipment — Sales and use taxes — Definitions
§ 48.43.300 Definitions
§ 48.43.305 Report of RBC levels — Distribution of report — Formula for determination — Commissioner may make adjustments
§ 48.43.310 Company action level event — Required RBC plan — Commissioner’s review — Notification — Challenge by carrier
§ 48.43.315 Regulatory action level event — Required RBC plan — Commissioner’s review — Notification — Challenge by carrier
§ 48.43.320 Authorized control level event — Commissioner’s options
§ 48.43.325 Mandatory control level event — Commissioner’s duty — Regulatory control
§ 48.43.330 Carrier’s right to hearing — Request by carrier — Date set by commissioner
§ 48.43.335 Confidentiality of RBC reports and plans — Use of certain comparisons prohibited — Certain information intended solely for use by commissioner
§ 48.43.340 Powers or duties of commissioner not limited — Rules
§ 48.43.345 Foreign or alien carriers — Required RBC report — Commissioner may require RBC plan — Mandatory control level event
§ 48.43.350 No liability or cause of action against commissioner or department
§ 48.43.355 Notice by commissioner to carrier — When effective
§ 48.43.360 Initial RBC reports — Calculation of initial RBC levels — Subsequent reports
§ 48.43.366 Self-funded multiple employer welfare arrangements
§ 48.43.370 RBC standards not applicable to certain carriers
§ 48.43.400 Prescription drug utilization management — Definitions
§ 48.43.410 Prescription drug utilization management — Clinical review criteria — Requirement to be evidence-based and updated regularly
§ 48.43.420 Prescription drug utilization management — Exception request process — Conditions, requirements, and time frames for approval or denial of requests — Emergency fill coverage — Notice of new policies and pro
§ 48.43.430 Prescription medication — Maximum charge at point of sale — Requirements
§ 48.43.435 Prescription medication — Cost-sharing calculation — Application — Rules
§ 48.43.500 Intent — Purpose — 2000 c 5
§ 48.43.505 Enrollee’s and protected individual’s right to privacy and confidential services — Health carrier or insurer duties — Requests for confidential communications — Rules
§ 48.43.5051 Requests for confidential communications — Monitoring and ensuring compliance — Standardized form for submission of requests — Rules
§ 48.43.510 Carrier required to disclose health plan information — Marketing and advertising restrictions — Rules
§ 48.43.515 Access to appropriate health services — Enrollee options — Rules
§ 48.43.517 Enrollment of child participating in medical assistance program — Employer-sponsored health plan
§ 48.43.520 Requirement to maintain a documented utilization review program description and written utilization review criteria — Rules
§ 48.43.525 Prohibition against retrospective denial of health plan coverage — Rules
§ 48.43.530 Requirement for carriers to have comprehensive grievance and appeal processes — Carrier’s duties — Procedures — Appeals — Rules
§ 48.43.535 Independent review of health care disputes — System for using certified independent review organizations — Rules
§ 48.43.537 Health care disputes — Certifying independent review organizations — Application — Restrictions — Maximum fee schedule for conducting reviews — Rules
§ 48.43.540 Requirement to designate a licensed medical director — Exemption
§ 48.43.545 Standard of care — Liability — Causes of action — Defense — Exception
§ 48.43.550 Delegation of duties — Carrier accountability
§ 48.43.600 Overpayment recovery — Carrier
§ 48.43.605 Overpayment recovery — Health care provider
§ 48.43.650 Fixed payment insurance products — Commissioner’s annual report
§ 48.43.670 Plan or contract renewal — Modification of wellness program
§ 48.43.680 Lifetime limit on transplants — Definition
§ 48.43.690 Assessments under RCW 70.290.040 considered medical expenses
§ 48.43.700 Exchange — Plans that a carrier must offer — Review — Rules
§ 48.43.705 Plans offered outside of exchange
§ 48.43.710 Certification as qualified health plan not an exemption
§ 48.43.715 Individual and small group market — Selection of benchmark plan — Minimum requirements — Criteria — List of state-mandated health benefits
§ 48.43.720 Reinsurance and risk adjustment programs — Affordable care act — Rules
§ 48.43.725 Exclusion of mandated benefits from health plan — Carrier requirements — Notice — Fees — Commissioner’s duties
§ 48.43.730 Carrier must file provider contracts and compensation agreements with commissioner — Approval or disapproval — Confidentiality — Hearings — Rules — Definitions
§ 48.43.731 Health care benefit management contracts — Carrier filing requirements — Notice to enrollees — Confidentiality of filings
§ 48.43.733 Rates and forms of group health benefit plans — Timing of filings — Exceptions — Rules
§ 48.43.734 Health carrier rate filings — Review of surplus, capital, and profit levels
§ 48.43.735 Reimbursement of health care services provided through telemedicine or store and forward technology — Audio-only telemedicine
§ 48.43.740 Dental only plan — Emergency dental conditions — Definitions
§ 48.43.743 Dental only plan — Annual data statement — Contents — Public use — Definition
§ 48.43.745 Dental only plan — Denturist services
§ 48.43.750 Health care provider credentialing applications — Use of electronic database by health carriers
§ 48.43.755 Health care provider credentialing applications — Use of electronic database by providers
§ 48.43.757 Health care provider credentialing applications — Reimbursement requirements
§ 48.43.760 Opioid use disorder — Coverage without prior authorization
§ 48.43.761 Withdrawal management services — Substance use disorder treatment services — Prior authorization — Utilization review — Medical necessity review
§ 48.43.762 Opioid overdose reversal medication bulk purchasing and distribution program
§ 48.43.765 Health carrier network adequacy — Mental health and substance abuse treatment
§ 48.43.767 Behavioral health services — Network access
§ 48.43.770 Individual market health plan availability — Annual report
§ 48.43.775 Qualified health plan participation — Reimbursement rate for other health plans
§ 48.43.780 Insulin drugs — Cap on enrollee’s required payment amount — Cost-sharing requirements
§ 48.43.785 COVID-19 personal protective equipment expenses — Health care provider reimbursement
§ 48.43.790 Behavioral services — Next-day appointments
§ 48.43.795 Qualified health plans — Acceptance of premium and cost-sharing assistance
§ 48.43.800 Primary care expenditures assessment — Review
§ 48.43.805 Prescription drug upper payment limit — Rules
§ 48.43.810 Biomarker testing — Standards — Construction
§ 48.43.815 Donor human milk — Standards
§ 48.43.820 Consolidated appropriations act enforcement — Implementation of federal regulations
§ 48.43.825 Certified peer specialist services — Network access standards
§ 48.43.830 Prior authorization
§ 48.43.902 Effective date — 1996 c 312
§ 48.43.904 Construction — Chapter applicable to state registered domestic partnerships — 2009 c 521
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Terms Used In Washington Code > Chapter 48.43 - Insurance reform

  • Amendment: A proposal to alter the text of a pending bill or other measure by striking out some of it, by inserting new language, or both. Before an amendment becomes part of the measure, thelegislature must agree to it.
  • Appeal: A request made after a trial, asking another court (usually the court of appeals) to decide whether the trial was conducted properly. To make such a request is "to appeal" or "to take an appeal." One who appeals is called the appellant.
  • Assets: (1) The property comprising the estate of a deceased person, or (2) the property in a trust account.
  • Beneficiary: A person who is entitled to receive the benefits or proceeds of a will, trust, insurance policy, retirement plan, annuity, or other contract. Source: OCC
  • Case law: The law as laid down in cases that have been decided in the decisions of the courts.
  • Complaint: A written statement by the plaintiff stating the wrongs allegedly committed by the defendant.
  • Continuance: Putting off of a hearing ot trial until a later time.
  • Contract: A legal written agreement that becomes binding when signed.
  • Corporation: A legal entity owned by the holders of shares of stock that have been issued, and that can own, receive, and transfer property, and carry on business in its own name.
  • Damages: Money paid by defendants to successful plaintiffs in civil cases to compensate the plaintiffs for their injuries.
  • Dependent: A person dependent for support upon another.
  • Donor: The person who makes a gift.
  • Evidence: Information presented in testimony or in documents that is used to persuade the fact finder (judge or jury) to decide the case for one side or the other.
  • Fraud: Intentional deception resulting in injury to another.
  • Grace period: The number of days you'll have to pay your bill for purchases in full without triggering a finance charge. Source: Federal Reserve
  • Guardian: A person legally empowered and charged with the duty of taking care of and managing the property of another person who because of age, intellect, or health, is incapable of managing his (her) own affairs.
  • Indemnification: In general, a collateral contract or assurance under which one person agrees to secure another person against either anticipated financial losses or potential adverse legal consequences. Source: FDIC
  • Interest rate: The amount paid by a borrower to a lender in exchange for the use of the lender's money for a certain period of time. Interest is paid on loans or on debt instruments, such as notes or bonds, either at regular intervals or as part of a lump sum payment when the issue matures. Source: OCC
  • Jurisdiction: (1) The legal authority of a court to hear and decide a case. Concurrent jurisdiction exists when two courts have simultaneous responsibility for the same case. (2) The geographic area over which the court has authority to decide cases.
  • Lease: A contract transferring the use of property or occupancy of land, space, structures, or equipment in consideration of a payment (e.g., rent). Source: OCC
  • Legal tender: coins, dollar bills, or other currency issued by a government as official money. Source: U.S. Mint
  • Liabilities: The aggregate of all debts and other legal obligations of a particular person or legal entity.
  • Mortgage: The written agreement pledging property to a creditor as collateral for a loan.
  • Obligation: An order placed, contract awarded, service received, or similar transaction during a given period that will require payments during the same or a future period.
  • Oversight: Committee review of the activities of a Federal agency or program.
  • Partnership: A voluntary contract between two or more persons to pool some or all of their assets into a business, with the agreement that there will be a proportional sharing of profits and losses.
  • person: may be construed to include the United States, this state, or any state or territory, or any public or private corporation or limited liability company, as well as an individual. See Washington Code 1.16.080
  • Real property: Land, and all immovable fixtures erected on, growing on, or affixed to the land.
  • Remainder: An interest in property that takes effect in the future at a specified time or after the occurrence of some event, such as the death of a life tenant.
  • Rescission: The cancellation of budget authority previously provided by Congress. The Impoundment Control Act of 1974 specifies that the President may propose to Congress that funds be rescinded. If both Houses have not approved a rescission proposal (by passing legislation) within 45 days of continuous session, any funds being withheld must be made available for obligation.
  • Statute: A law passed by a legislature.
  • Subpoena: A command to a witness to appear and give testimony.
  • Tort: A civil wrong or breach of a duty to another person, as outlined by law. A very common tort is negligent operation of a motor vehicle that results in property damage and personal injury in an automobile accident.
  • Trial: A hearing that takes place when the defendant pleads "not guilty" and witnesses are required to come to court to give evidence.
  • Uphold: The decision of an appellate court not to reverse a lower court decision.