wa-law.org > bill > 2025-26 > SB 6210 > Original Bill

SB 6210 - Health plan certification

Source

Section 1

  1. The legislature finds that:

    1. Access to health care is fundamental to the health and safety of Washington state residents;

    2. Health insurance coverage is necessary for most people to access health care;

    3. Uncertainty in the health insurance marketplace is significantly impacted by the volatility in the federal legislative and regulatory environment;

    4. Rising health care costs are impacting access and affordability for Washington state residents;

    5. An unstable and volatile individual insurance market would be catastrophic and lead to:

      1. Deteriorating health outcomes;

      2. Declining work force productivity;

      3. Lower quality of life; and

      4. Increased burdens on safety net providers from the rising demand for uncompensated care;

    6. Each year, the Washington health benefit exchange board uses 19 basic criteria that were established in the affordable care act to review and certify health plans that will be offered to Washington state residents in the exchange market;

    7. These 19 basic criteria do not address access and affordability issues in the exchange market; and

    8. The affordable care act authorizes state exchanges to ensure that certified health plans are in the interest of the residents of the state by adopting additional health plan certification criteria to that effect. Access to and affordability of health plans are in the interest of residents of the state.

  2. Therefore, the legislature intends to authorize the Washington health benefit exchange to add criteria in the health plan certification process to address access and affordability issues impacting residents who purchase health insurance coverage on the exchange market and help reduce volatility in the exchange market.

Section 2

  1. The board shall certify a plan as a qualified health plan to be offered through the exchange if the plan is determined by the:

    1. Insurance commissioner to meet the requirements of Title 48 RCW and rules adopted by the commissioner pursuant to chapter 34.05 RCW to implement the requirements of Title 48 RCW;

    2. Board to meet the requirements of applicable federal law for certification as a qualified health plan;

    3. Board to meet the market factor criteria that address access and affordability as established in section 3 of this act; and

    4. Board to include tribal clinics and urban Indian clinics as essential community providers in the plan's provider network consistent with federal law. If consistent with federal law, integrated delivery systems shall be exempt from the requirement to include essential community providers in the provider network.

  2. Consistent with applicable federal law, the board shall allow stand-alone dental plans to offer coverage in the exchange beginning January 1, 2014. Dental benefits offered in the exchange must be offered and priced separately to assure transparency for consumers.

  3. The board may permit direct primary care medical home plans, consistent with applicable federal law, to be offered in the exchange.

  4. Upon request by the board, a state agency shall provide information to the board for its use in determining if the requirements under subsection (1)(b) or (c) of this section have been met. Unless the agency and the board agree to a later date, the agency shall provide the information within sixty days of the request. The exchange shall reimburse the agency for the cost of compiling and providing the requested information within one hundred eighty days of its receipt.

  5. A decision by the board denying a request to certify or recertify a plan as a qualified health plan may be appealed according to procedures adopted by the board.

Section 3

  1. Each year, after the board has reviewed and certified health plans to be offered on the exchange market in the following plan year, the exchange shall review market conditions and identify access and affordability issues in the exchange market that impact the next plan year for which the exchange has not yet certified plans.

  2. Each year, the exchange may adopt market factor certification criteria for the next plan year to address market conditions that impact access to and affordability of health plans for individuals or employers who are eligible to purchase coverage on the exchange market in Washington state. When developing the criteria, the exchange may consider whether health plans available in each county are:

    1. Meaningfully different with respect to a combination of or all of these measures, as determined by the exchange:

      1. Cost-sharing;

      2. Covered benefits;

      3. Premiums;

      4. Provider networks; or

    2. Quality;

    3. Offered by more than one carrier;

    4. Maximizing federal premium tax credits;

    5. Efficiently utilizing state premium assistance and other state investments; and

    6. Offered at each metal level required by the exchange.

  3. Market factor certification criteria shall be developed in consultation with the commissioner and the authority, and the exchange shall consider comments from:

    1. Carriers that offer or seek to offer qualified health plans on the exchange in the state;

    2. Federally recognized tribes in the state through the American Indian health commission; and

    3. Other health care stakeholders through their statewide associations or organizations.

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    1. For plan year 2028 and later, market factor certification criteria shall be developed in accordance with the following timeline:

      1. By December 15th of the calendar year two years before the plan year in which the market factor certification criteria are to apply, the exchange shall identify preliminary criteria and provide those criteria to the commissioner and the governor;

      2. By January 15th of the calendar year before the plan year in which the market factor certification criteria are to apply, the commissioner and the governor may submit to the exchange a written objection to any of the preliminary criteria;

      3. By January 31st of the calendar year before the plan year in which the market factor certification criteria are to apply, the exchange shall provide a written response to any objection, including whether and how the objection was addressed and what criteria were amended or removed based on the objection;

      4. By January 31st of the calendar year before the plan year in which the market factor certification criteria are to apply, the exchange shall publish the notice of the proposed market factor certification criteria on the exchange website and distribute the notice electronically to any person requesting the notice. The notice shall include:

(A) An explanation of the proposed market factor certification criteria;

(B) The time, date, and place for a public hearing; and

(C) The procedures and timelines for submitting written comments and supporting information;

v. No later than five business days before the publication of the final market factor certification criteria, the exchange shall hold at least one public hearing;

vi. By March 1st of the calendar year before the plan year in which the market factor certification criteria are to apply, the exchange shall provide written notice of the final market factor certification criteria to carriers that offer health plans subject to certification under RCW 43.71.065, and shall publish the notice of the final market factor certification criteria on the exchange website and distribute the notice electronically to any person requesting the notice;

vii. After March 1st of the calendar year before the plan year in which the market factor certification criteria are to apply, the exchange may only modify the market factor certification criteria as necessary to respond to any applicable changes to state or federal laws or regulations. Any modification initiated under this subsection that impacts a carrier's preliminary health plan filings is only in effect if agreed to by the commissioner.

b. For plan year 2027, market factor certification criteria shall be developed in accordance with procedures established by the exchange.

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    1. The exchange may require a carrier that is intending to offer health plans on the exchange to submit information, including the carrier's proposed service areas, proposed plan offerings and rates on the exchange, and how the carrier intends to meet the market factor certification criteria.

    2. No earlier than March 1st and no later than May 1st each year, the carrier shall provide the information to the exchange. The specific date must be determined by the exchange before March 1st.

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    1. A carrier may request a waiver of the market factor certification criteria.

    2. Requests for a waiver must be submitted to the exchange at a date specified by the exchange but will be no earlier than March 1st and no later than 14 days prior to the deadline established by the commissioner each year for preliminary health plans filings.

    3. In evaluating a request for a waiver, the exchange may:

      1. Review information that demonstrates the carrier attempted to meet the market factor certification criteria, such as information that the carrier made a good faith effort to contract with providers to establish an adequate network, the cost of the potential provider network, impact on premiums, legal prohibitions, or other barriers that impact the carrier's ability to offer coverage in certain service areas, and any impact on other service areas;

      2. Request that the carrier submit information about service areas and rates that would be in place with the market factor certification criteria and if the waiver were granted;

      3. Consider the totality of the proposed health plans and the impact of granting or not granting the waiver of the market factor certification criteria on the interests of Washington state residents.

    4. The exchange shall conclude any waiver determinations regarding market factor certification criteria from any carrier that has requested a waiver prior to the carrier submitting preliminary health plan filings for the upcoming plan year to the commissioner.

  3. Any information and data submitted by a carrier to the exchange under this section is confidential and not subject to public disclosure under chapter 42.56 RCW.

  4. Market factor certification criteria may not directly impose network participation requirements or reimbursement limits on hospitals or providers except as otherwise required by federal or state laws.

  5. Nothing in this section prohibits a carrier from offering a health plan that does not meet the requirements in RCW 43.71.065 in the individual market or small group market outside the exchange.

Section 4

Any information or data submitted by a carrier to the health benefit exchange for the purposes of the market factor certification criteria under section 3 of this act are confidential and exempt from disclosure under this chapter.

Section 5

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.

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