RCW 48.46.243
Contract—Participant liability.
(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.
(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.
[ 2016 c 122 § 3. Prior: 2013 c 325 § 2; 2013 c 277 § 3; 2008 c 217 § 56; 1990 c 119 § 7.]
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.
Structure Revised Code of Washington
Chapter 48.46 - Health Maintenance Organizations.
48.46.010 - Legislative declaration—Purpose.
48.46.012 - Filings with secretary of state—Copy for commissioner.
48.46.027 - Registration, required—Issuance of securities—Penalty.
48.46.033 - Unregistered activities—Acts committed in this state—Sanctions.
48.46.045 - Catastrophic health plans permitted.
48.46.062 - Schedule of rates for individual agreements—Loss ratio—Definitions.
48.46.064 - Calculation of premiums—Adjusted community rate—Definitions.
48.46.068 - Requirements for plans offered to small employers—Definitions.
48.46.080 - Annual statement—Filings—Contents—Fee—Penalty for failure to file—Accuracy required.
48.46.090 - Standard of services provided.
48.46.100 - Grievance procedure.
48.46.135 - Fine in addition to or in lieu of suspension, revocation, or refusal.
48.46.170 - Effect of chapter as to other laws—Construction.
48.46.190 - Payroll deductions for capitation payments to health maintenance organizations.
48.46.200 - Rules and regulations.
48.46.210 - Compliance with federal funding requirements—Construction.
48.46.220 - Review of administrative action.
48.46.225 - Financial failure—Supervision of commissioner—Priority of distribution of assets.
48.46.235 - Minimum net worth—Requirement to maintain—Determination of amount.
48.46.237 - Minimum net worth—Domestic or foreign health maintenance organization.
48.46.240 - Funded reserve requirements.
48.46.243 - Contract—Participant liability.
48.46.245 - Plan for handling insolvency—Commissioner's review.
48.46.247 - Insolvency—Commissioner's duties—Participants' options—Allocation of coverage.
48.46.272 - Diabetes coverage—Definitions.
48.46.274 - Prescribed, self-administered anticancer medication.
48.46.275 - Mammograms—Insurance coverage.
48.46.277 - Prostate cancer screening.
48.46.280 - Reconstructive breast surgery.
48.46.285 - Mastectomy, lumpectomy.
48.46.291 - Mental health services—Health plans—Definition—Coverage required, when.
48.46.292 - Mental health treatment—Waiver of preauthorization for persons involuntarily committed.
48.46.300 - Future dividends or refunds, restricted—Issuance or sale of securities regulated.
48.46.310 - Registration not endorsement.
48.46.320 - Dependent children, termination of coverage, conditions.
48.46.325 - Option to cover child under age twenty-six.
48.46.340 - Return of agreement within ten days.
48.46.350 - Chemical dependency treatment.
48.46.355 - "Chemical dependency" defined.
48.46.370 - Coverage not denied for disability.
48.46.380 - Notice of reason for cancellation, denial, or refusal to renew agreement.
48.46.400 - False or misleading advertising prohibited.
48.46.410 - Misrepresentations to induce termination or retention of agreement prohibited.
48.46.420 - Penalty for violations.
48.46.430 - Enforcement authority of commissioner.
48.46.440 - Continuation option to be offered.
48.46.450 - Conversion agreement to be offered—Exceptions, conditions.
48.46.460 - Conversion agreement—Restrictions and requirements—Rules.
48.46.470 - Endorsement of modifications.
48.46.480 - Continuation of coverage of former family members.
48.46.490 - Coverage for adopted children.
48.46.500 - Cancellation of rider.
48.46.520 - Neurodevelopmental therapies—Employer-sponsored group contracts.
48.46.530 - Temporomandibular joint disorders—Insurance coverage.
48.46.540 - Nonresident pharmacies.
48.46.565 - Foot care services.
48.46.570 - Denturist services.
48.46.580 - When injury caused by intoxication or use of narcotics.
48.46.600 - Disclosure of certain material transactions—Report—Information is confidential.
48.46.605 - Material acquisitions or dispositions.
48.46.610 - Asset acquisitions—Asset dispositions.
48.46.615 - Report of a material acquisition or disposition of assets—Information required.
48.46.620 - Material nonrenewals, cancellations, or revisions of ceded reinsurance agreements.
48.46.900 - Liberal construction.
48.46.930 - Construction—Chapter applicable to state registered domestic partnerships—2009 c 521.