Health carrier reimbursement

AN ACT Relating to ensuring access to primary care, behavioral 1
health, and affordable hospital services; and adding a new section to 2
chapter 41.05 RCW. 3
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF WASHINGTON:4
NEW SECTION. Sec. 1. A new section is added to chapter 41.05 5
RCW to read as follows: 6
(1) For purposes of this section, "contractor" means a health 7
carrier that provides medical insurance offered to public employees 8
and their covered dependents under this chapter, or a third-party 9
administrator contracted by the authority to provide medical coverage 10
to public employees under this chapter. 11
(2) Upon a good faith offer from a contractor, a hospital 12
licensed under chapter 70.41 RCW that receives payment for services 13
through any program administered by the authority under chapter 74.09 14
RCW must contract with that contractor. This subsection does not 15
apply to a hospital owned and operated by a health maintenance 16
organization licensed under chapter 48.46 RCW. 17
(3) Each contractor, for its health plans that provide medical 18
coverage offered to public employees and their covered dependents, 19
must meet the following requirements: 20
(a) Beginning January 1, 2027: 21
Z-0050.3
SENATE BILL 5083
State of Washington 69th Legislature 2025 Regular Session
By Senators Robinson, Harris, Liias, Nobles, Salomon, and Valdez; by
request of Health Care Authority
Prefiled 12/19/24. Read first time 01/13/25. Referred to Committee
on Health & Long-Term Care.
p. 1 SB 5083
(i) Except as provided in (a)(ii) of this subsection, 1
reimbursement to any provider or facility for inpatient and 2
outpatient hospital services may not exceed the lesser of billed 3
charges, the contractor's contracted rate for the provider, or 200 4
percent of the total amount medicare would have reimbursed for the 5
same or similar services; 6
(ii) Reimbursement to any provider or facility for inpatient and 7
outpatient hospital services provided at a specialty hospital 8
primarily engaged in the care and treatment of children may not 9
exceed the lesser of billed charges, the contractor's contracted rate 10
for the provider, or 350 percent of the total amount medicare would 11
have reimbursed providers and facilities for the same or similar 12
services; 13
(iii) Reimbursement for services provided by rural hospitals 14
certified by the centers for medicare and medicaid services as 15
critical access hospitals or sole community hospitals may not be less 16
than 101 percent of allowable costs as defined by the United States 17
centers for medicare and medicaid services for purposes of medicare 18
cost reporting; 19
(iv) Reimbursement for primary care services, as defined by the 20
authority, may not be less than 150 percent of the amount that would 21
have been reimbursed under the medicare program for the same or 22
similar services; and 23
(v) Reimbursement for nonfacility-based behavioral health 24
services, as defined by the authority, may not be less than 150 25
percent of the amount that would have been reimbursed under the 26
medicare program for the same or similar services.27
(b) Beginning January 1, 2029: 28
(i) Except as provided in (b)(ii) of this subsection, 29
reimbursement to any provider or facility for inpatient and 30
outpatient hospital services may not exceed the lesser of billed 31
charges, the contractor's contracted rate for the provider, or 190 32
percent of the total amount medicare would have reimbursed providers 33
and facilities for the same or similar services; and34
(ii) Reimbursement to any provider or facility for inpatient and 35
outpatient hospital services provided at a specialty hospital 36
primarily engaged in the care and treatment of children may not 37
exceed the lesser of billed charges, the contractor's contracted rate 38
for the provider, or 300 percent of the total amount medicare would 39
p. 2 SB 5083
have reimbursed the providers and facilities for the same or similar 1
services. 2
(4) Nothing in this section prohibits a contractor from 3
reimbursing a hospital through a nonfee-for-service payment 4
methodology, so long as the payments incentivize higher quality or 5
improved health outcomes and the contractor continues to comply with 6
the reimbursement requirements in this section. 7
(5) Premiums must take into account changes in reimbursement for 8
hospital, primary care, and behavioral health services anticipated to 9
result from the application of this section. 10
(6) At the request of the authority for monitoring, enforcement, 11
or program and quality improvement activities, a contractor must 12
provide cost and quality of care information and data to the 13
authority and may not enter into an agreement with a provider or 14
third party that would restrict the contractor from providing this 15
information or data. 16
(7) By December 31, 2030, the authority, in consultation with the 17
office of the insurance commissioner, shall provide a report to the 18
governor's office and relevant committees of the legislature 19
analyzing the initial impacts of this section on network access, 20
enrollee premiums, and state expenditures for medical coverage 21
offered to public employees under this chapter. The report may 22
include recommendations for legislative changes to the policy 23
established in this section. 24
(8) The authority may adopt rules to implement this section, 25
including rules for levying fines and taking other contract actions 26
it deems necessary to enforce compliance with this section.27
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p. 3 SB 5083