Health Insurance Benefit Coverage Law Summaries
Washington, Health Insurance Benefit Coverage Law Summaries
Washington's mandated health care law is located in the Annotated Revised Code of Washington at Title 48, Chapter 48.21. Coordination of benefits provisions are located in the Washington Administrative Code at Title 284.
DEFINITIONS
“Small employer” means any person, firm, corporation, partnership, association, political subdivision, sole proprietor, or self-employed individual that is actively engaged in business that employed an average of at least two but no more than 50 employees, during the previous calendar year and employed at least two employees on the first day of the plan year, is not formed primarily for purposes of buying health insurance, and in which a bona fide employer-employee relationship exists. In determining the number of employees, companies that are affiliated companies, or that are eligible to file a combined tax return for purposes of taxation by Washington, will be considered an employer. Subsequent to the issuance of a health plan to a small employer and for the purpose of determining eligibility, the size of a small employer will be determined annually. Except as otherwise specifically provided, a small employer will continue to be considered a small employer until the plan anniversary following the date the small employer no longer meets the requirements of this definition. A self-employed individual or sole proprietor who is covered as a group of one on the day prior to June 10, 2004, shall also be considered a “small employer” to the extent that individual or group of one is entitled to have his or her coverage renewed as provided in RCW 48.43.035(6) (Sec. 48.43.005(24), as amended by H. 2560, L. 2007, enacted March 25, 2008).
COVERAGE
Drug-related injuries.- Insurers, health care service contractors and health maintenance organizations may not deny coverage for the treatment of an injury solely because the injury was sustained as a consequence of the insured's being intoxicated or under the influence of a narcotic (Ch. 112 (H. 2014), L. 2004, adding new sections to chapters 48.20, 48.21, 48.44 and 48.46, effective June 10, 2004).
WHAT THE EMPLOYER MUST DO
Washington does not require employers to provide health insurance for their employees. However, if an employer does provide insurance, it must be aware of specific coverage required to be included in health insurance policies and contracts. This coverage is summarized below.
Mental health coverage.- Each group insurer providing disability insurance coverage in Washington for hospital or medical care under contracts that are issued, delivered, or renewed in Washington, must offer optional supplemental coverage for mental health treatment for the insured and the insured's covered dependents (Sec. 48.21.240).
Benefits must be provided under the optional supplemental coverage for mental health treatment whether treatment is rendered by a physician, psychologist, community mental health agency, or state hospital. The treatment must be covered at the usual and customary rates for such treatment (Sec. 48.21.240).
Such coverage need not be provided by a group disability insurance contract that has been entered into in accordance with a collective bargaining agreement between management and labor representatives prior to March 1, 1987 (Sec. 48.21.240).
Every health carrier that provides coverage for any outpatient mental health service must comply with the following requirements (Sec. 1, Ch. 87 (S. 5313), L. 1999, effective July 25, 1999):
in performing a utilization review of mental health services for a specific enrollee, the utilization review is limited to accessing only the specific health care information contained in the enrollee's record.
in performing an audit of a provider that has furnished mental health services to a carrier's enrollees, the audit is limited to accessing only the records of enrollees covered by the specific health carrier for which the audit is being performed, except as otherwise permitted by Washington law.
Dependent care coverage.- Any group disability insurance contract, other than a blanket disability insurance contract, providing hospital and medical expenses and health care services, that is renewed, delivered or issued for delivery in Washington, and that provides coverage for the dependent children of persons in the insured group, must provide coverage for newborn infant children of persons in the insured group from and after the moment of birth. Coverage must include, but is not limited to, coverage for congenital anomalies of such infant children from the moment of birth (Sec. 48.21.155).
If payment of an additional premium is required to provide coverage for a child, the contract may require that notification of birth of a newly born child and payment of the required premium must be furnished to the insurer. The notification period must be no less than 60 days from the date of birth (Sec. 48.21.155).
Effective January 1, 2009, any group disability insurance contract or health care service plan contract or health maintenance agreement that provides coverage for a participating member's dependent must offer each participating member the option of covering any unmarried dependent under the age of 25 who is a qualifying child or qualifying relative under Sec. 152 of the Internal Revenue Code (Secs. 48.21.157; 48.44.215).
Disabilities.- Any group disability insurance contract or blanket disability insurance contract providing health care services which is delivered or issued for delivery in Washington and which provides that coverage of a dependent child of an employee or other member of the covered group terminates upon attainment of the limiting age for dependent children specified in the contract must also provide in substance that attainment of such limiting age will not operate to terminate the coverage of such child while the child is and continues to be both incapable of self-sustaining employment by reason of developmental disability or physical disability and chiefly dependent upon the employee or member for support and maintenance (Sec. 48.21.150).
Prenatal testing.- Every group disability contract entered into or renewed that covers hospital, medical, or surgical expenses on a group basis, and that provides benefits for pregnancy, childbirth, or related medical conditions to enrollees of such groups, must offer benefits for prenatal diagnosis of congenital disorders of the fetus by means of screening and diagnostic procedures during pregnancy to such enrollees when those services are determined to be medically necessary by the disability contractor (Sec. 48.21.244).
Substance abuse coverage.- Each group disability insurance contract that insures for hospital or medical care must contain provisions providing benefits for the treatment of chemical dependency rendered to the insured by a provider that is an approved treatment facility or program (Sec. 48.21.180).
Exceptions.- Chemical dependency benefits need not be provided by contracts that provide only accident coverage, nor by any contract written as supplemental coverage to any federal or state programs of health care including (Sec. 48.44.240).
Coordination of benefits.- An employer or the insurer, managed care plan, or third-party administrator that manages a health benefit plan for an employer may share the payment of expenses with another benefit plan sponsored by another employer, with the government through Medicare benefits, or with another type of insurance company through automobile or homeowners' insurance (subrogation). To determine which plan has primary responsibility for payment, coordination of benefits (COB) language specifies the order of benefit payments. Preserving cost management initiatives, such as deductibles and coinsurance, is known as maintenance of benefits. The National Association of Insurance Commissioners (NAIC) has established model guidelines for COB which many states apply to insurance companies, HMOs, or other health care benefit providers. Self-insured employee benefit plans are not required to adopt coordination of benefits language; however, most self-insured health plans do specify how they will coordinate benefit payments with other plans.
Group and individual disability insurance plans must specify how benefits will be coordinated. The following plans may specify how benefits will be coordinated: individual and group health care service contracts and HMO agreements whose hospital, medical, or surgical benefits may be reduced because of other existing coverage (Washington Administrative Code Title 284, Ch. 51, Secs. 010-185).
Order of benefits.- The following priority applies when coordinating health benefit payments (Washington Administrative Code Sec. 284-51-075):
Employee/Dependent: Benefits will be paid first by a health benefit plan, HMO, or health insurance policy that covers the individual as an employee, subscriber, or member before a plan or policy that covers the individual as a dependent;
Dependent Child/Birthday Rule: For a dependent child whose parents are not separated or divorced and who is covered by two health benefit plans, HMOs, or health insurance policies, benefits will be paid first by the plan that covers the parent whose birthday month and day is earlier in the calendar year. If only one plan specifies the birthday rule, benefits will be paid first according to the order of benefits specified in the plan without the birthday rule;
Dependent Child/Divorced or Separated Parents: For a dependent child whose parents are separated or divorced and who is covered by two health benefit plans, HMOs, or health insurance policies, benefits will be paid first by the plan that covers the custodial parent, second by the plan of the spouse of the custodial parent, and third by the plan of the noncustodial parent. If a court decree states that one of the parents is responsible for health care expenses of the child, benefits will be paid first by the plan of that parent;
Active/Inactive Employee: Benefits will be paid first by a health benefit plan, HMO, or health insurance policy that covers the individual as an employee who is neither laid off or retired or as that person's dependent before a plan or policy that covers the individual as a laid-off or retired employee or dependent. If only one of the two plans specifies this rule, this standard is ignored; and
Longer/Shorter Length of Coverage: Benefits will be paid first by a health benefit plan, HMO, or health insurance policy that has covered the individual as an employee, subscriber, or member for a longer period of time before a plan or policy that covered the individual for a shorter period of time.
Maintenance of benefits.- No health contract may reduce total benefits payable for preventive care to less than 100 percent of total allowable expenses. For benefits other than preventive care, no health contract may reduce total benefits payable to less than 100 percent of total allowable expenses exclusive of copayments, deductibles, and similar cost sharing arrangements (Washington Administrative Code Sec. 284-51-015).
Required language.- Each certificate of coverage that provides for coordination of benefits must contain at least a summary description of the coordination provision and a statement such as “If you have other coverage besides ours, we recommend that you submit your claim to us and to each other insurer at the same time. In that way, the proper coordinated benefits may be most quickly determined and paid.” (Washington Administrative Code Sec. 284-51-150)
Providers.-Chiropodists.- A group disability insurance contract or blanket disability insurance contract must not deny benefits for any medical or surgical service performed by a holder of a licensed chiropodist, provided that the service performed was within the lawful scope of such person's license and such contract would have provided benefits if such service had been performed by a physician (Sec. 48.21.130).
Optometrists.- A group disability insurance contract or blanket disability insurance contract may not deny benefits for any eye care service rendered by a holder of a licensed optometrist, provided that (1) the service rendered was within the lawful scope of such person's license, and such contract would have provided the benefits for such service if rendered by a physician (Sec. 48.21.140).
Nurses.- A group disability insurance contract or blanket disability insurance contract may not deny benefits for any health service performed by a holder of a license for registered nursing practice or advanced registered nursing practice if the service performed was within the lawful scope of such person's license and such contract would have provided benefits if such service had been performed by a physician (Sec. 48.21.141).
Chiropractors.- A group disability insurance contract or blanket disability insurance contract may not deny benefits for any health service performed by a holder of a licensed chiropractor if the service performed was within the lawful scope of such person's license and such contract would have provided benefits if such service had been performed by a physician (Sec. 48.21.142).
Psychologists.- A group disability insurance contract or blanket disability insurance contract may not deny benefits for any psychological service rendered by a psychologist, provided that the service rendered was within the lawful scope of such person's license and such contract would have provided the benefits for such service if rendered by a physician (Sec. 48.21.144).
Dentists.- A group disability insurance contract or blanket disability insurance contract may not deny benefits for any health service performed by a holder of a licensed dentist if the service performed was within the lawful scope of such person's license, and such contract would have provided benefits if such service had been performed by a physician (Sec. 48.21.146).
Mammograms.- Each group disability insurance policy that provides coverage for hospital or medical expenses must provide coverage for screening or diagnostic mammography services, provided that such services are delivered upon the recommendation of the patient's physician, advanced registered nurse practitioner or physician assistant (Sec. 48.21.225).
Exceptions.- Coverage for screening mammography need not be provided by Medicare supplement policies or supplemental contracts covering a specified disease or other limited benefits (Sec. 48.21.225).
Mastectomies.- No person engaged in the business of insurance may refuse to issue any contract of insurance or cancel or decline to renew the contract solely because of a mastectomy or lumpectomy performed on the insured or prospective insured more than five years previously. The amount of benefits payable, or any term, rate, condition, or type of coverage may not be restricted, modified, excluded, increased, or reduced solely on the basis of a mastectomy or lumpectomy performed on the insured or prospective insured more than five years previously (Sec. 48.21.235).
Reconstructive surgery.- Each group disability insurance contract that insures for hospital or medical care must provide coverage for reconstructive breast surgery resulting from a mastectomy that resulted from disease, illness, or injury. Coverage must be provided for all stages of one reconstructive breast reduction on the nondiseased breast to make it equal in size with the diseased breast after definitive reconstructive surgery on the diseased breast has been performed (Sec. 48.21.230).
Maternity benefits.- Health carriers that provide coverage for maternity services must permit the attending provider, in consultation with the mother, to make decisions on the length of inpatient stay and follow-up care, rather than making such decisions through contracts or agreements between providers, hospitals, and insurers. These decisions must be based on accepted medical practice. Written notice of this new coverage requirement must be provided to policyholders in the earliest of the next mailing to policyholders, the yearly summary of benefits sent to policyholders, or January 1, 1997 (Sec. 1, Ch. 281, L. 1996).
Prostate cancer screenings.- Each group disability insurance policy issued or renewed after December 31, 2006, that provides coverage for hospital or medical expenses shall provide coverage for prostate coverage for prostate cancer screening, provided that the screening is delivered upon the recommendation of the patient's physician, advanced registered nurse practitioner, or physician assistant (Sec. 3, S. 6188, L. 2005, enacted March 31, 2006).
Colorectal cancer screenings.- Health plans issued or renewed on or after July 1, 2008, must provide benefits or coverage for colorectal cancer examinations and lab tests consistent with the guidelines or recommendations of the U.S. Preventive Services Task Force or the federal Centers for Disease Control and Prevention. Benefits or coverage must be provided (H. 1337, L. 2007):
For any of the colorectal screening examinations and tests in the selected guidelines or recommendations, at a frequency identified in such guidelines or recommendations, as deemed appropriate by the patient's physician after consultation with the patient; and
To a covered individual who is (a) at least 50 years old; or (b) less than 50 years old and at high risk or very high risk for colorectal cancer according to such guidelines or recommendations.
Diabetes.- All group disability insurance contracts and blanket disability insurance contracts providing health care services, issued or renewed after January 1, 1998, shall provide benefits for at least the following services and supplies for persons with diabetes (Sec. 48.21.143, as amended by H. 2460, L. 2003, enacted March 31, 2004):
for group disability insurance contracts and blanket disability insurance contracts that includes coverage for pharmacy services, appropriate and medically necessary equipment and supplies, as prescribed by a health care provider, that includes but is not limited to insulin, syringes, injection aids, blood glucose monitors, test strips for blood glucose monitors, visual reading and urine test strips, insulin pumps and accessories to the pumps, insulin infusion devices, prescriptive oral agents for controlling blood sugar levels, foot care appliances for prevention of complications associated with diabetes, and glucagon emergency kits; and
for all group disability insurance contracts and blanket disability insurance contracts providing health care services, outpatient self-management training and education, including medical nutrition therapy, as ordered by the health care provider. Diabetes outpatient self-management training and education may be provided only by health care providers with expertise in diabetes.
These provisions also apply to health benefit plans and HMOs (Secs. 48.44.315 and 48.46.272, as amended by H. 2460, L. 2003, enacted March 31, 2004).
Domestic abuse victims.- No insurer may deny or refuse to accept an application for insurance, refuse to insure, refuse to renew, cancel, restrict, or otherwise terminate a policy of insurance, or charge a different rate for the same coverage, on the basis that the applicant or insured person is, has been, or may be a victim of domestic abuse (Sec. 1, S. 6565, L. 1998, effective June 11, 1998).
However, insurers may still take action based on loss history or medical condition or for any other reason not otherwise prohibited by this section, any other law, regulation, or rule. Likewise, the provision does not prohibit insurers from investigating claims. However, coverage may be excluded if caused by the intentional or fraudulent acts of any insured (Secs. 2–4, S. 6565, L. 1998, effective June 11, 1998).
Dental care.- Each group health benefit plan that provides coverage for hospital, medical or ambulatory surgery center services must cover general anesthesia services and related facility charges in conjunction with any dental procedure performed in a hospital or ambulatory surgical center if such anesthesia services and related facility charges are medically necessary because the covered person (Sec. 2, H. 1364, L. 2001, effective January 1, 2002):
is under the age of seven, or physically or developmentally disabled, with a dental condition that cannot be safely and effectively treated in a dental office; or
has a medical condition that the person's physician determines would place the person at undue risk if the dental procedure were performed in a dental office. The procedure must be approved by the person's physician.
Each group health benefit plan or group dental plan that provides coverage for dental services must cover medically necessary general anesthesia services in conjunction with any covered dental procedure performed in a dental office if the general anesthesia services are medically necessary because the covered person is under the age of seven or physically or developmentally disabled (Sec. 2, H. 1364, L. 2001, effective January 1, 2002).
Home health care benefits.- Every insurer entering into or renewing group or blanket disability insurance policies must offer optional coverage for home health care for persons who are homebound and would otherwise require hospitalization. Such optional coverage need only be offered in conjunction with a policy that provides payment for hospitalization as a part of health care coverage (Sec. 48.21.220).
The coverage must provide benefits for, and restrict benefits to, services rendered by home health agencies licensed by the Department of Social and Health Services. Home health care coverage must provide benefits for a minimum of 130 health care visits per calendar year (Sec. 48.21.220).
Hospice services.- Every insurer entering into or renewing group or blanket disability insurance policies must offer optional coverage for hospice care for persons who are homebound and would otherwise require hospitalization. Such optional coverage need only be offered in conjunction with a policy that provides payment for hospitalization as a part of health care coverage (Sec. 48.21.220).
The coverage must provide benefits for, and restrict benefits to, services rendered by hospice agencies licensed by the Department of Social and Health Services. Hospice care coverage must provide benefits for terminally ill patients for an initial period of care of not less than six months and may provide benefits for an additional six months of care in cases where the patient is facing imminent death or is entering remission if certified in writing by the attending physician (Sec. 48.21.220).
Organ transplants.- For health benefit plans issued or renewed on or after January 1, 2010, health carriers must reduce any organ transplant waiting period by the amount of time a covered person had prior creditable coverage. Credible coverage has the same meaning as under the federal Health Insurance Portability and Accountability Act (HIPAA), and also includes coverage that terminated during the period beginning 90 days and ending 64 days before the date of application for the new plan if that coverage would otherwise have qualified as credible coverage under HIPAA. Benefits are subject to all other plan terms and conditions, including coinsurance, deductibles and copayments (Ch. 82 (H. 1308), L. 2009, enacted April 13, 2009).
Small employers.- An insurer, HMO, or health care services contractor offering any health benefit plan to a small employer, either directly or through an association or member-governed group formed specifically for the purpose of purchasing health care, may offer and actively market to the small employer a health benefit plan featuring a limited schedule of covered health care services. A small employer may purchase other health benefit plans that may have more comprehensive benefits than those included in the product offered under this subsection (Secs. 48.21.045(1); 48.44.023(1); and 48.46.066(1), as amended by H. 2460, L. 2003, enacted March 31, 2004).
Except as provided below, requirements used by an insurer, health maintenance organization, or health care services contractor in determining whether to provide coverage to a small employer must be applied uniformly among all small employers applying for coverage or receiving coverage from the carrier (Secs. 48.21.045(5)(a); 48.44.023(5)(a); and 48.46.066(5)(a), as amended by H. 2460, L. 2003, enacted March 31, 2004).
An insurer, health maintenance organization, or health care services contractor must not require a minimum participation level greater than (a) 100 percent of eligible employees working for groups with three or less employees; and (b) 75 percent of eligible employees working for groups with more than three employees (Secs. 48.21.045(5)(b); 48.44.023(5)(b); and 48.46.066(5)(b), as amended by H. 2460, L. 2003, enacted March 31, 2004).
An insurer, health maintenance organization, or health care services contractor may not increase any requirement for minimum employee participation or modify any requirement for minimum employer contribution applicable to a small employer at any time after the small employer has been accepted for coverage (Secs. 48.21.045(5)(d); 48.44.023(5)(d); and 48.46.066(5)(d), as amended by H. 2460, L. 2003, enacted March 31, 2004).
An insurer, health maintenance organization, or health care services contractor must offer coverage to all eligible employees of a small employer and their dependents. Coverage may not be offered to only certain individuals or dependents in a small employer group or to only part of the group. An insurer, HMO, or contractor may not modify a health plan with respect to a small employer or any eligible employee or dependent, through riders, endorsements or otherwise, to restrict or exclude coverage or benefits for specific diseases, medical conditions, or services otherwise covered by the plan (Secs. 48.21.045(6); 48.44.023(6); and 48.46.066(6), as amended by H. 2460, L. 2003, enacted March 31, 2004).
Medical use of marijuana.- Washington has a medical use of marijuana law. However, the law does not require any health insurance provider to be liable for any claim for reimbursement for the medical use of marijuana (Sec. 69.51A.060).
Note: The U.S. Supreme Court, in Gonzales v. Raich, Dkt. No. 03-1454, June 6, 2005, ruled that federal authorities legally may prosecute persons using marijuana under state medical marijuana laws that allow such use.
Social security numbers.- A health carrier that issues a card identifying a person as an enrollee, and requires the person to present the card to providers for purposes of claims processing, may not display on the card an identification number that includes more than a four-digit portion of the person's complete social security number. This also applies to managed health care systems (S. 6494, L. 2003).
Health care information.- A patient may authorize a health care provider or health care facility to disclose the patient's health care information. When an authorization permits the disclosure of health care information to an employer of the patient for purposes other than payment, the authorization as it pertains to the disclosure shall expire 90 days after the signing of the authorization, unless the authorization is renewed by the patient (Sec. 70.02.030, as amended by Ch. 468 (S. 5158), L. 2005).
Domestic partnerships.- The state has enacted a domestic partnership law for (1) same-sex couples and (2) different-sex couples in which either or both of the partners is at least 62 years of age. The law creates a state domestic partnership registry within the secretary of state's office. To enter into a state registered domestic partnership, the two persons involved must meet the following requirements (S. 5336, L. 2007, enacted April 21, 2007):
Both persons share a common residence;
Both persons are at least 18 years of age;
Neither person is married to someone other than the party to the domestic partnership and neither person is in a state registered domestic partnership with another person;
Both persons are capable of consenting to the domestic partnership;
Both of the following are true: (a) the persons are not nearer of kin to each other than second cousins, whether of the whole or half blood computing by the rules of the civil law; and (b) neither person is a sibling, child, grandchild, aunt, uncle, niece, or nephew to the other person; and
Either (a) both persons are members of the same sex; or (b) at least one of the persons is 62 years of age or older.
Two persons desiring to become state registered domestic partners who meet the requirements set out just above may register their domestic partnership by filing a declaration of state registered domestic partnership with the secretary of state (S. 5336, L. 2007, enacted April 21, 2007).
A domestic partnership created by a subdivision of the state is not a state registered domestic partnership for the purposes of a state registered domestic partnership under this chapter. Those persons desiring to become state registered domestic partners under this chapter must register as described just above (S. 5336, L. 2007, enacted April 21, 2007).
A subdivision of the state that provides benefits to the domestic partners of its employees and chooses to use the definition of state registered domestic partner as set forth in Sec. 2 of S. 5336, L. 2007 (i.e., two adults who meet the requirements for a valid state registered domestic partnership as described above and who have been issued a certificate of state registered domestic partnership by the secretary) must allow the certificate issued by the secretary of state to satisfy any registration requirements of the subdivision. A subdivision that uses the definition of state registered domestic partner as described in the preceding sentence shall notify the secretary of state. The secretary of state shall compile and maintain a list of all subdivisions that have filed such notice. The secretary of state shall post this list on the secretary's web page and provide a copy of the list to each person that receives a certificate of state registered domestic partnership (S. 5336, L. 2007, enacted April 21, 2007).
A certificate of domestic partnership issued to a couple of the same sex as described above shall be recognized as evidence of a qualified same sex domestic partnership fulfilling all necessary eligibility criteria for the partner of the employee to receive benefits (Sec. 9, S. 5336, L. 2007, enacted April 21, 2007).
The Public Employees' Benefits Board shall design benefits and determine the terms and conditions of employee and retired employee participation and coverage, including establishment of eligibility criteria subject to the requirements of Sec. 9, S. 5336, L. 2007 (just above). The same terms and conditions of participation and coverage, including eligibility criteria, shall apply to state employees and to school district employees and educational service district employees (Sec. 41.05.065, as amended by S. 5336, L. 2007, enacted April 21, 2007).
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