H-2499.1
HOUSE BILL 2285
State of Washington 68th Legislature 2024 Regular Session
By Representatives Riccelli, Schmick, Bronoske, Leavitt, Kloba,
Davis, Ramel, Peterson, Doglio, Ormsby, Fosse, Pollet, Simmons, and
Macri
Read first time 01/10/24. Referred to Committee on Health Care &
Wellness.
1 AN ACT Relating to protecting consumers from charges for out-of-
2 network health care services by prohibiting balance billing for
3 ground ambulance services and addressing coverage of transports to
4 treatment for emergency medical conditions; amending RCW 48.43.005,
5 48.49.003, 48.49.060, 48.49.070, 48.49.090, 48.49.100, and 48.49.130;
6 adding new sections to chapter 48.49 RCW; adding new sections to
7 chapter 18.73 RCW; adding a new section to chapter 48.43 RCW;
8 creating a new section; and repealing RCW 48.49.190.
9 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF WASHINGTON:
10 Sec. 1. RCW 48.43.005 and 2023 c 433 s 20 are each amended to
11 read as follows:
12 Unless otherwise specifically provided, the definitions in this
13 section apply throughout this chapter.
14 (1) "Adjusted community rate" means the rating method used to
15 establish the premium for health plans adjusted to reflect
16 actuarially demonstrated differences in utilization or cost
17 attributable to geographic region, age, family size, and use of
18 wellness activities.
19 (2) "Adverse benefit determination" means a denial, reduction, or
20 termination of, or a failure to provide or make payment, in whole or
21 in part, for a benefit, including a denial, reduction, termination,
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 1 or failure to provide or make payment that is based on a
2 determination of an enrollee's or applicant's eligibility to
3 participate in a plan, and including, with respect to group health
4 plans, a denial, reduction, or termination of, or a failure to
5 provide or make payment, in whole or in part, for a benefit resulting
6 from the application of any utilization review, as well as a failure
7 to cover an item or service for which benefits are otherwise provided
8 because it is determined to be experimental or investigational or not
9 medically necessary or appropriate.
10 (3) "Air ambulance service" has the same meaning as defined in
11 section 2799A-2 of the public health service act (42 U.S.C. Sec.
12 300gg-112) and implementing federal regulations in effect on March
13 31, 2022.
14 (4) "Allowed amount" means the maximum portion of a billed charge
15 a health carrier will pay, including any applicable enrollee cost-
16 sharing responsibility, for a covered health care service or item
17 rendered by a participating provider or facility or by a
18 nonparticipating provider or facility.
19 (5) "Applicant" means a person who applies for enrollment in an
20 individual health plan as the subscriber or an enrollee, or the
21 dependent or spouse of a subscriber or enrollee.
22 (6) "Balance bill" means a bill sent to an enrollee by a
23 nonparticipating provider or facility for health care services
24 provided to the enrollee after the provider or facility's billed
25 amount is not fully reimbursed by the carrier, exclusive of permitted
26 cost-sharing.
27 (7) "Basic health plan" means the plan described under chapter
28 70.47 RCW, as revised from time to time.
29 (8) "Basic health plan model plan" means a health plan as
30 required in RCW 70.47.060(2)(e).
31 (9) "Basic health plan services" means that schedule of covered
32 health services, including the description of how those benefits are
33 to be administered, that are required to be delivered to an enrollee
34 under the basic health plan, as revised from time to time.
35 (10) "Behavioral health emergency services provider" means
36 emergency services provided in the following settings:
37 (a) A crisis stabilization unit as defined in RCW 71.05.020;
38 (b) A 23-hour crisis relief center as defined in RCW 71.24.025;
39 (c) An evaluation and treatment facility that can provide
40 directly, or by direct arrangement with other public or private
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 1 agencies, emergency evaluation and treatment, outpatient care, and
2 timely and appropriate inpatient care to persons suffering from a
3 mental disorder, and which is licensed or certified as such by the
4 department of health;
5 (d) An agency certified by the department of health under chapter
6 71.24 RCW to provide outpatient crisis services;
7 (e) An agency certified by the department of health under chapter
8 71.24 RCW to provide medically managed or medically monitored
9 withdrawal management services; or
10 (f) A mobile rapid response crisis team as defined in RCW
11 71.24.025 that is contracted with a behavioral health administrative
12 services organization operating under RCW 71.24.045 to provide crisis
13 response services in the behavioral health administrative services
14 organization's service area.
15 (11) "Board" means the governing board of the Washington health
16 benefit exchange established in chapter 43.71 RCW.
17 (12)(a) For grandfathered health benefit plans issued before
18 January 1, 2014, and renewed thereafter, "catastrophic health plan"
19 means:
20 (i) In the case of a contract, agreement, or policy covering a
21 single enrollee, a health benefit plan requiring a calendar year
22 deductible of, at a minimum, ((one thousand seven hundred fifty
23 dollars)) $1,750 and an annual out-of-pocket expense required to be
24 paid under the plan (other than for premiums) for covered benefits of
25 at least ((three thousand five hundred dollars)) $3,500, both amounts
26 to be adjusted annually by the insurance commissioner; and
27 (ii) In the case of a contract, agreement, or policy covering
28 more than one enrollee, a health benefit plan requiring a calendar
29 year deductible of, at a minimum, ((three thousand five hundred
30 dollars)) $3,500 and an annual out-of-pocket expense required to be
31 paid under the plan (other than for premiums) for covered benefits of
32 at least ((six thousand dollars)) $6,000, both amounts to be adjusted
33 annually by the insurance commissioner.
34 (b) In July 2008, and in each July thereafter, the insurance
35 commissioner shall adjust the minimum deductible and out-of-pocket
36 expense required for a plan to qualify as a catastrophic plan to
37 reflect the percentage change in the consumer price index for medical
38 care for a preceding ((twelve)) 12 months, as determined by the
39 United States department of labor. For a plan year beginning in 2014,
40 the out-of-pocket limits must be adjusted as specified in section
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 1 1302(c)(1) of P.L. 111-148 of 2010, as amended. The adjusted amount
2 shall apply on the following January 1st.
3 (c) For health benefit plans issued on or after January 1, 2014,
4 "catastrophic health plan" means:
5 (i) A health benefit plan that meets the definition of
6 catastrophic plan set forth in section 1302(e) of P.L. 111-148 of
7 2010, as amended; or
8 (ii) A health benefit plan offered outside the exchange
9 marketplace that requires a calendar year deductible or out-of-pocket
10 expenses under the plan, other than for premiums, for covered
11 benefits, that meets or exceeds the commissioner's annual adjustment
12 under (b) of this subsection.
13 (13) "Certification" means a determination by a review
14 organization that an admission, extension of stay, or other health
15 care service or procedure has been reviewed and, based on the
16 information provided, meets the clinical requirements for medical
17 necessity, appropriateness, level of care, or effectiveness under the
18 auspices of the applicable health benefit plan.
19 (14) "Concurrent review" means utilization review conducted
20 during a patient's hospital stay or course of treatment.
21 (15) "Covered person" or "enrollee" means a person covered by a
22 health plan including an enrollee, subscriber, policyholder,
23 beneficiary of a group plan, or individual covered by any other
24 health plan.
25 (16) "Dependent" means, at a minimum, the enrollee's legal spouse
26 and dependent children who qualify for coverage under the enrollee's
27 health benefit plan.
28 (17) "Emergency medical condition" means a medical, mental
29 health, or substance use disorder condition manifesting itself by
30 acute symptoms of sufficient severity including, but not limited to,
31 severe pain or emotional distress, such that a prudent layperson, who
32 possesses an average knowledge of health and medicine, could
33 reasonably expect the absence of immediate medical, mental health, or
34 substance use disorder treatment attention to result in a condition
35 (a) placing the health of the individual, or with respect to a
36 pregnant woman, the health of the woman or her unborn child, in
37 serious jeopardy, (b) serious impairment to bodily functions, or (c)
38 serious dysfunction of any bodily organ or part.
39 (18) "Emergency services" means:
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 1 (a)(i) A medical screening examination, as required under section
2 1867 of the social security act (42 U.S.C. Sec. 1395dd), that is
3 within the capability of the emergency department of a hospital,
4 including ancillary services routinely available to the emergency
5 department to evaluate that emergency medical condition;
6 (ii) Medical examination and treatment, to the extent they are
7 within the capabilities of the staff and facilities available at the
8 hospital, as are required under section 1867 of the social security
9 act (42 U.S.C. Sec. 1395dd) to stabilize the patient. Stabilize, with
10 respect to an emergency medical condition, has the meaning given in
11 section 1867(e)(3) of the social security act (42 U.S.C. Sec.
12 1395dd(e)(3)); and
13 (iii) Covered services provided by staff or facilities of a
14 hospital after the enrollee is stabilized and as part of outpatient
15 observation or an inpatient or outpatient stay with respect to the
16 visit during which screening and stabilization services have been
17 furnished. Poststabilization services relate to medical, mental
18 health, or substance use disorder treatment necessary in the short
19 term to avoid placing the health of the individual, or with respect
20 to a pregnant woman, the health of the woman or her unborn child, in
21 serious jeopardy, serious impairment to bodily functions, or serious
22 dysfunction of any bodily organ or part; or
23 (b)(i) A screening examination that is within the capability of a
24 behavioral health emergency services provider including ancillary
25 services routinely available to the behavioral health emergency
26 services provider to evaluate that emergency medical condition;
27 (ii) Examination and treatment, to the extent they are within the
28 capabilities of the staff and facilities available at the behavioral
29 health emergency services provider, as are required under section
30 1867 of the social security act (42 U.S.C. Sec. 1395dd) or as would
31 be required under such section if such section applied to behavioral
32 health emergency services providers, to stabilize the patient.
33 Stabilize, with respect to an emergency medical condition, has the
34 meaning given in section 1867(e)(3) of the social security act (42
35 U.S.C. Sec. 1395dd(e)(3)); and
36 (iii) Covered behavioral health services provided by staff or
37 facilities of a behavioral health emergency services provider after
38 the enrollee is stabilized and as part of outpatient observation or
39 an inpatient or outpatient stay with respect to the visit during
40 which screening and stabilization services have been furnished.
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 1 Poststabilization services relate to mental health or substance use
2 disorder treatment necessary in the short term to avoid placing the
3 health of the individual, or with respect to a pregnant woman, the
4 health of the woman or her unborn child, in serious jeopardy, serious
5 impairment to bodily functions, or serious dysfunction of any bodily
6 organ or part.
7 (19) "Employee" has the same meaning given to the term, as of
8 January 1, 2008, under section 3(6) of the federal employee
9 retirement income security act of 1974.
10 (20) "Enrollee point-of-service cost-sharing" or "cost-sharing"
11 means amounts paid to health carriers directly providing services,
12 health care providers, or health care facilities by enrollees and may
13 include copayments, coinsurance, or deductibles.
14 (21) "Essential health benefit categories" means:
15 (a) Ambulatory patient services;
16 (b) Emergency services;
17 (c) Hospitalization;
18 (d) Maternity and newborn care;
19 (e) Mental health and substance use disorder services, including
20 behavioral health treatment;
21 (f) Prescription drugs;
22 (g) Rehabilitative and habilitative services and devices;
23 (h) Laboratory services;
24 (i) Preventive and wellness services and chronic disease
25 management; and
26 (j) Pediatric services, including oral and vision care.
27 (22) "Exchange" means the Washington health benefit exchange
28 established under chapter 43.71 RCW.
29 (23) "Final external review decision" means a determination by an
30 independent review organization at the conclusion of an external
31 review.
32 (24) "Final internal adverse benefit determination" means an
33 adverse benefit determination that has been upheld by a health plan
34 or carrier at the completion of the internal appeals process, or an
35 adverse benefit determination with respect to which the internal
36 appeals process has been exhausted under the exhaustion rules
37 described in RCW 48.43.530 and 48.43.535.
38 (25) "Grandfathered health plan" means a group health plan or an
39 individual health plan that under section 1251 of the patient
40 protection and affordable care act, P.L. 111-148 (2010) and as
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 1 amended by the health care and education reconciliation act, P.L.
2 111-152 (2010) is not subject to subtitles A or C of the act as
3 amended.
4 (26) "Grievance" means a written complaint submitted by or on
5 behalf of a covered person regarding service delivery issues other
6 than denial of payment for medical services or nonprovision of
7 medical services, including dissatisfaction with medical care,
8 waiting time for medical services, provider or staff attitude or
9 demeanor, or dissatisfaction with service provided by the health
10 carrier.
11 (27) "Ground ambulance services" means:
12 (a) The rendering of medical treatment and care at the scene of a
13 medical emergency or while transporting a patient to an appropriate
14 emergency services provider when the services are provided by one or
15 more ground ambulance vehicles designed for this purpose; and
16 (b) Ground ambulance transport between emergency services
17 providers, emergency services providers and medical facilities, and
18 between medical facilities when the services are medically necessary
19 and are provided by one or more ground ambulance vehicles designed
20 for this purpose.
21 (28) "Ground ambulance services organization" means a public or
22 private organization licensed by the department of health under
23 chapter 18.73 RCW to provide ground ambulance services. For purposes
24 of this chapter, ground ambulance services organizations are not
25 considered providers.
26 (29) "Health care facility" or "facility" means hospices licensed
27 under chapter 70.127 RCW, hospitals licensed under chapter 70.41 RCW,
28 rural health care facilities as defined in RCW 70.175.020,
29 psychiatric hospitals licensed under chapter 71.12 RCW, nursing homes
30 licensed under chapter 18.51 RCW, community mental health centers
31 licensed under chapter 71.05 or 71.24 RCW, kidney disease treatment
32 centers licensed under chapter 70.41 RCW, ambulatory diagnostic,
33 treatment, or surgical facilities licensed under chapter 70.41 or
34 70.230 RCW, drug and alcohol treatment facilities licensed under
35 chapter 70.96A RCW, and home health agencies licensed under chapter
36 70.127 RCW, and includes such facilities if owned and operated by a
37 political subdivision or instrumentality of the state and such other
38 facilities as required by federal law and implementing regulations.
39 (((28))) (30) "Health care provider" or "provider" means:
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 1 (a) A person regulated under Title 18 or chapter 70.127 RCW, to
2 practice health or health-related services or otherwise practicing
3 health care services in this state consistent with state law; or
4 (b) An employee or agent of a person described in (a) of this
5 subsection, acting in the course and scope of his or her employment.
6 (((29))) (31) "Health care service" means that service offered or
7 provided by health care facilities and health care providers relating
8 to the prevention, cure, or treatment of illness, injury, or disease.
9 (((30))) (32) "Health carrier" or "carrier" means a disability
10 insurer regulated under chapter 48.20 or