Washington Health Study Guide

Start with the vocabulary or nothing else lands. Washington’s line of authority for accident and health is “Disability” — RCW 48.17.170(1)(b): “insurance coverage for accident, health, and disability or sickness, bodily injury, or accidental death,” which “may include benefits for disability income.” When a Washington item says disability, it usually means what your national course called health. Then the structural surprise: this state’s best-known health rules are standards on a book of business, not promises to one claimant.

Prompt pay is a standard on the monthly book, not a per-claim deadline

The rule reads nothing like “every clean claim must be paid in 30 days.” WAC 284-170-431(2)(a)(i) requires 95% of the monthly volume of CLEAN claims to be PAID within 30 days of receipt by the carrier or its agent — a standard on the book, working through participating provider and facility contracts.

The 60-day prong is not that rule at a slower speed. WAC 284-170-431(2)(a)(ii) requires 95% of the monthly volume of ALL claims to be paid OR DENIED within 60 days, except as agreed in writing by the parties on a claim-by-claim basis. Count the differences: clean versus all, and pay versus pay-or-deny. Two changes, not one.

Then a third number, not 60. Interest of 1% per month, simple and prorated for part of a month, attaches to claims that are undenied, unpaid, clean and more than 61 days old (WAC 284-170-431(2)(d), (6), (7)). The carrier adds it automatically, and may not charge it against the covered person’s deductible, copayment or coinsurance.

One distinction Washington does not draw: electronic versus paper. WAC 284-170-431(2)(b) treats “either written or electronic notice” alike.

External review — one two-pronged clock, and a 45 that belongs to somebody else

The independent review organization decides within 15 days after receiving the necessary information, OR 20 days after receiving the referral, whichever is EARLIER (WAC 284-43A-070(3)(a)) — a single two-pronged test in one sentence, not two competing deadlines. Extendable to 25 days after referral in exceptional circumstances; expedited review is 72 hours (RCW 48.43.535(7)(a)).

The decision binds the carrier, which “must timely implement the certified independent review organization’s determination, and must pay the certified independent review organization’s charges.” Review is without cost to the appellant (RCW 48.43.535(3), (8)).

Continuation runs to the group; conversion runs to the person

Federal COBRA applies at 20 or more employees. Washington does not answer it with a mini-COBRA. RCW 48.21.250, RCW 48.44.360 and RCW 48.46.440 create an offer duty running to the group: every insurer, health care service contractor and HMO “shall offer the policyholder an option to include a policy provision” granting continuation to a person who becomes ineligible. Whether any employee gets it depends on whether the group bought the option.

That is why no month count exists. All three sections say the continuation runs “for a period of time and at a rate agreed upon.” No duration, no maximum premium percentage, no election window appears in any of them.

The real individual right is conversion, and it has a hard number. Written application and the first premium payment not later than 31 days after coverage terminates, or 31 days after the person received notice of termination, whichever is LATER (RCW 48.21.260(3); RCW 48.44.370(3)). A slow notice extends the window. The policy takes effect without a lapse in coverage, and its premium comes from the insurer’s rate table for the age and class of risk — not a percentage of the group rate (RCW 48.21.260(5)).

Two carve-outs finish it. A person terminated for misconduct need not be offered conversion — but a conversion policy “shall be offered to the spouse and/or dependents” of that person, on the same terms as anyone terminated for other reasons (RCW 48.21.260(2)(a)-(c)). And a covered spouse or dependent who stops being a qualified family member by reason of termination of marriage or death of the principal enrollee may continue the coverage without a physical examination, statement of health, or other proof of insurability (RCW 48.44.400; RCW 48.46.480) — with no stated duration at all.

Two numbers that sit lower than you expect

A short-term limited duration medical plan runs a maximum of three months from the original effective date, including any extension the member may elect, and cannot be renewed or extended — except while a member remains hospitalized as an inpatient on the expiration date (WAC 284-43-8000).

Washington’s small employer employed an average of at least ONE but no more than 50 employees (RCW 48.43.005(47)). The floor is one, and the state merges “small employer” and “small group” into one term.