Health Care Benefit Manager Laws and Regulations - The National Law Review
New Law Regulating Health Care Benefit Managers in Washington State
We have previously reported on the new law that became effective this past summer in Washington requiring TPAs that administer self-funded workers’ compensation to become licensed with the Washington Department of Labor. However, Washington has enacted another law governing Health Care Benefit Managers (“HCBMs”), effective January 1, 2022, codified at Wash. Rev. Code §§ 48.200.010 et seq. The law requires HCBMs to become registered with the Washington Office of Insurance Regulation (“OIC”). The purpose of the new law is to regulate entities not currently subject to regulation that act as intermediaries between health carriers, health care providers, and consumers and that are involved in making health care decisions on behalf of health carriers. The OIC has recently adopted regulations to implement the new law. See Wash. Admin. Code §§ 284-180-110 et seq.
The term “HCBM” is defined in the new Washington law in section 48.200.020(4)(a) as:
[A] person or entity providing services to, or acting on behalf of, a health carrier or employee benefits programs, that directly or indirectly impacts the determination or utilization of benefits for, or patients access to, health care services, drugs, and supplies including but not limited to the following services:
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Prior authorization or preauthorization of benefits or care.
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Certification of benefits or care.
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Medical necessity determinations.
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