Senate Bill 6248 — Travel Insurance (Washington Legislature, 2026 Regular Session)
Summary
Senate Bill 6248, State of Washington, 69th Legislature, 2026 Regular Session, by Senators Stanford, Dozier, Hasegawa, Kauffman, and Nobles, read first time 01/21/26 and referred to the Committee on Business, Trade & Economic Development. The title describes an act relating to travel insurance. The bill states its purpose as creating a comprehensive legal framework within which travel insurance may be sold in this state. It provides that an unlicensed travel retailer is permitted to provide only general information about the insurance offered. The closing pages contain definitions such as special enrollment, standard health questionnaire, utilization review and wellness activity, and provide that sections 1 through 13 take effect January 1, 2027.
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“Senate Bill 6248 — Travel Insurance (Washington Legislature, 2026 Regular Session).”
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S-4047.1
SENATE BILL 6248
State of Washington 69th Legislature 2026 Regular Session
By Senators Stanford, Dozier, Hasegawa, Kauffman, and Nobles
Read first time 01/21/26. Referred to Committee on Business, Trade &
Economic Development.
1 AN ACT Relating to travel insurance; amending RCW 48.17.060 and
2 48.43.005; adding a new section to chapter 48.43 RCW; adding a new
3 chapter to Title 48 RCW; and providing an effective date.
4 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF WASHINGTON:
5 NEW SECTION. Sec. 1. (1) The purpose of this chapter is to
6 promote the public welfare by creating a comprehensive legal
7 framework within which travel insurance may be sold in this state.
8 (2) The requirements of this chapter:
9 (a) Apply to travel insurance that covers any resident of this
10 state, and is sold, solicited, negotiated, or offered in this state,
11 and policies and certificates that are delivered or issued for
12 delivery in this state; and
13 (b) Do not apply to cancellation fee waivers or travel assistance
14 services, except as expressly provided in this chapter.
15 (3) All other applicable provisions of this state's insurance
16 laws continue to apply to travel insurance except that the specific
17 provisions of this chapter supersede any general provisions of law
18 that would otherwise be applicable to travel insurance.
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1 NEW SECTION. Sec. 2. The definitions in this section apply
2 throughout this chapter unless the context clearly requires
3 otherwise.
4 (1) "Aggregator site" means a website that provides access to
5 information regarding insurance products from more than one insurer,
6 including product and insurer information, for use in comparison
7 shopping.
8 (2) "Blanket travel insurance" means a policy of travel insurance
9 issued to any eligible group providing coverage for specific classes
10 of persons defined in the policy with coverage provided to all
11 members of the eligible group without a separate charge to individual
12 members of the eligible group.
13 (3) "Cancellation fee waiver" means a contractual agreement
14 between a supplier of travel services and its customer to waive some
15 or all of the nonrefundable cancellation fee provisions of the
16 supplier's underlying travel contract with or without regard to the
17 reason for the cancellation or form of reimbursement. A cancellation
18 fee waiver is not insurance.
19 (4) "Eligible group" means two or more persons who are engaged in
20 a common enterprise, or have an economic, educational, or social
21 affinity or relationship including, but not limited to, any of the
22 following:
23 (a) Any entity engaged in the business of providing travel or
24 travel services including, but not limited to: Tour operators,
25 lodging providers, vacation property owners, hotels and resorts,
26 travel clubs, travel agencies, property managers, cultural exchange
27 programs, and common carriers or the operator, owner, or lessor of a
28 means of transportation of passengers including, but not limited to,
29 airlines, cruise lines, railroads, steamship companies, and public
30 bus carriers, wherein with regard to any particular travel or type of
31 travel or travelers, all members or customers of the group must have
32 a common exposure to risk attendant to such travel;
33 (b) Any college, school, or other institution of learning,
34 covering students, teachers, employees, or volunteers;
35 (c) Any employer covering any group of employees, volunteers,
36 contractors, board of directors, dependents, or guests;
37 (d) Any sports team, camp, or sponsor thereof, covering
38 participants, members, campers, employees, officials, supervisors, or
39 volunteers;
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1 (e) Any religious, charitable, recreational, educational, or
2 civic organization, or branch thereof, covering any group of members,
3 participants, or volunteers;
4 (f) Any financial institution or financial institution vendor, or
5 parent holding company, trustee, or agent of or designated by one or
6 more financial institutions or financial institution vendors,
7 including account holders, credit card holders, debtors, guarantors,
8 or purchasers;
9 (g) Any incorporated or unincorporated association, including
10 labor unions, having a common interest, constitution and bylaws, and
11 organized and maintained in good faith for purposes other than
12 obtaining insurance for members or participants of such association
13 covering its members;
14 (h) Any trust or the trustees of a fund established, created, or
15 maintained for the benefit of and covering members, employees, or
16 customers, subject to the commissioner permitting the use of a trust
17 and the state's premium tax provisions in section 4 of this act of
18 one or more associations meeting the requirements of (g) of this
19 subsection;
20 (i) Any entertainment production company covering any group of
21 participants, volunteers, audience members, contestants, or workers;
22 (j) Any volunteer fire department, ambulance, rescue, police,
23 court, or any first aid, civil defense, or other such volunteer
24 group;
25 (k) Preschools, day care institutions for children or adults, and
26 senior citizen clubs;
27 (l) Any automobile or truck rental or leasing company covering a
28 group of individuals who may become renters, lessees, or passengers
29 defined by their travel status on the rented or leased vehicles,
30 subject to the requirement that the common carrier, operator, owner,
31 or lessor of a means of transportation, or the automobile or truck
32 rental or leasing company, is the policyholder under a policy to
33 which this chapter applies; or
34 (m) Any other group where the commissioner has determined that
35 the members are engaged in a common enterprise, or have an economic,
36 educational, or social affinity or relationship, and that issuance of
37 the policy would not be contrary to the public interest.
38 (5) "Fulfillment materials" means documentation sent to the
39 purchaser of a travel protection plan confirming the purchase and
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1 providing the travel protection plan's coverage and assistance
2 details.
3 (6) "Group travel insurance" means travel insurance issued to any
4 eligible group.
5 (7) "Limited lines travel insurance producer" means a:
6 (a) Licensed insurance producer, including a licensed limited
7 lines producer of travel insurance; or
8 (b) Travel administrator.
9 (8) "Offer and disseminate" means providing general information,
10 including a description of the coverage and price, as well as
11 processing the application and collecting premiums.
12 (9) "Primary certificate holder" means an individual person who
13 elects and purchases travel insurance under a group policy.
14 (10) "Primary policyholder" means an individual person who elects
15 and purchases individual travel insurance.
16 (11) "Travel administrator" means a person who directly or
17 indirectly underwrites, collects charges, collateral, or premiums
18 from, or adjusts or settles claims on residents of this state, in
19 connection with travel insurance, except that a person may not be
20 considered a travel administrator if that person's only actions that
21 would otherwise cause it to be considered a travel administrator are
22 among the following:
23 (a) A person working for a travel administrator to the extent
24 that the person's activities are subject to the supervision and
25 control of the travel administrator;
26 (b) An insurance producer selling insurance or engaged in
27 administrative and claims-related activities within the scope of the
28 producer's license;
29 (c) A travel retailer offering and disseminating travel insurance
30 and registered under the license of a limited lines travel insurance
31 producer in accordance with this chapter;
32 (d) An individual adjusting or settling claims in the normal
33 course of that individual's practice or employment as an attorney-at-
34 law and who does not collect charges or premiums in connection with
35 insurance coverage; or
36 (e) A business entity that is affiliated with a licensed insurer
37 while acting as a travel administrator for the direct and assumed
38 insurance business of an insurer.
39 (12) "Travel assistance services" means noninsurance services for
40 which the consumer is not indemnified based on a fortuitous event,
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1 and where providing the service does not result in transfer or
2 shifting of risk that would constitute the business of insurance.
3 (a) "Travel assistance services" include, but are not limited to:
4 Security advisories, destination information, vaccination and
5 immunization information services, travel reservation services,
6 entertainment, activity and event planning, translation assistance,
7 emergency messaging, international legal and medical referrals,
8 medical case monitoring, coordination of transportation arrangements,
9 emergency cash transfer assistance, medical prescription replacement
10 assistance, passport and travel document replacement assistance, lost
11 luggage assistance, concierge services, and any other service that is
12 furnished in connection with planned travel.
13 (b) "Travel assistance services" are not insurance and not
14 related to insurance.
15 (13)(a) "Travel insurance" means, except as excluded in (b) of
16 this subsection, insurance coverage for personal risks incident to
17 planned travel, including:
18 (i) Interruption or cancellation of trip or event;
19 (ii) Loss of baggage or personal effects;
20 (iii) Damages to accommodations or rental vehicles;
21 (iv) Sickness, accident, disability, or death occurring during
22 travel, provided that the health benefits are not offered on a stand-
23 alone basis and are incidental to other coverage;
24 (v) Emergency evacuation;
25 (vi) Repatriation of remains; or
26 (vii) Any other contractual obligations to indemnify or pay a
27 specified amount to the traveler upon determinable contingencies
28 related to travel as approved by the commissioner.
29 (b) "Travel insurance" does not include major medical plans that
30 provide comprehensive medical protection for travelers with trips
31 lasting longer than six months including, for example, those working
32 or residing overseas as an expatriate, or any other product that
33 requires a specific insurance producer license.
34 (14) "Travel protection plans" means plans that provide one or
35 more of the following: Travel insurance, travel assistance services,
36 and cancellation fee waivers.
37 (15) "Travel retailer" means a business entity that makes,
38 arranges, or offers planned travel and may offer and disseminate
39 travel insurance as a service to its customers on behalf of and under
40 the direction of a limited lines travel insurance producer.
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1 NEW SECTION. Sec. 3. (1) In accordance with RCW 48.17.170, the
2 commissioner may issue a limited lines travel insurance producer
3 license to an individual or business entity that has filed with the
4 commissioner an application for a limited lines travel insurance
5 producer license in a form and manner prescribed by the commissioner.
6 Such limited lines travel insurance producer must be licensed to
7 sell, solicit, or negotiate travel insurance through an authorized
8 insurer. No person may act as a limited lines travel insurance
9 producer or travel insurance retailer unless properly licensed or
10 registered, respectively.
11 (2) A travel retailer may offer and disseminate travel insurance
12 under a limited lines travel insurance producer business entity
13 license only if the following conditions are met:
14 (a) The limited lines travel insurance producer or travel
15 retailer provides to purchasers of travel insurance:
16 (i) A description of the material terms or the actual material
17 terms of the insurance coverage;
18 (ii) A description of the process for filing a claim;
19 (iii) A description of the review or cancellation process for the
20 travel insurance policy; and
21 (iv) The identity and contact information of the insurer and
22 limited lines travel insurance producer;
23 (b) At the time of licensure, the limited lines travel insurance
24 producer shall establish and maintain a register, on a form
25 prescribed by the commissioner, of each travel retailer that offers
26 travel insurance on the limited lines travel insurance producer's
27 behalf. The register must be maintained and updated by the limited
28 lines travel insurance producer and must include the name, address,
29 and contact information of the travel retailer and an officer or
30 person who directs or controls the travel retailer's operations, and
31 the travel retailer's federal tax identification number. The limited
32 lines travel insurance producer shall submit such register to the
33 state insurance department annually. The limited lines travel
34 insurance producer shall certify that the travel retailer registered
35 complies with 18 U.S.C. Sec. 1033. The grounds for the suspension,
36 revocation, and penalties applicable to resident insurance producers
37 under RCW 48.17.530 apply to the limited lines travel insurance
38 producers and travel retailers;
39 (c) The limited lines travel insurance producer has designated
40 one of its employees who is a licensed individual producer as the
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1 person responsible for the compliance with the travel insurance laws
2 and regulations applicable to the limited lines travel insurance
3 producer and its registrants;
4 (d) The employee designated under (c) of this subsection,
5 president, secretary, treasurer, and any other officer or person who
6 directs or controls the limited lines travel insurance producer's
7 insurance operations complies with the fingerprinting requirements
8 applicable to insurance producers in the resident state of the
9 limited lines travel insurance producer;
10 (e) The limited lines travel insurance producer has paid all
11 applicable licensing fees as set forth in applicable state law; and
12 (f) The limited lines travel insurance producer requires each
13 employee and authorized representative of the travel retailer whose
14 duties include offering and disseminating travel insurance to receive
15 a program of instruction or training, which is subject, at the
16 discretion of the commissioner, to review and approval. The training
17 material must, at a minimum, contain adequate instructions on the
18 types of insurance offered, ethical sales practices, and required
19 disclosures to prospective customers.
20 (3) Any travel retailer offering or disseminating travel
21 insurance shall make available to prospective purchasers brochures or
22 other written materials that have been approved by the travel
23 insurer. Such materials must include information that, at a minimum:
24 (a) Provides the identity and contact information of the insurer
25 and the limited lines travel insurance producer;
26 (b) Explains that the purchase of travel insurance is not
27 required in order to purchase any other product or service from the
28 travel retailer; and
29 (c) Explains that an unlicensed travel retailer is permitted to
30 provide only general information about the insurance offered by the
31 travel retailer, including a description of the coverage and price,
32 but is not qualified or authorized to answer technical questions
33 about the terms and conditions of the insurance offered by the travel
34 retailer or to evaluate the adequacy of the customer's existing
35 insurance coverage.
36 (4) A travel retailer employee or authorized representative who
37 is not licensed as an insurance producer may not:
38 (a) Evaluate or interpret the technical terms, benefits, and
39 conditions of the offered travel insurance coverage;
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1 (b) Evaluate or provide advice concerning a prospective
2 purchaser's existing insurance coverage; or
3 (c) Hold himself or itself out as an authorized insurer, licensed
4 producer, or insurance expert.
5 (5) Notwithstanding any other provision in law, a travel retailer
6 whose insurance-related activities, and those of its employees and
7 authorized representatives, are limited to offering and disseminating
8 travel insurance on behalf of and under the direction of a limited
9 lines travel insurance producer meeting the conditions stated in this
10 chapter, is authorized to receive related compensation, upon
11 registration by the limited lines travel insurance producer as
12 described in subsection (2)(b) of this section.
13 (6) As the insurer's designee, the limited lines travel insurance
14 producer is responsible for the acts of the travel retailer and shall
15 ensure compliance by the travel retailer with this chapter.
16 NEW SECTION. Sec. 4. (1) A travel insurer shall pay premium tax
17 as provided in RCW 48.14.020 on travel insurance premiums paid by any
18 of the following:
19 (a) An individual primary policyholder who is a resident of this
20 state;
21 (b) A primary certificate holder who is a resident of this state
22 who elects coverage under a group travel insurance policy; or
23 (c) A blanket travel insurance policyholder that is a resident
24 in, or has its principal place of business or the principal place of
25 business of an affiliate or subsidiary that has purchased blanket
26 travel insurance in this state for eligible blanket group members,
27 subject to any apportionment rules that apply to the insurer across
28 multiple taxing jurisdictions or that permit the insurer to allocate
29 premium on an apportioned basis in a reasonable and equitable manner
30 in those jurisdictions.
31 (2) A travel insurer shall:
32 (a) Document the state of residence or principal place of
33 business of the policyholder or certificate holder, as required in
34 subsection (1) of this section; and
35 (b) Report as premium only the amount allocable to travel
36 insurance and not any amounts received for travel assistance
37 services, cancellation fee waivers, or other noninsurance services.
p. 8 SB 6248
1 NEW SECTION. Sec. 5. Travel protection plans may be offered for
2 one price for the combined features that the travel protection plan
3 offers in this state if:
4 (1) The travel protection plan clearly discloses to the consumer,
5 at or prior to the time of purchase, that it includes travel
6 insurance, travel assistance services, and cancellation fee waivers
7 as applicable, and provides information and an opportunity, at or
8 prior to the time of purchase, for the consumer to obtain additional
9 information regarding the features and pricing of each; and
10 (2) The fulfillment materials:
11 (a) Describe and delineate the travel insurance, travel
12 assistance services, and cancellation fee waivers in the travel
13 protection plan; and
14 (b) Include the travel insurance disclosures and the contact
15 information for persons providing travel assistance services, and
16 cancellation fee waivers, as applicable.
17 NEW SECTION. Sec. 6. (1) All persons offering travel insurance
18 to residents of this state are subject to chapter 48.30 RCW, except
19 as otherwise provided in this section. In the event of a conflict
20 between this chapter and other provisions of this title regarding the
21 sale and marketing of travel insurance and travel protection plans,
22 the provisions of this chapter control.
23 (2) Pursuant to section 12 of this act, offering or selling a
24 travel insurance policy that could never result in payment of any
25 claims for any insured under the policy is an unfair trade practice
26 under chapter 48.30 RCW.
27 (3) The marketing requirements in this subsection apply to travel
28 insurance.
29 (a) All documents provided to consumers prior to the purchase of
30 travel insurance including, but not limited to, sales materials,
31 advertising materials, and marketing materials, must be consistent
32 with the travel insurance policy itself including, but not limited
33 to, forms, endorsements, policies, rate filings, and certificates of
34 insurance.
35 (b) For travel insurance policies or certificates that contain
36 preexisting condition exclusions, information and an opportunity to
37 learn more about the preexisting condition exclusions must be
38 provided any time prior to the time of purchase, and in the
39 coverage's fulfillment materials.
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1 (c) The fulfillment materials and the information described in
2 section 3(2)(a) of this act must be provided to a policyholder or
3 certificate holder as soon as practicable, following the purchase of
4 a travel protection plan. Unless the insured has either started a
5 covered trip or filed a claim under the travel insurance coverage, a
6 policyholder or certificate holder may cancel a policy or certificate
7 for a full refund of the travel protection plan price from the date
8 of purchase of a travel protection plan until at least: (i) 15 days
9 following the date of delivery of the travel protection plan's
10 fulfillment materials by postal mail; or (ii) 10 days following the
11 date of delivery of the travel protection plan's fulfillment
12 materials by means other than postal mail. For the purposes of this
13 subsection, "delivery" means handing fulfillment materials to the
14 policyholder or certificate holder or sending fulfillment materials
15 by postal mail or electronic means to the policyholder or certificate
16 holder.
17 (d) The company shall disclose in the policy documentation and
18 fulfillment materials whether the travel insurance is primary or
19 secondary to other applicable coverage.
20 (e) Where travel insurance is marketed directly to a consumer
21 through an insurer's website or by others through an aggregator site,
22 it is not an unfair trade practice or other violation of law where an
23 accurate summary or short description of coverage is provided on the
24 web page, so long as the consumer has access to the full provisions
25 of the policy through electronic means.
26 (4) No person offering, soliciting, or negotiating travel
27 insurance or travel protection plans on an individual or group basis
28 may do so by using negative option or opt out, which would require a
29 consumer to take an affirmative action to deselect coverage, such as
30 unchecking a box on an electronic form, when the consumer purchases a
31 trip.
32 (5) Pursuant to section 12 of this act, it is an unfair trade
33 practice to market blanket travel insurance coverage as free.
34 (6) Where a consumer's destination jurisdiction requires
35 insurance coverage, it is not an unfair trade practice to require
36 that a consumer choose between the following options as a condition
37 of purchasing a trip or travel package:
38 (a) Purchasing the coverage required by the destination
39 jurisdiction through the travel retailer or limited lines travel
40 insurance producer supplying the trip or travel package; or
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1 (b) Agreeing to obtain and provide proof of coverage that meets
2 the destination jurisdiction's requirements prior to departure.
3 NEW SECTION. Sec. 7. (1) Notwithstanding any other provisions
4 of this title, no person may act or represent itself as a travel
5 administrator for travel insurance in this state unless that person
6 is a licensed property and casualty insurance producer in this state
7 for activities permitted under that producer license.
8 (2) A travel administrator and its employees are exempt from the
9 licensing requirements of RCW 48.17.060(2) for travel insurance it
10 administers.
11 (3) An insurer is responsible for the acts of a travel
12 administrator administering travel insurance underwritten by the
13 insurer, and is responsible for ensuring that the travel
14 administrator maintains all books and records relevant to the insurer
15 to be made available by the travel administrator to the commissioner
16 upon request.
17 NEW SECTION. Sec. 8. (1)(a) Subject to (b) and (c) of this
18 subsection, notwithstanding any other provision of this title, travel
19 insurance is classified and filed for purposes of rates and forms
20 under an inland marine line of insurance.
21 (b) Travel insurance that provides coverage for sickness,
22 accident, disability, or death occurring during travel, either
23 exclusively, or in conjunction with related coverages of emergency
24 evacuation or repatriation of remains, or incidental limited property
25 and casualty benefits such as baggage or trip cancellation, may be
26 filed under either an accident and health line of insurance or an
27 inland marine line of insurance.
28 (c) The rates and forms filings per product may only be filed
29 under one line of insurance.
30 (2) Travel insurance may be in the form of an individual, group,
31 or blanket policy.
32 (3) Eligibility and underwriting standards for travel insurance
33 may be developed and provided based on travel protection plans
34 designed for individual or identified marketing or distribution
35 channels, provided those standards also meet the state's underwriting
36 standards for inland marine.
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1 NEW SECTION. Sec. 9. The commissioner may adopt rules as
2 necessary to implement and administer this chapter and shall repeal
3 existing rules pertaining to travel insurance that are inconsistent
4 with this chapter.
5 NEW SECTION. Sec. 10. This chapter may be known and cited as
6 the Washington travel insurance act.
7 NEW SECTION. Sec. 11. Sections 1 through 10 of this act
8 constitute a new chapter in Title 48 RCW.
9 NEW SECTION. Sec. 12. A new section is added to chapter 48.43
10 RCW to read as follows:
11 In accordance with section 6 of this act, it is an unfair trade
12 practice to:
13 (1) Offer or sell a travel insurance policy that could never
14 result in payment of any claims for any insured under the policy; or
15 (2) Market blanket travel insurance coverage as free.
16 Sec. 13. RCW 48.17.060 and 2010 c 67 s 3 are each amended to
17 read as follows:
18 (1) A person shall not sell, solicit, or negotiate insurance in
19 this state for any line or lines of insurance unless the person is
20 licensed for that line of authority in accordance with this chapter.
21 (2)(a) A person may not act as or hold himself or herself out to
22 be an adjuster in this state unless licensed by the commissioner or
23 otherwise authorized to act as an adjuster under this chapter.
24 (b) In accordance with section 7(2) of this act, a travel
25 administrator, as defined in section 2 of this act, and its employees
26 are exempt from the licensing requirements of this subsection (2) for
27 travel insurance it administers.
28 (3) A person may not act as or hold himself or herself out to be
29 a crop adjuster in this state unless licensed by the commissioner or
30 otherwise authorized to act as a crop adjuster under this chapter.
31 Sec. 14. RCW 48.43.005 and 2024 c 218 s 1 are each amended to
32 read as follows:
33 Unless otherwise specifically provided, the definitions in this
34 section apply throughout this chapter.
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1 (1) "Adjusted community rate" means the rating method used to
2 establish the premium for health plans adjusted to reflect
3 actuarially demonstrated differences in utilization or cost
4 attributable to geographic region, age, family size, and use of
5 wellness activities.
6 (2) "Adverse benefit determination" means a denial, reduction, or
7 termination of, or a failure to provide or make payment, in whole or
8 in part, for a benefit, including a denial, reduction, termination,
9 or failure to provide or make payment that is based on a
10 determination of an enrollee's or applicant's eligibility to
11 participate in a plan, and including, with respect to group health
12 plans, a denial, reduction, or termination of, or a failure to
13 provide or make payment, in whole or in part, for a benefit resulting
14 from the application of any utilization review, as well as a failure
15 to cover an item or service for which benefits are otherwise provided
16 because it is determined to be experimental or investigational or not
17 medically necessary or appropriate.
18 (3) "Air ambulance service" has the same meaning as defined in
19 section 2799A-2 of the public health service act (42 U.S.C. Sec.
20 300gg-112) and implementing federal regulations in effect on March
21 31, 2022.
22 (4) "Allowed amount" means the maximum portion of a billed charge
23 a health carrier will pay, including any applicable enrollee cost-
24 sharing responsibility, for a covered health care service or item
25 rendered by a participating provider or facility or by a
26 nonparticipating provider or facility.
27 (5) "Applicant" means a person who applies for enrollment in an
28 individual health plan as the subscriber or an enrollee, or the
29 dependent or spouse of a subscriber or enrollee.
30 (6) "Balance bill" means a bill sent to an enrollee by a
31 nonparticipating provider or facility for health care services
32 provided to the enrollee after the provider or facility's billed
33 amount is not fully reimbursed by the carrier, exclusive of permitted
34 cost-sharing.
35 (7) "Basic health plan" means the plan described under chapter
36 70.47 RCW, as revised from time to time.
37 (8) "Basic health plan model plan" means a health plan as
38 required in RCW 70.47.060(2)(e).
39 (9) "Basic health plan services" means that schedule of covered
40 health services, including the description of how those benefits are
p. 13 SB 6248
1 to be administered, that are required to be delivered to an enrollee
2 under the basic health plan, as revised from time to time.
3 (10) "Behavioral health emergency services provider" means
4 emergency services provided in the following settings:
5 (a) A crisis stabilization unit as defined in RCW 71.05.020;
6 (b) A 23-hour crisis relief center as defined in RCW 71.24.025;
7 (c) An evaluation and treatment facility that can provide
8 directly, or by direct arrangement with other public or private
9 agencies, emergency evaluation and treatment, outpatient care, and
10 timely and appropriate inpatient care to persons suffering from a
11 mental disorder, and which is licensed or certified as such by the
12 department of health;
13 (d) An agency certified by the department of health under chapter
14 71.24 RCW to provide outpatient crisis services;
15 (e) An agency certified by the department of health under chapter
16 71.24 RCW to provide medically managed or medically monitored
17 withdrawal management services; or
18 (f) A mobile rapid response crisis team as defined in RCW
19 71.24.025 that is contracted with a behavioral health administrative
20 services organization operating under RCW 71.24.045 to provide crisis
21 response services in the behavioral health administrative services
22 organization's service area.
23 (11) "Board" means the governing board of the Washington health
24 benefit exchange established in chapter 43.71 RCW.
25 (12)(a) For grandfathered health benefit plans issued before
26 January 1, 2014, and renewed thereafter, "catastrophic health plan"
27 means:
28 (i) In the case of a contract, agreement, or policy covering a
29 single enrollee, a health benefit plan requiring a calendar year
30 deductible of, at a minimum, $1,750 and an annual out-of-pocket
31 expense required to be paid under the plan (other than for premiums)
32 for covered benefits of at least $3,500, both amounts to be adjusted
33 annually by the insurance commissioner; and
34 (ii) In the case of a contract, agreement, or policy covering
35 more than one enrollee, a health benefit plan requiring a calendar
36 year deductible of, at a minimum, $3,500 and an annual out-of-pocket
37 expense required to be paid under the plan (other than for premiums)
38 for covered benefits of at least $6,000, both amounts to be adjusted
39 annually by the insurance commissioner.
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1 (b) In July 2008, and in each July thereafter, the insurance
2 commissioner shall adjust the minimum deductible and out-of-pocket
3 expense required for a plan to qualify as a catastrophic plan to
4 reflect the percentage change in the consumer price index for medical
5 care for a preceding 12 months, as determined by the United States
6 department of labor. For a plan year beginning in 2014, the out-of-
7 pocket limits must be adjusted as specified in section 1302(c)(1) of
8 P.L. 111-148 of 2010, as amended. The adjusted amount shall apply on
9 the following January 1st.
10 (c) For health benefit plans issued on or after January 1, 2014,
11 "catastrophic health plan" means:
12 (i) A health benefit plan that meets the definition of
13 catastrophic plan set forth in section 1302(e) of P.L. 111-148 of
14 2010, as amended; or
15 (ii) A health benefit plan offered outside the exchange
16 marketplace that requires a calendar year deductible or out-of-pocket
17 expenses under the plan, other than for premiums, for covered
18 benefits, that meets or exceeds the commissioner's annual adjustment
19 under (b) of this subsection.
20 (13) "Certification" means a determination by a review
21 organization that an admission, extension of stay, or other health
22 care service or procedure has been reviewed and, based on the
23 information provided, meets the clinical requirements for medical
24 necessity, appropriateness, level of care, or effectiveness under the
25 auspices of the applicable health benefit plan.
26 (14) "Concurrent review" means utilization review conducted
27 during a patient's hospital stay or course of treatment.
28 (15) "Covered person" or "enrollee" means a person covered by a
29 health plan including an enrollee, subscriber, policyholder,
30 beneficiary of a group plan, or individual covered by any other
31 health plan.
32 (16) "Dependent" means, at a minimum, the enrollee's legal spouse
33 and dependent children who qualify for coverage under the enrollee's
34 health benefit plan.
35 (17) "Emergency medical condition" means a medical, mental
36 health, or substance use disorder condition manifesting itself by
37 acute symptoms of sufficient severity including, but not limited to,
38 severe pain or emotional distress, such that a prudent layperson, who
39 possesses an average knowledge of health and medicine, could
40 reasonably expect the absence of immediate medical, mental health, or
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1 substance use disorder treatment attention to result in a condition
2 (a) placing the health of the individual, or with respect to a
3 pregnant woman, the health of the woman or her unborn child, in
4 serious jeopardy, (b) serious impairment to bodily functions, or (c)
5 serious dysfunction of any bodily organ or part.
6 (18) "Emergency services" means:
7 (a)(i) A medical screening examination, as required under section
8 1867 of the social security act (42 U.S.C. Sec. 1395dd), that is
9 within the capability of the emergency department of a hospital,
10 including ancillary services routinely available to the emergency
11 department to evaluate that emergency medical condition;
12 (ii) Medical examination and treatment, to the extent they are
13 within the capabilities of the staff and facilities available at the
14 hospital, as are required under section 1867 of the social security
15 act (42 U.S.C. Sec. 1395dd) to stabilize the patient. Stabilize, with
16 respect to an emergency medical condition, has the meaning given in
17 section 1867(e)(3) of the social security act (42 U.S.C. Sec.
18 1395dd(e)(3)); and
19 (iii) Covered services provided by staff or facilities of a
20 hospital after the enrollee is stabilized and as part of outpatient
21 observation or an inpatient or outpatient stay with respect to the
22 visit during which screening and stabilization services have been
23 furnished. Poststabilization services relate to medical, mental
24 health, or substance use disorder treatment necessary in the short
25 term to avoid placing the health of the individual, or with respect
26 to a pregnant woman, the health of the woman or her unborn child, in
27 serious jeopardy, serious impairment to bodily functions, or serious
28 dysfunction of any bodily organ or part; or
29 (b)(i) A screening examination that is within the capability of a
30 behavioral health emergency services provider including ancillary
31 services routinely available to the behavioral health emergency
32 services provider to evaluate that emergency medical condition;
33 (ii) Examination and treatment, to the extent they are within the
34 capabilities of the staff and facilities available at the behavioral
35 health emergency services provider, as are required under section
36 1867 of the social security act (42 U.S.C. Sec. 1395dd) or as would
37 be required under such section if such section applied to behavioral
38 health emergency services providers, to stabilize the patient.
39 Stabilize, with respect to an emergency medical condition, has the
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1 meaning given in section 1867(e)(3) of the social security act (42
2 U.S.C. Sec. 1395dd(e)(3)); and
3 (iii) Covered behavioral health services provided by staff or
4 facilities of a behavioral health emergency services provider after
5 the enrollee is stabilized and as part of outpatient observation or
6 an inpatient or outpatient stay with respect to the visit during
7 which screening and stabilization services have been furnished.
8 Poststabilization services relate to mental health or substance use
9 disorder treatment necessary in the short term to avoid placing the
10 health of the individual, or with respect to a pregnant woman, the
11 health of the woman or her unborn child, in serious jeopardy, serious
12 impairment to bodily functions, or serious dysfunction of any bodily
13 organ or part.
14 (19) "Employee" has the same meaning given to the term, as of
15 January 1, 2008, under section 3(6) of the federal employee
16 retirement income security act of 1974.
17 (20) "Enrollee point-of-service cost-sharing" or "cost-sharing"
18 means amounts paid to health carriers directly providing services,
19 health care providers, or health care facilities by enrollees and may
20 include copayments, coinsurance, or deductibles.
21 (21) "Essential health benefit categories" means:
22 (a) Ambulatory patient services;
23 (b) Emergency services;
24 (c) Hospitalization;
25 (d) Maternity and newborn care;
26 (e) Mental health and substance use disorder services, including
27 behavioral health treatment;
28 (f) Prescription drugs;
29 (g) Rehabilitative and habilitative services and devices;
30 (h) Laboratory services;
31 (i) Preventive and wellness services and chronic disease
32 management; and
33 (j) Pediatric services, including oral and vision care.
34 (22) "Exchange" means the Washington health benefit exchange
35 established under chapter 43.71 RCW.
36 (23) "Final external review decision" means a determination by an
37 independent review organization at the conclusion of an external
38 review.
39 (24) "Final internal adverse benefit determination" means an
40 adverse benefit determination that has been upheld by a health plan
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1 or carrier at the completion of the internal appeals process, or an
2 adverse benefit determination with respect to which the internal
3 appeals process has been exhausted under the exhaustion rules
4 described in RCW 48.43.530 and 48.43.535.
5 (25) "Grandfathered health plan" means a group health plan or an
6 individual health plan that under section 1251 of the patient
7 protection and affordable care act, P.L. 111-148 (2010) and as
8 amended by the health care and education reconciliation act, P.L.
9 111-152 (2010) is not subject to subtitles A or C of the act as
10 amended.
11 (26) "Grievance" means a written complaint submitted by or on
12 behalf of a covered person regarding service delivery issues other
13 than denial of payment for medical services or nonprovision of
14 medical services, including dissatisfaction with medical care,
15 waiting time for medical services, provider or staff attitude or
16 demeanor, or dissatisfaction with service provided by the health
17 carrier.
18 (27) "Ground ambulance services" means:
19 (a) The rendering of medical treatment and care at the scene of a
20 medical emergency or while transporting a patient from the scene to
21 an appropriate health care facility or behavioral health emergency
22 services provider when the services are provided by one or more
23 ground ambulance vehicles designed for this purpose; and
24 (b) Ground ambulance transport between hospitals or behavioral
25 health emergency services providers, hospitals or behavioral health
26 emergency services providers and other health care facilities or
27 locations, and between health care facilities when the services are
28 medically necessary and are provided by one or more ground ambulance
29 vehicles designed for this purpose.
30 (28) "Ground ambulance services organization" means a public or
31 private organization licensed by the department of health under
32 chapter 18.73 RCW to provide ground ambulance services. For purposes
33 of this chapter, ground ambulance services organizations are not
34 considered providers.
35 (29) "Health care facility" or "facility" means hospices licensed
36 under chapter 70.127 RCW, hospitals licensed under chapter 70.41 RCW,
37 rural health care facilities as defined in RCW 70.175.020,
38 ((psychiatric)) behavioral health hospitals licensed under chapter
39 71.12 RCW, nursing homes licensed under chapter 18.51 RCW, community
40 mental health centers licensed under chapter 71.05 or 71.24 RCW,
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1 kidney disease treatment centers licensed under chapter 70.41 RCW,
2 ambulatory diagnostic, treatment, or surgical facilities licensed
3 under chapter 70.41 or 70.230 RCW, drug and alcohol treatment
4 facilities licensed under chapter 70.96A RCW, and home health
5 agencies licensed under chapter 70.127 RCW, and includes such
6 facilities if owned and operated by a political subdivision or
7 instrumentality of the state and such other facilities as required by
8 federal law and implementing regulations.
9 (30) "Health care provider" or "provider" means:
10 (a) A person regulated under Title 18 or chapter 70.127 RCW, to
11 practice health or health-related services or otherwise practicing
12 health care services in this state consistent with state law; or
13 (b) An employee or agent of a person described in (a) of this
14 subsection, acting in the course and scope of his or her employment.
15 (31) "Health care service" means that service offered or provided
16 by health care facilities and health care providers relating to the
17 prevention, cure, or treatment of illness, injury, or disease.
18 (32) "Health carrier" or "carrier" means a disability insurer
19 regulated under chapter 48.20 or 48.21 RCW, a health care service
20 contractor as defined in RCW 48.44.010, or a health maintenance
21 organization as defined in RCW 48.46.020, and includes "issuers" as
22 that term is used in the patient protection and affordable care act
23 (P.L. 111-148).
24 (33) "Health plan" or "health benefit plan" means any policy,
25 contract, or agreement offered by a health carrier to provide,
26 arrange, reimburse, or pay for health care services except the
27 following:
28 (a) Long-term care insurance governed by chapter 48.84 or 48.83
29 RCW;
30 (b) Medicare supplemental health insurance governed by chapter
31 48.66 RCW;
32 (c) Coverage supplemental to the coverage provided under chapter
33 55, Title 10, United States Code;
34 (d) Limited health care services offered by limited health care
35 service contractors in accordance with RCW 48.44.035;
36 (e) Disability income;
37 (f) Coverage incidental to a property/casualty liability
38 insurance policy such as automobile personal injury protection
39 coverage and homeowner guest medical;
40 (g) Workers' compensation coverage;
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1 (h) Accident only coverage;
2 (i) Specified disease or illness-triggered fixed payment
3 insurance, hospital confinement fixed payment insurance, or other
4 fixed payment insurance offered as an independent, noncoordinated
5 benefit;
6 (j) Employer-sponsored self-funded health plans;
7 (k) Dental only and vision only coverage;
8 (l) Plans deemed by the insurance commissioner to have a short-
9 term limited purpose or duration, or to be a student-only plan that
10 is guaranteed renewable while the covered person is enrolled as a
11 regular full-time undergraduate or graduate student at an accredited
12 higher education institution, after a written request for such
13 classification by the carrier and subsequent written approval by the
14 insurance commissioner;
15 (m) Civilian health and medical program for the veterans affairs
16 administration (CHAMPVA); ((and))
17 (n) Stand-alone prescription drug coverage that exclusively
18 supplements medicare part D coverage provided through an employer
19 group waiver plan under federal social security act regulation 42
20 C.F.R. Sec. 423.458(c); and
21 (o) Beginning January 1, 2027, travel insurance as defined in
22 section 2 of this act.
23 (34) "Individual market" means the market for health insurance
24 coverage offered to individuals other than in connection with a group
25 health plan.
26 (35) "In-network" or "participating" means a provider or facility
27 that has contracted with a carrier or a carrier's contractor or
28 subcontractor to provide health care services to enrollees and be
29 reimbursed by the carrier at a contracted rate as payment in full for
30 the health care services, including applicable cost-sharing
31 obligations.
32 (36) "Local governmental entity" means any entity that is
33 authorized to establish or provide ground ambulance services or set
34 rates for ground ambulance services, including those as authorized in
35 RCW 35.27.370, 35.23.456, 52.12.135, chapter 35.21 RCW, or as
36 authorized under any state law.
37 (37) "Material modification" means a change in the actuarial
38 value of the health plan as modified of more than five percent but
39 less than fifteen percent.
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1 (38) "Nonemergency health care services performed by
2 nonparticipating providers at certain participating facilities" means
3 covered items or services other than emergency services with respect
4 to a visit at a participating health care facility, as provided in
5 section 2799A-1(b) of the public health service act (42 U.S.C. Sec.
6 300gg-111(b)), 45 C.F.R. Sec. 149.30, and 45 C.F.R. Sec. 149.120 as
7 in effect on March 31, 2022.
8 (39) "Open enrollment" means a period of time as defined in rule
9 to be held at the same time each year, during which applicants may
10 enroll in a carrier's individual health benefit plan without being
11 subject to health screening or otherwise required to provide evidence
12 of insurability as a condition for enrollment.
13 (40) "Out-of-network" or "nonparticipating" means a provider or
14 facility that has not contracted with a carrier or a carrier's
15 contractor or subcontractor to provide health care services to
16 enrollees.
17 (41) "Out-of-pocket maximum" or "maximum out-of-pocket" means the
18 maximum amount an enrollee is required to pay in the form of cost-
19 sharing for covered benefits in a plan year, after which the carrier
20 covers the entirety of the allowed amount of covered benefits under
21 the contract of coverage.
22 (42) "Preexisting condition" means any medical condition,
23 illness, or injury that existed any time prior to the effective date
24 of coverage.
25 (43) "Premium" means all sums charged, received, or deposited by
26 a health carrier as consideration for a health plan or the
27 continuance of a health plan. Any assessment or any "membership,"
28 "policy," "contract," "service," or similar fee or charge made by a
29 health carrier in consideration for a health plan is deemed part of
30 the premium. "Premium" shall not include amounts paid as enrollee
31 point-of-service cost-sharing.
32 (44)(a) "Protected individual" means:
33 (i) An adult covered as a dependent on the enrollee's health
34 benefit plan, including an individual enrolled on the health benefit
35 plan of the individual's registered domestic partner; or
36 (ii) A minor who may obtain health care without the consent of a
37 parent or legal guardian, pursuant to state or federal law.
38 (b) "Protected individual" does not include an individual deemed
39 not competent to provide informed consent for care under RCW
40 11.88.010(1)(e).
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1 (45) "Review organization" means a disability insurer regulated
2 under chapter 48.20 or 48.21 RCW, health care service contractor as
3 defined in RCW 48.44.010, or health maintenance organization as
4 defined in RCW 48.46.020, and entities affiliated with, under
5 contract with, or acting on behalf of a health carrier to perform a
6 utilization review.
7 (46) "Sensitive health care services" means health services
8 related to reproductive health, sexually transmitted diseases,
9 substance use disorder, gender dysphoria, gender-affirming care,
10 domestic violence, and mental health.
11 (47) "Small employer" or "small group" means any person, firm,
12 corporation, partnership, association, political subdivision, sole
13 proprietor, or self-employed individual that is actively engaged in
14 business that employed an average of at least one but no more than 50
15 employees, during the previous calendar year and employed at least
16 one employee on the first day of the plan year, is not formed
17 primarily for purposes of buying health insurance, and in which a
18 bona fide employer-employee relationship exists. In determining the
19 number of employees, companies that are affiliated companies, or that
20 are eligible to file a combined tax return for purposes of taxation
21 by this state, shall be considered an employer. Subsequent to the
22 issuance of a health plan to a small employer and for the purpose of
23 determining eligibility, the size of a small employer shall be
24 determined annually. Except as otherwise specifically provided, a
25 small employer shall continue to be considered a small employer until
26 the plan anniversary following the date the small employer no longer
27 meets the requirements of this definition. A self-employed individual
28 or sole proprietor who is covered as a group of one must also: (a)
29 Have been employed by the same small employer or small group for at
30 least twelve months prior to application for small group coverage,
31 and (b) verify that he or she derived at least 75 percent of his or
32 her income from a trade or business through which the individual or
33 sole proprietor has attempted to earn taxable income and for which he
34 or she has filed the appropriate internal revenue service form 1040,
35 schedule C or F, for the previous taxable year, except a self-
36 employed individual or sole proprietor in an agricultural trade or
37 business, must have derived at least 51 percent of his or her income
38 from the trade or business through which the individual or sole
39 proprietor has attempted to earn taxable income and for which he or
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1 she has filed the appropriate internal revenue service form 1040, for
2 the previous taxable year.
3 (48) "Special enrollment" means a defined period of time of not
4 less than thirty-one days, triggered by a specific qualifying event
5 experienced by the applicant, during which applicants may enroll in
6 the carrier's individual health benefit plan without being subject to
7 health screening or otherwise required to provide evidence of
8 insurability as a condition for enrollment.
9 (49) "Standard health questionnaire" means the standard health
10 questionnaire designated under chapter 48.41 RCW.
11 (50) "Utilization review" means the prospective, concurrent, or
12 retrospective assessment of the necessity and appropriateness of the
13 allocation of health care resources and services of a provider or
14 facility, given or proposed to be given to an enrollee or group of
15 enrollees.
16 (51) "Wellness activity" means an explicit program of an activity
17 consistent with department of health guidelines, such as, smoking
18 cessation, injury and accident prevention, reduction of alcohol
19 misuse, appropriate weight reduction, exercise, automobile and
20 motorcycle safety, blood cholesterol reduction, and nutrition
21 education for the purpose of improving enrollee health status and
22 reducing health service costs.
23 NEW SECTION. Sec. 15. Sections 1 through 13 of this act take
24 effect January 1, 2027.
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