Health carriers & providers

AN ACT Relating to the relationships between health carriers and 1
contracting providers; amending RCW 48.49.135; adding a new section 2
to chapter 48.43 RCW; creating a new section; and providing an 3
effective date. 4
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF WASHINGTON:5
Sec. 1. RCW 48.49.135 and 2022 c 263 s 18 are each amended to 6
read as follows: 7
(1) When determining the adequacy of a proposed provider network 8
or the ongoing adequacy of an in-force provider network, the 9
commissioner must review the carrier's proposed provider network or 10
in-force provider network to determine whether the network includes a 11
sufficient number of contracted providers of emergency medicine, 12
anesthesiology, pathology, radiology, neonatology, surgery, 13
hospitalist, intensivist (([,])), and diagnostic services, including 14
radiology and laboratory services at or for the carrier's contracted 15
in-network hospitals or ambulatory surgical facilities to reasonably 16
ensure enrollees have in-network access to covered benefits delivered 17
at that facility. 18
(2)(a) When determining the adequacy of a proposed provider 19
network or the ongoing adequacy of an in-force provider network, the 20
commissioner may allow a carrier to submit an alternate access 21
S-0972.1
SENATE BILL 5588
State of Washington 69th Legislature 2025 Regular Session
By Senators Cleveland, Nobles, and Short
Read first time 01/30/25. Referred to Committee on Health & Long-
Term Care.
p. 1 SB 5588
delivery request. The commissioner shall define the circumstances 1
under which a carrier may submit an alternate access delivery request 2
and the requirements for submission and approval of such a request in 3
rule. To submit an alternate access delivery request, a carrier 4
shall: 5
(i) Ensure that enrollees will not bear any greater cost of 6
receiving services under the alternate access delivery request than 7
if the provider or facility was contracted with the carrier or make 8
other arrangements acceptable to the commissioner; 9
(ii) Provide substantial evidence of good faith efforts on its 10
part to contract with providers or facilities. If a carrier is 11
submitting an alternate access delivery request for the same service 12
and geographic area as a previously approved request, the carrier 13
shall provide new or additional evidence of good faith efforts to 14
contract associated with the current request; 15
(iii) Demonstrate that there is not an available provider or 16
facility with which the carrier can contract to meet the 17
commissioner's provider network standards; and 18
(iv) For services for which balance billing is prohibited under 19
RCW 48.49.020, notify out-of-network providers or facilities that 20
deliver the services referenced in the alternate access delivery 21
request within five days of submitting the request to the 22
commissioner. Any notification provided under this subsection shall 23
include contact information for carrier staff who can provide 24
detailed information to the affected provider or facility regarding 25
the submitted alternate access delivery request. 26
(b) For services for which balance billing is prohibited under 27
RCW 48.49.020, a carrier may not treat its payment of 28
nonparticipating providers or facilities under this chapter or P.L. 29
116-260 (enacted December 27, 2020) as a means to satisfy network 30
access standards established by the commissioner unless all 31
requirements of this subsection are met. 32
(i) If a carrier is unable to obtain a contract with a provider 33
or facility delivering services addressed in an alternate access 34
delivery request to meet network access requirements, the carrier may 35
ask the commissioner to amend the alternate access delivery request 36
if the carrier's communication to the commissioner occurs at least 37
three months after the effective date of the alternate access 38
delivery request and demonstrates substantial evidence of good faith 39
efforts on its part to contract for delivery of services during that 40
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three-month time period. If the carrier has demonstrated substantial 1
evidence of good faith efforts on its part to contract, the 2
commissioner shall allow a carrier to use the dispute resolution 3
process provided in RCW 48.49.040 to determine the amount that will 4
be paid to providers or facilities for services referenced in the 5
alternate access delivery request. The commissioner may determine by 6
rule the associated processes for use of the dispute resolution 7
process under this subsection. 8
(ii) Once notification is provided by the carrier to a provider 9
or facility under (a) of this subsection, a carrier is not 10
responsible for reimbursing a provider's or facility's charges in 11
excess of the amount charged by the provider or facility for the same 12
or similar service at the time the notification was provided. The 13
provider or facility shall accept this reimbursement as payment in 14
full. 15
(3) When determining the adequacy of a carrier's proposed 16
provider network or the ongoing adequacy of an in-force provider 17
network, beginning January 1, 2023, the commissioner shall require 18
that the carrier's proposed provider network or in-force provider 19
network include a sufficient number of contracted behavioral health 20
emergency services providers. 21
(4) When determining the ongoing adequacy of an in-force provider 22
network, the commissioner shall determine whether providers included 23
in a carrier's network are actually providing services to the 24
carrier's enrollees. For purposes of implementing this subsection, 25
the commissioner shall adopt, by rule, a uniform data request form 26
and may adopt additional requirements consistent with this 27
subsection. When adopting the form, the commissioner shall consider 28
the model data request form developed by the Bowman family 29
foundation's mental health treatment and research institute.30
NEW SECTION. Sec. 2. A new section is added to chapter 48.43 31
RCW to read as follows: 32
(1) Prior to entering into or renewing a contract with a health 33
care provider, a health carrier shall offer the provider a meaningful 34
opportunity to negotiate the terms of the contract. Any negotiations 35
conducted under this subsection must be in good faith. The following 36
conduct violates this subsection: 37
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(a) Failure to furnish the provider with the name and contact 1
information of a person the carrier has designated as the primary 2
contact for contract negotiations; 3
(b) When a contract is being renewed, failure to furnish the 4
provider, upon the provider's request, a copy of the new contract 5
that clearly indicates the differences between the new contract and 6
the previous contract; 7
(c) Refusal to negotiate with a group of providers with the same 8
employer or the same federal tax identification number;9
(d) Failure to furnish the provider, upon the provider's request, 10
with a fee schedule in a manner that does not require access to a 11
secure website or other portal, such as by mailing a hard copy to the 12
provider or by emailing an electronic copy to the provider; or13
(e) Any other conduct determined, in rules adopted by the 14
commissioner, to violate this subsection. 15
(2) Provider contracts entered into or renewed on or after the 16
effective date of this section may not include: 17
(a) An all-or-nothing clause; or 18
(b) A requirement that the provider accept a discounted rate 19
under any other contract to which the provider is a party.20
(3) A health carrier shall provide contract and payment policy 21
updates in a manner that does not require access to a secure website 22
or other portal, such as by mailing a hard copy to the provider or by 23
emailing an electronic copy to the provider. 24
(4) This section applies to a health care benefit manager acting 25
on behalf of the carrier. 26
(5) For purposes of this section: 27
(a) "All-or-nothing clause" means a provision in a provider 28
contract that requires a provider to contract with multiple health 29
plans or other insurance products offered by, or associated with, the 30
health carrier. 31
(b) "Health care benefit manager" has the same meaning as 32
provided in RCW 48.200.020. 33
(c) In addition to the definition in RCW 48.43.005, "health 34
carrier" also includes a limited health care service contractor 35
offering dental only coverage and a health carrier offering dental 36
only coverage. 37
(6) Any trade secrets or other confidential information disclosed 38
to the commissioner under this section are confidential and exempt 39
from public disclosure under chapter 42.56 RCW. 40
p. 4 SB 5588
(7) This section does not apply to negotiations between a health 1
carrier and a provider who is an employee of the health carrier or a 2
provider who is an employee of a hospital. 3
NEW SECTION. Sec. 3. The insurance commissioner may adopt any 4
rules necessary to implement this act.5
NEW SECTION. Sec. 4. Sections 1 and 2 of this act take effect 6
January 1, 2027.7
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