New law governing health care delivery managers

We have previously reported on new law that came into effect last summer in Washington requiring PTAs that administer self-funded workers’ compensation to obtain a license from the Washington Department of Labor. However, Washington enacted another law governing healthcare delivery managers (“HCBM”), effective January 1, 2022, codified in the Wash Code. Rev. §§ 48.200.010 et seq. The law requires that HCBMs be registered with the Washington Office of Insurance Regulation (“OIC”). The purpose of the new law is to regulate currently unregulated entities that act as intermediaries between healthcare carriers, healthcare providers and consumers and who are involved in decision-making in such matters. health care on behalf of health carriers. The OIC recently adopted regulations to implement the new law. See Admin Wash. Code §§ 284-180-110 and following.

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 provider of health care or employee benefit programs, that have a direct or indirect impact on the determination or use of benefits for, or the ” patient access to health care services, drugs and supplies, including but not limited to the following:

  • Prior authorization or pre-authorization of services or care.

  • Certificate of services or care.

  • Determinations of medical necessity.

  • Review of use.

  • Determination of benefits.

  • Processing of complaints and re-pricing of services and procedures.

  • Results management.

  • Identification and reaccreditation of the supplier.

  • Payment or authorization of payment to providers and facilities for services or procedures.

  • Resolution of disputes, grievances or appeals relating to the determination or use of benefits.

  • Supplier network management.

  • Disease management.

Washington’s new law requires that Pharmacy Benefit Managers (“PBMs”), who previously had to register as PBMs, are now registered as HCBMs. Additionally, the new law applies to TPAs ​​that provide services such as handling complaints, reviewing prices, or determining benefits for healthcare providers in Washington. The law does not apply to PTAs who administer life insurance benefits or who only collect and remit premiums. Prior to the enactment of this law, Washington was one of the few states that had no obligation to authorize or regulate PTAs.

Entities providing services to “employee benefit programs” are also subject to the new law. However, the legal definition of employee benefit programs is limited only to programs under the state public employee benefits commission or the school employee benefits commission. In accordance with the regulations, the law does not apply to service providers for self-insured health plans under ERISA. Washing. Admin. Code § 284-180-120.

Under the new law, carriers health and benefit programs are strictly “responsible for the compliance of any person or organization acting directly or indirectly on behalf of or on instruction from the carrier or program, or acting in accordance with standards. or the carrier’s requirements for coverage, payment or provision of health care benefits, services, drugs and supplies. Wash. Rev. Code § 48.200.050 (5) (b). Healthcare carriers are also liable for violations of the new law by an HCBM, and carriers are subject to fines for acts of an HCBM under their contract with an HCBM. If an HCBM violates any of the laws or regulations relating to HCBMs, the Commissariat is authorized to place an HCBM on probation, suspend or revoke registration, issue a cease and desist order, impose a fine of up to $ 5,000 per violation or require corrective action. Carriers must file all contracts and contract amendments with an HCBM with the Commissariat within 30 days of the effective date of the contract or amendment.

To obtain an application for HCBM, an application must be submitted to the Commissariat for an HCBM. Once OCOL staff have reviewed the information in the application, OCOL will send an email with instructions on how to log into the OCOL online system and pay the required $ 200 fee.

© Polsinelli PC, Polsinelli LLP in CaliforniaRevue nationale de droit, volume XI, number 322

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