Vision benefits

AN ACT Relating to the administration of vision benefits; 1
reenacting and amending RCW 48.200.020 and 41.05.017; adding a new 2
section to chapter 48.200 RCW; adding a new section to chapter 48.43 3
RCW; creating a new section; and providing an effective date.4
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF WASHINGTON:5
Sec. 1. RCW 48.200.020 and 2024 c 242 s 1 are each reenacted and 6
amended to read as follows: 7
The definitions in this section apply throughout this chapter 8
unless the context clearly requires otherwise. 9
(1) "Affiliate" or "affiliated employer" means a person who 10
directly or indirectly through one or more intermediaries, controls 11
or is controlled by, or is under common control with, another 12
specified person. 13
(2) "Certification" has the same meaning as in RCW 48.43.005.14
(3) "Covered person" has the same meaning as in RCW 48.43.005.15
(4) "Employee benefits programs" means programs under both the 16
public employees' benefits board established in RCW 41.05.055 and the 17
school employees' benefits board established in RCW 41.05.740.18
(5)(a) "Health care benefit manager" means a person or entity 19
providing services to, or acting on behalf of, a health carrier or 20
employee benefits programs, that directly or indirectly impacts the 21
H-0753.1
HOUSE BILL 1770
State of Washington 69th Legislature 2025 Regular Session
By Representatives Thai, Stonier, Pollet, and Reed
Read first time 01/31/25. Referred to Committee on Health Care &
Wellness.
p. 1 HB 1770
determination or utilization of benefits for, or patient access to, 1
health care services, drugs, and supplies including, but not limited 2
to: 3
(i) Prior authorization or preauthorization of benefits or care;4
(ii) Certification of benefits or care; 5
(iii) Medical necessity determinations; 6
(iv) Utilization review; 7
(v) Benefit determinations; 8
(vi) Claims processing and repricing for services and procedures;9
(vii) Outcome management; 10
(viii) Payment or authorization of payment to providers and 11
facilities for services or procedures; 12
(ix) Dispute resolution, grievances, or appeals relating to 13
determinations or utilization of benefits; 14
(x) Provider network management; or 15
(xi) Disease management. 16
(b) "Health care benefit manager" includes, but is not limited 17
to, health care benefit managers that specialize in specific types of 18
health care benefit management such as pharmacy benefit managers, 19
radiology benefit managers, laboratory benefit managers, vision 20
benefit managers, and mental health benefit managers.21
(c) "Health care benefit manager" does not include:22
(i) Health care service contractors as defined in RCW 48.44.010;23
(ii) Health maintenance organizations as defined in RCW 24
48.46.020; 25
(iii) Issuers as defined in RCW 48.01.053; 26
(iv) The public employees' benefits board established in RCW 27
41.05.055; 28
(v) The school employees' benefits board established in RCW 29
41.05.740; 30
(vi) Discount plans as defined in RCW 48.155.010;31
(vii) Direct patient-provider primary care practices as defined 32
in RCW 48.150.010; 33
(viii) An employer administering its employee benefit plan or the 34
employee benefit plan of an affiliated employer under common 35
management and control; 36
(ix) A union, either on its own or jointly with an employer, 37
administering a benefit plan on behalf of its members;38
(x) An insurance producer selling insurance or engaged in related 39
activities within the scope of the producer's license;40
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(xi) A creditor acting on behalf of its debtors with respect to 1
insurance, covering a debt between the creditor and its debtors;2
(xii) A behavioral health administrative services organization or 3
other county-managed entity that has been approved by the state 4
health care authority to perform delegated functions on behalf of a 5
carrier; 6
(xiii) A hospital licensed under chapter 70.41 RCW or ambulatory 7
surgical facility licensed under chapter 70.230 RCW, to the extent 8
that it performs provider credentialing or recredentialing, but no 9
other functions of a health care benefit manager as described in (a) 10
of this subsection (((5)(a) of this section [ (a) of this 11
subsection])); 12
(xiv) The Robert Bree collaborative under chapter 70.250 RCW;13
(xv) The health technology clinical committee established under 14
RCW 70.14.090; 15
(xvi) The prescription drug purchasing consortium established 16
under RCW 70.14.060; or 17
(xvii) Any other entity that performs provider credentialing or 18
recredentialing, but no other functions of a health care benefit 19
manager as described in (a) of this subsection (((5)(a) of this 20
section [(a) of this subsection])). 21
(6) "Health care provider" or "provider" has the same meaning as 22
in RCW 48.43.005. 23
(7) "Health care service" has the same meaning as in RCW 24
48.43.005. 25
(8) "Health carrier" or "carrier" has the same meaning as in RCW 26
48.43.005. 27
(9) "Laboratory benefit manager" means a person or entity 28
providing service to, or acting on behalf of, a health carrier, 29
employee benefits programs, or another entity under contract with a 30
carrier, that directly or indirectly impacts the determination or 31
utilization of benefits for, or patient access to, health care 32
services, drugs, and supplies relating to the use of clinical 33
laboratory services and includes any requirement for a health care 34
provider to submit a notification of an order for such services.35
(10) "Mail order pharmacy" means a pharmacy that primarily 36
dispenses prescription drugs to patients through the mail or common 37
carrier. 38
(11) "Mental health benefit manager" means a person or entity 39
providing service to, or acting on behalf of, a health carrier, 40
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employee benefits programs, or another entity under contract with a 1
carrier, that directly or indirectly impacts the determination of 2
utilization of benefits for, or patient access to, health care 3
services, drugs, and supplies relating to the use of mental health 4
services and includes any requirement for a health care provider to 5
submit a notification of an order for such services.6
(12) "Network" means the group of participating providers, 7
pharmacies, and suppliers providing health care services, drugs, or 8
supplies to beneficiaries of a particular carrier or plan.9
(13) "Person" includes, as applicable, natural persons, licensed 10
health care providers, carriers, corporations, companies, trusts, 11
unincorporated associations, and partnerships. 12
(14)(a) "Pharmacy benefit manager" means a person that contracts 13
with pharmacies on behalf of a health carrier, employee benefits 14
program, or medicaid managed care program to: 15
(i) Process claims for prescription drugs or medical supplies or 16
provide retail network management for pharmacies or pharmacists;17
(ii) Pay pharmacies or pharmacists for prescription drugs or 18
medical supplies; 19
(iii) Negotiate rebates, discounts, or other price concessions 20
with manufacturers for drugs paid for or procured as described in 21
this subsection; 22
(iv) Establish or manage pharmacy networks; or23
(v) Make credentialing determinations. 24
(b) "Pharmacy benefit manager" does not include a health care 25
service contractor as defined in RCW 48.44.010. 26
(15) "Pharmacy network" means the pharmacies located in the state 27
or licensed under chapter 18.64 RCW and contracted by a pharmacy 28
benefit manager to dispense prescription drugs to covered persons.29
(16)(a) "Radiology benefit manager" means any person or entity 30
providing service to, or acting on behalf of, a health carrier, 31
employee benefits programs, or another entity under contract with a 32
carrier, that directly or indirectly impacts the determination or 33
utilization of benefits for, or patient access to, the services of a 34
licensed radiologist or to advanced diagnostic imaging services 35
including, but not limited to: 36
(i) Processing claims for services and procedures performed by a 37
licensed radiologist or advanced diagnostic imaging service provider; 38
or 39
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(ii) Providing payment or payment authorization to radiology 1
clinics, radiologists, or advanced diagnostic imaging service 2
providers for services or procedures. 3
(b) "Radiology benefit manager" does not include a health care 4
service contractor as defined in RCW 48.44.010, a health maintenance 5
organization as defined in RCW 48.46.020, or an issuer as defined in 6
RCW 48.01.053. 7
(17) "Utilization review" has the same meaning as in RCW 8
48.43.005. 9
(18) "Vision benefit manager" means a person or entity providing 10
service to, or acting on behalf of, a health carrier, employee 11
benefits programs, or another entity under contract with a carrier, 12
that directly or indirectly impacts the determination of utilization 13
of benefits for, or patient access to, health care services, 14
materials, drugs, and supplies relating to the use of vision services 15
or vision materials.16
(19) "Vision materials" means ophthalmic devices including, but 17
not limited to, devices containing lenses, artificial intraocular 18
lenses, ophthalmic frames and other lens mounting apparatuses, 19
prisms, lens treatments and coatings, contact lenses, or prosthetic 20
devices to correct, relieve, or treat defects or abnormal conditions 21
of the human eye or its adnexa.22
NEW SECTION. Sec. 2. A new section is added to chapter 48.200 23
RCW to read as follows: 24
(1) A vision benefit manager may not: 25
(a) Provide different reimbursement amounts for covered vision 26
services or covered vision materials among tiers of contracting 27
providers of the same licensed profession in the same health plan;28
(b) Reimburse a provider licensed under chapter 18.53 RCW, acting 29
within the provider's scope of practice, less than it reimburses 30
ophthalmologists licensed under chapter 18.57 or 18.71 RCW for the 31
same covered vision services or covered vision materials;32
(c) Require a contracting provider to purchase vision services or 33
vision materials from suppliers, including optical laboratories, in 34
which the vision benefit manager has a financial interest;35
(d) Require a contracting provider to provide vision services or 36
vision materials at a fee limited or set by the vision benefit 37
manager, unless the vision materials or services are covered vision 38
services or covered vision materials; 39
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(e) Require a provider of covered vision services or covered 1
vision materials, as a condition of becoming a participating provider 2
for a specific health plan, to: 3
(i) Join a network of providers maintained by the vision benefit 4
manager in lieu of contracting directly with the health carrier;5
(ii) Participate with any other health plan, including another 6
health plan managed by, or affiliated with, the vision benefit 7
manager; or 8
(iii) Participate with any discount plan regulated under chapter 9
48.155 RCW; 10
(f) Require an enrollee's cost sharing, including copayments, for 11
covered vision services or vision materials to exceed 50 percent of 12
the amount the provider is reimbursed for those services or 13
materials, unless a higher amount is necessary to preserve the 14
enrollee's ability to claim tax exempt contributions from the 15
enrollee's health savings account under internal revenue service laws 16
and regulations; or 17
(g) Impose different credentialing standards for providers 18
licensed under chapter 18.53 RCW than it imposes for ophthalmologists 19
licensed under chapter 18.57 or 18.71 RCW. 20
(2) For purposes of this section, "health plan" includes:21
(a) A health plan as defined in chapter 48.43 RCW;22
(b) A health plan issued by an employee benefits program; and23
(c) Vision-only coverage issued by a limited health care service 24
contractor under chapter 48.44 RCW or a health carrier as defined in 25
chapter 48.43 RCW. 26
(3) This section applies to contracts entered into or renewed on 27
or after the effective date of this section. 28
NEW SECTION. Sec. 3. A new section is added to chapter 48.43 29
RCW to read as follows: 30
(1) A health carrier offering vision coverage or a limited health 31
care service contractor offering vision-only coverage may not:32
(a) Provide different reimbursement amounts for covered vision 33
services or covered vision materials among tiers of contracting 34
providers of the same licensed profession in the same health plan;35
(b) Reimburse a provider licensed under chapter 18.53 RCW, acting 36
within the provider's scope of practice, less than it reimburses 37
ophthalmologists licensed under chapter 18.57 or 18.71 RCW for the 38
same covered vision services or covered vision materials;39
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(c) Require a contracting provider to purchase vision services or 1
vision materials from suppliers, including optical laboratories, in 2
which the health carrier, limited health care service contractor, or 3
affiliated vision benefit manager has a financial interest;4
(d) Require a contracting provider to provide vision services or 5
materials at a fee limited or set by the health carrier, limited 6
health care service contractor, or affiliated vision benefit manager, 7
unless the vision services or vision materials are covered vision 8
services or covered vision materials; 9
(e) Require a provider of covered vision services or covered 10
vision materials, as a condition of becoming a participating provider 11
for a specific health plan, to: 12
(i) Join a network of providers maintained by a vision benefit 13
manager in lieu of contracting directly with the health carrier;14
(ii) Participate with any other health plan, including another 15
health plan managed by, or affiliated with, an affiliated vision 16
benefit manager; or 17
(iii) Participate with any discount plan regulated under chapter 18
48.155 RCW; 19
(f) Require an enrollee's cost sharing, including copayments, for 20
covered vision services or vision materials to exceed 50 percent of 21
the amount the provider is reimbursed for those services or 22
materials, unless a higher amount is necessary to preserve the 23
enrollee's ability to claim tax exempt contributions from the 24
enrollee's health savings account under internal revenue service laws 25
and regulations; or 26
(g) Impose different credentialing standards for providers 27
licensed under chapter 18.53 RCW than it imposes for ophthalmologists 28
licensed under chapter 18.57 or 18.71 RCW. 29
(2) For purposes of this section: 30
(a) "Health plan" means: 31
(i) A health plan as defined in RCW 48.43.005; and32
(ii) Vision-only coverage issued by a limited health care service 33
contractor under chapter 48.44 RCW or a health carrier.34
(b) "Limited health care service contractor" has the same meaning 35
as in RCW 48.44.035. 36
(c) "Vision benefit manager" has the same meaning as in RCW 37
48.200.020. 38
(d) "Vision materials" means ophthalmic devices including, but 39
not limited to, devices containing lenses, artificial intraocular 40
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lenses, ophthalmic frames and other lens mounting apparatuses, 1
prisms, lens treatments and coatings, contact lenses, or prosthetic 2
devices to correct, relieve, or treat defects or abnormal conditions 3
of the human eye or its adnexa. 4
(3) This section applies to contracts entered into or renewed on 5
or after the effective date of this section. 6
Sec. 4. RCW 41.05.017 and 2024 c 251 s 5 and 2024 c 242 s 10 are 7
each reenacted and amended to read as follows: 8
Each health plan that provides medical insurance offered under 9
this chapter, including plans created by insuring entities, plans not 10
subject to the provisions of Title 48 RCW, and plans created under 11
RCW 41.05.140, are subject to the provisions of RCW 48.43.500, 12
70.02.045, 48.43.505 through 48.43.535, 48.43.537, 48.43.545, 13
48.43.550, 70.02.110, 70.02.900, 48.43.190, 48.43.083, 48.43.0128, 14
48.43.780, 48.43.435, 48.43.815, 48.200.020 through 48.200.280, 15
48.200.300 through 48.200.320, 48.43.440, section 3 of this act, and 16
chapter 48.49 RCW. 17
NEW SECTION. Sec. 5. The insurance commissioner may adopt any 18
rules necessary to implement this act.19
NEW SECTION. Sec. 6. Sections 1 through 4 of this act take 20
effect January 1, 2026.21
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