Health plan certification

AN ACT Relating to safeguarding access and affordability for 1
exchange customers through the health plan certification process; 2
amending RCW 43.71.065; adding a new section to chapter 43.71 RCW; 3
adding a new section to chapter 42.56 RCW; creating a new section; 4
and declaring an emergency. 5
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF WASHINGTON:6
NEW SECTION. Sec. 1. (1) The legislature finds that: 7
(a) Access to health care is fundamental to the health and safety 8
of Washington state residents; 9
(b) Health insurance coverage is necessary for most people to 10
access health care; 11
(c) Uncertainty in the health insurance marketplace is 12
significantly impacted by the volatility in the federal legislative 13
and regulatory environment; 14
(d) Rising health care costs are impacting access and 15
affordability for Washington state residents; 16
(e) An unstable and volatile individual insurance market would be 17
catastrophic and lead to: 18
(i) Deteriorating health outcomes; 19
(ii) Declining work force productivity; 20
(iii) Lower quality of life; and 21
H-2988.1
HOUSE BILL 2564
State of Washington 69th Legislature 2026 Regular Session
By Representatives Stonier, Lekanoff, Parshley, Ramel, and Macri
Read first time 01/19/26. Referred to Committee on Health Care &
Wellness.
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(iv) Increased burdens on safety net providers from the rising 1
demand for uncompensated care; 2
(f) Each year, the Washington health benefit exchange board uses 3
19 basic criteria that were established in the affordable care act to 4
review and certify health plans that will be offered to Washington 5
state residents in the exchange market; 6
(g) These 19 basic criteria do not address access and 7
affordability issues in the exchange market; and 8
(h) The affordable care act authorizes state exchanges to ensure 9
that certified health plans are in the interest of the residents of 10
the state by adopting additional health plan certification criteria 11
to that effect. Access to and affordability of health plans are in 12
the interest of residents of the state. 13
(2) Therefore, the legislature intends to authorize the 14
Washington health benefit exchange to add criteria in the health plan 15
certification process to address access and affordability issues 16
impacting residents who purchase health insurance coverage on the 17
exchange market and help reduce volatility in the exchange market.18
Sec. 2. RCW 43.71.065 and 2018 c 44 s 5 are each amended to read 19
as follows: 20
(1) The board shall certify a plan as a qualified health plan to 21
be offered through the exchange if the plan is determined by the:22
(a) Insurance commissioner to meet the requirements of Title 48 23
RCW and rules adopted by the commissioner pursuant to chapter 34.05 24
RCW to implement the requirements of Title 48 RCW;25
(b) Board to meet the requirements of applicable federal law for 26
certification as a qualified health plan; ((and))27
(c) Board to meet the market factor criteria that address access 28
and affordability as established in section 3 of this act; and29
(d) Board to include tribal clinics and urban Indian clinics as 30
essential community providers in the plan's provider network 31
consistent with federal law. If consistent with federal law, 32
integrated delivery systems shall be exempt from the requirement to 33
include essential community providers in the provider network.34
(2) Consistent with applicable federal law, the board shall allow 35
stand-alone dental plans to offer coverage in the exchange beginning 36
January 1, 2014. Dental benefits offered in the exchange must be 37
offered and priced separately to assure transparency for consumers.38
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(3) The board may permit direct primary care medical home plans, 1
consistent with applicable federal law, to be offered in the 2
exchange. 3
(4) Upon request by the board, a state agency shall provide 4
information to the board for its use in determining if the 5
requirements under subsection (1)(b) or (c) of this section have been 6
met. Unless the agency and the board agree to a later date, the 7
agency shall provide the information within sixty days of the 8
request. The exchange shall reimburse the agency for the cost of 9
compiling and providing the requested information within one hundred 10
eighty days of its receipt. 11
(5) A decision by the board denying a request to certify or 12
recertify a plan as a qualified health plan may be appealed according 13
to procedures adopted by the board. 14
NEW SECTION. Sec. 3. A new section is added to chapter 43.71 15
RCW to read as follows: 16
(1) Each year, after the board has reviewed and certified health 17
plans to be offered on the exchange market in the following plan 18
year, the exchange shall review market conditions and identify access 19
and affordability issues in the exchange market that impact the next 20
plan year for which the exchange has not yet certified plans.21
(2) Each year, the exchange may adopt market factor certification 22
criteria for the next plan year to address market conditions that 23
impact access to and affordability of health plans for individuals or 24
employers who are eligible to purchase coverage on the exchange 25
market in Washington state. When developing the criteria, the 26
exchange may consider whether health plans available in each county 27
are: 28
(a) Meaningfully different with respect to a combination of or 29
all of these measures, as determined by the exchange:30
(i) Cost-sharing; 31
(ii) Covered benefits; 32
(iii) Premiums; 33
(iv) Provider networks; or 34
(v) Quality; 35
(b) Offered by more than one carrier; 36
(c) Maximizing federal premium tax credits; 37
(d) Efficiently utilizing state premium assistance and other 38
state investments; and 39
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(e) Offered at each metal level required by the exchange.1
(3) Market factor certification criteria shall be developed in 2
consultation with the commissioner and the authority, and the 3
exchange shall consider comments from: 4
(a) Carriers that offer or seek to offer qualified health plans 5
on the exchange in the state; 6
(b) Federally recognized tribes in the state through the American 7
Indian health commission; and 8
(c) Other health care stakeholders through their statewide 9
associations or organizations. 10
(4)(a) For plan year 2028 and later, market factor certification 11
criteria shall be developed in accordance with the following 12
timeline: 13
(i) By December 15th of the calendar year two years before the 14
plan year in which the market factor certification criteria are to 15
apply, the exchange shall identify preliminary criteria and provide 16
those criteria to the commissioner and the governor;17
(ii) By January 15th of the calendar year before the plan year in 18
which the market factor certification criteria are to apply, the 19
commissioner and the governor may submit to the exchange a written 20
objection to any of the preliminary criteria; 21
(iii) By January 31st of the calendar year before the plan year 22
in which the market factor certification criteria are to apply, the 23
exchange shall provide a written response to any objection, including 24
whether and how the objection was addressed and what criteria were 25
amended or removed based on the objection; 26
(iv) By January 31st of the calendar year before the plan year in 27
which the market factor certification criteria are to apply, the 28
exchange shall publish the notice of the proposed market factor 29
certification criteria on the exchange website and distribute the 30
notice electronically to any person requesting the notice. The notice 31
shall include: 32
(A) An explanation of the proposed market factor certification 33
criteria; 34
(B) The time, date, and place for a public hearing; and35
(C) The procedures and timelines for submitting written comments 36
and supporting information; 37
(v) No later than five business days before the publication of 38
the final market factor certification criteria, the exchange shall 39
hold at least one public hearing; 40
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(vi) By March 1st of the calendar year before the plan year in 1
which the market factor certification criteria are to apply, the 2
exchange shall provide written notice of the final market factor 3
certification criteria to carriers that offer health plans subject to 4
certification under RCW 43.71.065, and shall publish the notice of 5
the final market factor certification criteria on the exchange 6
website and distribute the notice electronically to any person 7
requesting the notice; 8
(vii) After March 1st of the calendar year before the plan year 9
in which the market factor certification criteria are to apply, the 10
exchange may only modify the market factor certification criteria as 11
necessary to respond to any applicable changes to state or federal 12
laws or regulations. Any modification initiated under this subsection 13
that impacts a carrier's preliminary health plan filings is only in 14
effect if agreed to by the commissioner. 15
(b) For plan year 2027, market factor certification criteria 16
shall be developed in accordance with procedures established by the 17
exchange. 18
(5)(a) The exchange may require a carrier that is intending to 19
offer health plans on the exchange to submit information, including 20
the carrier's proposed service areas, proposed plan offerings and 21
rates on the exchange, and how the carrier intends to meet the market 22
factor certification criteria. 23
(b) No earlier than March 1st and no later than May 1st each 24
year, the carrier shall provide the information to the exchange. The 25
specific date must be determined by the exchange before March 1st.26
(6)(a) A carrier may request a waiver of the market factor 27
certification criteria. 28
(b) Requests for a waiver must be submitted to the exchange at a 29
date specified by the exchange but will be no earlier than March 1st 30
and no later than 14 days prior to the deadline established by the 31
commissioner each year for preliminary health plans filings.32
(c) In evaluating a request for a waiver, the exchange may:33
(i) Review information that demonstrates the carrier attempted to 34
meet the market factor certification criteria, such as information 35
that the carrier made a good faith effort to contract with providers 36
to establish an adequate network, the cost of the potential provider 37
network, impact on premiums, legal prohibitions, or other barriers 38
that impact the carrier's ability to offer coverage in certain 39
service areas, and any impact on other service areas;40
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(ii) Request that the carrier submit information about service 1
areas and rates that would be in place with the market factor 2
certification criteria and if the waiver were granted;3
(iii) Consider the totality of the proposed health plans and the 4
impact of granting or not granting the waiver of the market factor 5
certification criteria on the interests of Washington state 6
residents. 7
(d) The exchange shall conclude any waiver determinations 8
regarding market factor certification criteria from any carrier that 9
has requested a waiver prior to the carrier submitting preliminary 10
health plan filings for the upcoming plan year to the commissioner.11
(7) Any information and data submitted by a carrier to the 12
exchange under this section is confidential and not subject to public 13
disclosure under chapter 42.56 RCW. 14
(8) Market factor certification criteria may not directly impose 15
network participation requirements or reimbursement limits on 16
hospitals or providers except as otherwise required by federal or 17
state laws. 18
(9) Nothing in this section prohibits a carrier from offering a 19
health plan that does not meet the requirements in RCW 43.71.065 in 20
the individual market or small group market outside the exchange.21
NEW SECTION. Sec. 4. A new section is added to chapter 42.56 22
RCW to read as follows: 23
Any information or data submitted by a carrier to the health 24
benefit exchange for the purposes of the market factor certification 25
criteria under section 3 of this act are confidential and exempt from 26
disclosure under this chapter. 27
NEW SECTION. Sec. 5. This act is necessary for the immediate 28
preservation of the public peace, health, or safety, or support of 29
the state government and its existing public institutions, and takes 30
effect immediately.31
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