Current through Register Vol. 24-06, March 15, 2024
(1) The
commissioner shall develop a standard template for a notice of consumer
protections from balance billing under the Balance Billing Protection Act and
the federal No Surprises Act (P.L. 116-260). The notice may
be modified periodically, as determined necessary by the commissioner. The
notice template will be posted on the public website of the office of the
insurance commissioner.
(2) The
standard template for the notice of consumer protections developed under
subsection (1) of this section must be provided to consumers enrolled in any
health plan issued in Washington state as follows:
(a) Carriers must:
(i) Include the notice in the carrier's
communication to an enrollee, in electronic or any other format, that
authorizes nonemergency services to be provided at facilities referenced in WAC
284-43B-010(2)(h)(ii);
(ii) Include the notice in each explanation
of benefits sent to an enrollee for items or services with respect to which the
requirements of
RCW
48.49.020 and WAC
284-43B-020 apply;
(iii) Post the notice on their website in a
prominent and relevant location, such as in a location that addresses coverage
of emergency services and prior authorization requirements for nonemergency
health care services performed by nonparticipating providers at certain
participating facilities; and
(iv)
Provide the notice to any enrollee upon request.
(b) Health care facilities and providers
must:
(i) For any facility or provider that is
owned and operated independently from all other businesses and that has more
than 50 employees, upon confirming that a patient's health plan is subject to
the Balance Billing Protection Act or the federal No Surprises Act
(P.L.
116-260):
(A)
Include the notice in any communication to a patient, in electronic or any
other format related to scheduling of nonemergency health care services
performed by nonparticipating providers at certain participating fa- cilities.
Text messaging used as a reminder or follow-up after a patient has already
received the full text of the notice under this subsection may provide the
notice through a link to the provider's web-page that takes the patient
directly to the notice. Telephone calls to patients following the patient's
receipt of the full text of the notice under this subsection do not need to
include the notice; and
(B) For
facilities providing emergency services, including behavioral health emergency
services providers, provide or mail the notice to a patient within 72 hours
following a patient's receipt of emergency services.
(ii) Post the notice on their website, if the
provider, behavioral health emergency services provider or facility maintains a
website, in a prominent and relevant location near the list of the carrier
health plan provider networks with which the provider, behavioral health
emergency services provider or facility is an in-network provider;
(iii) If services were provided at a health
care facility or in connection with a visit to a health care facility, provide
the notice to patients no later than the date and time on which the provider or
facility requests payment from the patient, or with respect to a patient from
who the provider or facility does not request payment, no later than the date
on which the provider or facility submits a claim to the carrier; and
(iv) Provide the notice upon request of a
patient.
(3)
The notice required in this section may be provided to a patient or an enrollee
electronically if it includes the full text of the notice and if the patient or
enrollee has affirmatively chosen to receive such communications from the
carrier, provider, or facility electronically. Except as authorized in
subsection (2)(b)(i)(A) of this section, the notice may not be provided through
a hyperlink in an electronic communication.
(4) For claims processed on or after July 1,
2020, when processing a claim that is subject to the balance billing
prohibition in
RCW
48.49.020, the carrier must indicate on any
form used by the carrier to notify enrollees of the amount the carrier has paid
on the claim:
(a) Whether the claim is
subject to the prohibition in the act; and
(b) The federal Center for Medicare and
Medicaid Services individual national provider identifier number, and
organizational national provider identifier number, if the provider works for
an organization or is in a group practice that has an organization
number.
(5) Carriers must
ensure that notices provided under this subsection are inclusive for those
patients who may have disabilities or limited-English proficiency, consistent
with carriers' obligations under WAC
284-43-5940 through
284-43-5965. To assist in meeting
this language access requirement, carriers may use translated versions of the
notice of consumer protections from balance billing posted on the website of
the office of the insurance commissioner.
(6) A facility, behavioral health emergency
services provider or health care provider meets its obligation under
RCW
48.49.070 or
48.49.080, to include a listing on
its website of the carrier health plan provider networks in which the facility
or health care provider participates by posting this information on its website
for in-force contracts, and for newly executed contracts within 14 calendar
days of receipt of the fully executed contract from a carrier. If the
information is posted in advance of the effective date of the contract, the
date that network participation will begin must be indicated.
(7) Not less than 30 days prior to executing
a contract with a carrier:
(a)
(i) A hospital, freestanding emergency
department, behavioral health emergency services provider or ambulatory
surgical facility must provide the carrier with a list of the nonemployed
providers or provider groups that have privileges to practice at the hospital,
freestanding emergency department, behavioral health emergency services
provider or ambulatory surgical facility;
(ii) A hospital, hospital outpatient
department, critical access hospital or ambulatory surgical center must provide
the carrier with a list of the nonemployed providers or provider groups that
are contracted to provide nonemergency health care services at the
facility.
(b) The list
must include the name of the provider or provider group, mailing address,
federal tax identification number or numbers and contact information for the
staff person responsible for the provider's or provider group's
contracting.
(c) Any facility
providing carriers information under this subsection must notify the carrier
within 30 days of a removal from or addition to the nonemployed provider list.
The facility also must provide an updated list of these providers within 14
calendar days of a written request for an updated list by a carrier.
(8) A participating provider must
submit accurate information to a carrier regarding the provider's network
status in a timely manner, consistent with the terms of the contract between
the provider and the carrier.