S-1006.1
SENATE BILL 5601
State of Washington | 66th Legislature | 2019 Regular Session |
BySenators Rolfes, Short, Keiser, Liias, Kuderer, Walsh, Hobbs, King, Warnick, Honeyford, and Conway
Read first time 01/24/19.Referred to Committee on Health & Long Term Care.
AN ACT Relating to health care benefit management; amending RCW
19.340.010,
48.02.120,
19.340.100,
19.340.020,
19.340.070,
19.340.080,
19.340.090, and
48.02.220; adding a new section to chapter
42.56 RCW; adding a new chapter to Title
48 RCW; creating new sections; recodifying RCW
19.340.010,
19.340.020,
19.340.040,
19.340.050,
19.340.060,
19.340.070,
19.340.080,
19.340.090,
19.340.100, and
19.340.110; repealing RCW
19.340.030 and
19.365.010; and providing an effective date.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF WASHINGTON:
NEW SECTION. Sec. 1. The legislature finds that growth in managed health care systems has shifted substantial authority over health care decisions from providers and patients to health carriers and benefit managers. Benefit managers acting as intermediaries between carriers, health care providers, and patients exercise broad discretion to affect health care services recommended and delivered by providers and the health care choices of patients. Regularly, these benefit managers are making care decisions on behalf of carriers and their decision makers routinely live outside of Washington and may not hold any Washington health care provider license. Benefit managers do not function as carriers. Therefore, it is in the best interest of the public to create a separate chapter for benefit managers.
The legislature intends to protect and promote the health, safety, and welfare of Washington residents by establishing standards for regulatory oversight of benefit managers.
Sec. 2. RCW
19.340.010 and 2016 c 210 s 3 are each amended to read as follows:
The definitions in this section apply throughout this chapter unless the context clearly requires otherwise.
(1)
"Certification" has the same meaning as in RCW 48.43.005.(2) "Claim" means a request from a pharmacy or pharmacist to be reimbursed for the cost of filling or refilling a prescription for a drug or for providing a medical supply or service.
((
(2) "Commissioner" means the insurance commissioner established in chapter 48.02 RCW.))
(3)
"Concurrent review" has the same meaning as in RCW 48.43.005.(4) "Health care benefit manager" means any person or entity providing service to, or acting on behalf of, a health carrier, a public employee benefit program, or a school employee benefit program, including a pharmacy benefit manager or a radiology benefit manager, that directly or indirectly impacts the determination or utilization of benefits for, or patient access to, health care services, drugs, and supplies including, but not limited to:
(a) Prior authorization or preauthorization of benefits or care;
(b) Certification of benefits or care;
(c) Medical necessity determinations;
(d) Utilization review;
(e) Benefit determinations;
(f) Claims processing and repricing;
(g) Provider credentialing and recredentialing;
(h) Dispute resolution, grievances, or appeals relating to determinations; and
(i) Provider network management.
(5) "Health care provider" or "provider" has the same meaning as in RCW 48.43.005. (6) "Health care service" has the same meaning as in RCW 48.43.005. (7) "Health carrier" or "carrier" has the same meaning as in RCW 48.43.005. (8) "Insurer" has the same meaning as in RCW
48.01.050.
(((4)))(9) "Network" means the group of participating providers, pharmacies, and suppliers providing health care services, drugs, or supplies to beneficiaries of a particular carrier or program benefit plan.
(10) "Person" includes, as applicable, natural persons, licensed health care providers, carriers, corporations, companies, trusts, unincorporated associations, and partnerships.
(11) "Pharmacist" has the same meaning as in RCW
18.64.011.
((
(5)))
(12) "Pharmacy" has the same meaning as in RCW
18.64.011.
((
(6)))
(13)(a) "Pharmacy benefit manager" means a person ((
that contracts with pharmacies on behalf of an insurer, a third-party payor, or the prescription drug purchasing consortium established under RCW 70.14.060 to))
providing service to, or acting on behalf of, a health carrier, a public employee benefit program, or a school employee benefit program, that directly or indirectly impacts the determination or utilization of benefits for, or patient access to, pharmacy benefits including but not limited to:
(i) ((Process))Processing claims for prescription drugs or medical supplies or ((provide))providing retail network management for pharmacies or pharmacists;
(ii) ((Pay))Payment or payment authorization to pharmacies or pharmacists for prescription drugs or medical supplies; or
(iii) ((Negotiate))Negotiation of rebates with manufacturers for drugs paid for or procured ((as described in this subsection))directly or indirectly on behalf of a health carrier or a state agency.
(b) "Pharmacy benefit manager" does not include a health care service contractor as defined in RCW
48.44.010, a health maintenance organization as defined in RCW 48.46.020, or an issuer as defined in RCW 48.01.053.
(((7)))(14)(a) "Radiology benefit manager" means any person or entity providing service to, or acting on behalf of, a health carrier, a public employee benefit program, or a school employee benefit program, that directly or indirectly impacts the determination or utilization of benefits for, or patient access to, the services of a licensed radiologist or to advanced diagnostic imaging services including but not limited to:
(i) Processing claims for services and procedures performed by a licensed radiologist or advanced diagnostic imaging service provider; or
(ii) Payment or payment authorization to radiology clinics, radiologists, or advanced diagnostic imaging service providers for services or procedures.
(b) "Radiology benefit manager" does not include a health care service contractor as defined in RCW 48.44.010, a health maintenance organization as defined in RCW 48.46.020, or an issuer as defined in RCW 48.01.053. (15) "Third-party payor" means a person licensed under RCW
48.39.005.
(16) "Utilization review" has the same meaning as in RCW 48.43.005. NEW SECTION. Sec. 3. (1) A person may not act in the capacity of a health care benefit manager with respect to benefits for Washington residents, unless that person obtains and maintains a license issued by the commissioner.
(2) To obtain a license, a health care benefit manager must:
(a) Submit an application on forms and in a manner prescribed by the commissioner and verified by the applicant by affidavit, or certificate under RCW
9A.72.085. Applications must contain at least the following information:
(i) The identity of the health care benefit manager and of persons with any ownership or controlling interest in the applicant including relevant business licenses and tax identification numbers, and the identity of any entity that the health care benefit manager has a controlling interest in;
(ii) The business name, address, phone number, and contact person for the manager;
(iii) Whether the person does business as a pharmacy benefit manager, a radiology benefit manager, a health care benefit manager other than a pharmacy benefit manager or radiology benefit manager, or a combination of different types of health care benefit managers; and
(iv) Any other information as the commissioner may reasonably require.
(b) Pay an initial license fee and annual renewal license fee established in rule by the commissioner for each license. The fees for each license must be set by the commissioner in an amount that ensures the licensing, renewal, and oversight activities are self-supporting. If one licensee has a contract with more than one carrier, the licensee shall complete only one application providing the detail necessary for each contract.
(3) All receipts from fees collected by the commissioner under this section must be deposited into the commissioner's regulatory account created in RCW
48.02.190.
(4) Before approving an application for or renewal of a license, the commissioner must find that the health care benefit manager:
(a) Has not committed any act that resulted in denial, suspension, or revocation of a license;
(b) Has paid the required fees; and
(c) Has the capacity to comply with and has designated a person responsible for compliance with state and federal laws.
(5) Any material change in information provided to obtain or renew a license must be filed with the commissioner within fifteen days of the change.
(6) Every licensee shall retain a record of all transactions completed under the license for a period of not less than seven years from the date of their creation. All such records as to any particular transaction must be kept available and open to inspection by the commissioner during the seven years after the date of completion of such transaction.
NEW SECTION. Sec. 4. (1) A licensee must file with the commissioner in the form and manner prescribed by the commissioner, every benefit management contract and contract amendment, and every contract and contract amendment between the licensee and any other person entered into directly or indirectly in support of such licensee contract, at least thirty days prior to use of the contract or amendment.
(2) Licensee contracts must be available for public inspection and posted on the commissioner's web site. Contract compensation provisions filed with the commissioner are confidential and are not subject to public disclosure under RCW
48.02.120(2) or chapter
42.56 RCW, if filed in accordance with commissioner procedures for submitting confidential filings, except