wa-law.org > bill > 2025-26 > SB 5967 > Original Bill
It is the intent of the legislature to preserve access to evidence-based preventive health services for people residing in Washington state who choose to use such services.
The legislature does not intend to establish new requirements that any individual receive any immunization or other preventive health service, nor does the legislature intend to modify, limit, or expand existing laws related to informed consent for health care decisions for minors or adults.
The department may issue immunization recommendations and related guidance. In developing its recommendations, the department must consider the recommendations of the advisory committee on immunization practices of the United States centers for disease control and prevention and experts and expert organizations that the department in its discretion deems relevant and based on reasonable scientific evidence and judgment. Any recommendations or guidance issued by the department under this section shall be posted on the department's website. Any recommendations or guidance issued by the department under this section are not subject to the rule-making requirements of chapter 34.05 RCW.
A nongrandfathered health plan issued on or after April 1, 2026, must, at a minimum, provide coverage for the following preventive services :
b.
With respect to infants, children, and adolescents, evidence-informed preventive care and screenings provided for in comprehensive guidelines supported by the health resources and services administration in effect on June 30, 2025, and preventive care and screenings included in rules adopted by the insurance commissioner under this section;
c. With respect to women, additional preventive care and screenings that are not listed with a rating of A or B by the United States preventive services task force but that are provided for in comprehensive guidelines supported by the health resources and services administration in effect on June 30, 2025, and preventive care and screenings included in rules adopted by the insurance commissioner under this section; and
d. Immunizations that have in effect a recommendation from the department of health under section 2 of this act.
A nongrandfathered health plan must provide coverage for :
The preventive services required to be covered under subsection (1)(a) through (c) of this section consistent with federal rules and guidance related to coverage of such preventive services in effect on June 30, 2025, and rules adopted by the insurance commissioner under this section; and
Immunizations required to be covered under subsection (1)(d) of this section consistent with department of health guidance issued under section 2 of this act.
A nongrandfathered health plan must provide coverage for the preventive services required to be covered under subsections (1) and (2) of this section for plan years that begin on or after the date that is one year after the date the recommendation or guideline is issued.
4.
a. Except as provided in (b) of this subsection, the health plan may not impose cost-sharing requirements for the preventive services required to be covered under subsections (1) and (2) of this section when the services are provided by an in-network provider. If a plan does not have in its network a provider who can provide an item or service described in subsections (1) and (2) of this section, the plan must cover the item or service when performed by an out-of-network provider and may not impose cost sharing with respect to the item or service.
b. For a health plan offered as a qualifying health plan for a health savings account, the carrier may apply cost sharing to coverage of the services required to be covered under subsections (1) and (2) of this section only at the minimum level necessary to preserve the enrollee's ability to claim tax exempt contributions and withdrawals from the enrollee's health savings account under internal revenue service laws and regulations.
A carrier may use reasonable medical management techniques to determine the frequency, method, treatment, or setting for an item or service described in subsections (1) and (2) of this section to the extent not specified in the relevant recommendation or guideline, federal rules and guidance related to the coverage of preventive services in effect on June 30, 2025, department of health guidance issued under section 2 of this act, and any rules adopted by the insurance commissioner.
The insurance commissioner may adopt rules necessary to implement the requirements of this section, including rules modifying coverage requirements for preventive services under subsection (1)(a) through (c) of this section based on the addition of preventive services or other changes to the recommendations and guidelines referenced in subsection (1)(a) through (c) of this section that are made after June 30, 2025. Any rules adopted by the insurance commissioner must be as or more favorable to enrollees with respect to coverage of preventive services than the recommendations and guidelines in effect on June 30, 2025. In adopting any rules under this subsection, the insurance commissioner must:
Consult with the health care authority and department of health; and
Consider the recommendations of the department of health issued under section 2 of this act and recommendations issued by the United States preventive services task force, the health resources and services administration, and experts and expert organizations that the commissioner in their discretion deems relevant and based on reasonable scientific evidence and judgment.
The definitions in this section apply throughout this chapter unless the context clearly requires otherwise.
"Association" means the Washington vaccine association.
"Covered lives" means all persons under the age of nineteen in Washington state who are:
Covered under an individual or group health benefit plan issued or delivered in Washington state or an individual or group health benefit plan that otherwise provides benefits to Washington residents; or
Enrolled in a group health benefit plan administered by a third-party administrator. Persons under the age of nineteen for whom federal funding is used to purchase vaccines or who are enrolled in state purchased health care programs covering low-income children including, but not limited to, apple health for kids under RCW 74.09.470 and the basic health plan under chapter 70.47 RCW are not considered "covered lives" under this chapter.
"Estimated vaccine cost" means the estimated cost to the state over the course of a state fiscal year for the purchase and distribution of vaccines purchased by the department of health.
"Health benefit plan" has the same meaning as defined in RCW 48.43.005 and also includes health benefit plans administered by a third-party administrator.
"Health carrier" has the same meaning as defined in RCW 48.43.005.
"Secretary" means the secretary of the department of health.
"State supplied vaccine" means vaccine purchased by the state department of health for covered lives for whom the state is purchasing vaccine using state funds raised via assessments on health carriers and third-party administrators as provided in this chapter.
"Third-party administrator" means any person or entity who, on behalf of a health insurer or health care purchaser, receives or collects charges, contributions, or premiums for, or adjusts or settles claims on or for, residents of Washington state or Washington health care providers and facilities.
"Total nonfederal program cost" means the estimated vaccine cost less the amount of federal revenue available to the state for the purchase and distribution of vaccines.
"Vaccine" means an immunization recommended by the department of health under section 2 of this act for administration to persons under the age of 19 years and approved by the federal food and drug administration as safe and effective in any manner.
The secretary shall estimate the total nonfederal program cost for the upcoming calendar year by October 1, 2010, and October 1st of each year thereafter, prioritizing purchasing at the federal discount rate or, if not available, at the most cost-effective rate. Additionally, the secretary shall subtract any amounts needed to serve children enrolled in state purchased health care programs covering low-income children for whom federal vaccine funding is not available, and report the final amount to the association. In addition, the secretary shall perform such calculation for the period of May 1st through December 31st, 2010, as soon as feasible but in no event later than April 1, 2010. The estimates shall be timely communicated to the association.
The board of directors of the association shall determine the method and timing of assessment collection in consultation with the department of health. The board shall use a formula designed by the board to ensure the total anticipated nonfederal program cost, minus costs for other children served through state purchased health care programs covering low-income children, calculated under subsection (1) of this section, is collected and transmitted to the universal vaccine purchase account created in RCW 43.70.720 in order to ensure adequacy of state funds to order state-supplied vaccine .
Each licensed health carrier and each third-party administrator on behalf of its clients' health benefit plans must be assessed and is required to timely remit payment for its share of the total amount needed to fund nonfederal program costs calculated by the department of health. Such an assessment includes additional funds as determined necessary by the board to cover the reasonable costs for the association's administration. The board shall determine the assessment methodology, with the intent of ensuring that the nonfederal costs are based on actual usage of vaccine for a health carrier or third-party administrator's covered lives. State and local governments and school districts must pay their portion of vaccine expense for covered lives under this chapter.
The board of the association shall develop a mechanism through which the number and cost of doses of vaccine purchased under this chapter that have been administered to children covered by each health carrier, and each third-party administrator's clients health benefit plans, are attributed to each such health carrier and third-party administrator. Except as otherwise permitted by the board, this mechanism must include at least the following: Date of service; patient name; vaccine received; and health benefit plan eligibility. The data must be collected and maintained in a manner consistent with applicable state and federal health information privacy laws. Beginning November 1, 2011, and each November 1st thereafter, the board shall factor the results of this mechanism for the previous year into the determination of the appropriate assessment amount for each health carrier and third-party administrator for the upcoming year.
For any year in which the total calculated cost to be received from association members through assessments is less than the total nonfederal program cost, the association must pay the difference to the state for deposit into the universal vaccine purchase account established in RCW 43.70.720. The board may assess, and the health carrier and third-party administrators are obligated to pay, their proportionate share of such costs and appropriate reserves as determined by the board.
The aggregate amount to be raised by the association in any year may be reduced by any surpluses remaining from prior years.
In order to generate sufficient start-up funding, the association may accept prepayment from member health carriers and third-party administrators, subject to offset of future amounts otherwise owing or other repayment method as determined by the board. The initial deposit of start-up funding must be deposited into the universal vaccine purchase account on or before April 30, 2010.
If any provision of this act or its application to any person or circumstance is held invalid, the remainder of the act or the application of the provision to other persons or circumstances is not affected.
This act is necessary for the immediate preservation of the public peace, health, or safety, or support of the state government and its existing public institutions, and takes effect immediately.