CurrentWashington Office of the Insurance CommissionerPolicy N/A

OIC's Interpretation of Chapter 48.200 RCW - Health care benefit managers

Customize your policy alerts

Sign up for all Washington Office of the Insurance Commissioner policy alerts

Know when Washington Office of the Insurance Commissioner releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Advisory guidance interpreting Chapter 48.200 RCW and E2SSB 5213 on registration, filing, and applicability requirements for HCBMs and PBMs operating in Washington State.

Policy Summary

PayerWashington Office of the Insurance Commissioner

PolicyOIC's Interpretation of Chapter 48.200 RCW - Health care benefit managers

Policy CodePolicy N/A

Change TypeAdvisory interpretation / Implementation guidance

Effective DateSep 15, 2025

Next Review DateN/A

Key ActionHCBMs and PBMs must register with the Insurance Commissioner and annually renew registration to conduct business in Washington.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

RequiredRegistration required

30 daysFile contracts within

60 daysPre-7/23/2023 contracts filed within

Dec 1, 2025Opt-in list posted by

Applicability, Registration, Filing, and Opt‑In Rules

Applicability and registration/filing obligations for HCBMs and PBMs operating in Washington

Applicability, registration, filing, and opt-in obligations for HCBMs and PBMs operating in Washington:

HCBMs must register with the Insurance Commissioner and annually renew registration to conduct business in Washington.

PBMs must register with the Insurance Commissioner and annually renew registration; PBMs are subject to general HCBM requirements (RCW 48.200.030–.050) and PBM-specific provisions (RCW 48.200.220–.320).

HCBMs must file with OIC all benefit management contracts and contract amendments between the HCBM and a health carrier, provider, pharmacy, pharmacy services administration organization, or other HCBM entered into directly or indirectly in support of a contract with a carrier or employee benefits program.

Contracts and contract amendments must be filed within 30 days following the effective date of the contract or contract amendment. Contracts and contract amendments between HCBMs and health carriers that were executed prior to July 23, 2023 and are currently in force must be filed no later than 60 days following July 23, 2023.

Exclusions (Chapter 48.200 does not apply when HCBMs provide services exclusively to):

Medicare supplement plans
Medicare Advantage plans (Part C of Medicare)
Medicaid (except PBMs that contract with pharmacies on behalf of Medicaid managed care plans)
Children's Health Insurance Program plans
Discount plans
Union plans
Self-insured health plans (unless the plan is an employee benefits program defined under RCW 48.200.020)
Plans that provide monetary payment (e.g., income replacement disability plans or life insurance accelerate benefits), unless they provide coverage for health care services, drugs, and supplies

E2SSB 5213 permits self-funded private group health plans governed by ERISA to opt in to RCW 48.200.280, .310, and .320; if a plan opts in, PBMs administering that plan must comply with those sections but are not subject to other provisions of Chapter 48.200 RCW, and OIC lacks enforcement authority over PBM conduct under opt-in contracts.

OIC will implement the self-funded private group health plan opt-in process in Fall 2025 and will publish a list of plans that have opted in on its website on or before December 1, 2025.

Provider‑Facing Actions and Impact

Prior Authorization

HCBM activities that affect benefit determination or access

Health care benefit managers (HCBMs) perform activities that can determine or restrict access to benefits and care, including prior authorization or preauthorization of benefits or care; certification of benefits or care; medical necessity determinations; utilization review; benefit determinations; claims processing and repricing; outcome management; payment or authorization of payment; dispute resolution, grievances, or appeals; provider network management; and disease management. These are treated as HCBM activities that affect benefit determination or access under Chapter 48.200 RCW.

Prior authorization or preauthorization of benefits or care
Certification of benefits or care
Medical necessity determinations
Utilization review
Benefit determinations
Claims processing and repricing for services and procedures
Outcome management
Payment or authorization of payment to providers and facilities
Dispute resolution, grievances, or appeals relating to determinations or utilization of benefits
Provider network management
Disease management

Key Definitions

inv-03: Definition — Health care benefit manager (HCBM)

DefinitionA person or entity providing services to, or acting on behalf of, a health carrier or employee benefits program that directly or indirectly impacts the determination or utilization of benefits for, or patient access to, health care services, drugs, and supplies (examples include prior authorization, certification of benefits, medical necessity determinations, utilization review, benefit determinations, claims processing and repricing, outcome management, payment authorization, dispute resolution, provider network management, and disease management).

Sub-typesIncludes sub-types such as laboratory benefit manager, mental health benefit manager, and pharmacy benefit manager.

Scope of applicationChapter 48.200 RCW applies to HCBMs that provide any of the listed services to, or act on behalf of, health carriers or employee benefits programs as defined in RCW 48.200.020.

Excluded entitiesHCBMs do not include certain specified entities (see advisory for complete list).

inv-04: Definition — Pharmacy benefit manager (PBM)

DefinitionA person that contracts with pharmacies on behalf of a health carrier, employee benefits program, or Medicaid managed care program to process claims for prescription drugs or medical supplies, provide retail network management, pay pharmacies, negotiate rebates/discounts, establish or manage pharmacy networks, or make credentialing determinations.

Registration requirementPBMs must register with the Office of the Insurance Commissioner and annually renew their registration to conduct business in Washington.

Applicable statutesPBMs must comply with RCW 48.200.030 through .050 (general HCBM requirements) and RCW 48.200.220 through .320 (PBM-specific provisions).

Scope of services coveredServices include processing claims, paying pharmacies, negotiating rebates/discounts, managing pharmacy networks, and making credentialing determinations when performed on behalf of health carriers, employee benefits programs, or Medicaid managed care programs.

Policy Summary

PayerWashington Office of the Insurance Commissioner

PolicyOIC's Interpretation of Chapter 48.200 RCW - Health care benefit managers

Policy CodePolicy N/A

Change TypeAdvisory interpretation / Implementation guidance

Effective DateSep 15, 2025

Next Review DateN/A

Key ActionHCBMs and PBMs must register with the Insurance Commissioner and annually renew registration to conduct business in Washington.

SourceLink

On This Page

OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

OIC's Interpretation of Chapter 48.200 RCW - Health care benefit managers

Customize your policy alerts

Sign up for all Washington Office of the Insurance Commissioner policy alerts

Know when Washington Office of the Insurance Commissioner releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Advisory guidance interpreting Chapter 48.200 RCW and E2SSB 5213 on registration, filing, and applicability requirements for HCBMs and PBMs operating in Washington State.

Applicability, Registration, Filing, and Opt‑In Rules

Applicability and registration/filing obligations for HCBMs and PBMs operating in Washington

Applicability, registration, filing, and opt-in obligations for HCBMs and PBMs operating in Washington:

HCBMs must register with the Insurance Commissioner and annually renew registration to conduct business in Washington.

Exclusions (Chapter 48.200 does not apply when HCBMs provide services exclusively to):

Medicare supplement plans
Medicare Advantage plans (Part C of Medicare)
Medicaid (except PBMs that contract with pharmacies on behalf of Medicaid managed care plans)
Children's Health Insurance Program plans
Discount plans
Union plans
Self-insured health plans (unless the plan is an employee benefits program defined under RCW 48.200.020)
Plans that provide monetary payment (e.g., income replacement disability plans or life insurance accelerate benefits), unless they provide coverage for health care services, drugs, and supplies

OIC will implement the self-funded private group health plan opt-in process in Fall 2025 and will publish a list of plans that have opted in on its website on or before December 1, 2025.

Provider‑Facing Actions and Impact

Prior Authorization

HCBM activities that affect benefit determination or access

Prior authorization or preauthorization of benefits or care
Certification of benefits or care
Medical necessity determinations
Utilization review
Benefit determinations
Claims processing and repricing for services and procedures
Outcome management
Payment or authorization of payment to providers and facilities
Dispute resolution, grievances, or appeals relating to determinations or utilization of benefits
Provider network management
Disease management

Key Definitions

inv-03: Definition — Health care benefit manager (HCBM)

Sub-typesIncludes sub-types such as laboratory benefit manager, mental health benefit manager, and pharmacy benefit manager.

Scope of applicationChapter 48.200 RCW applies to HCBMs that provide any of the listed services to, or act on behalf of, health carriers or employee benefits programs as defined in RCW 48.200.020.

Excluded entitiesHCBMs do not include certain specified entities (see advisory for complete list).

inv-04: Definition — Pharmacy benefit manager (PBM)

Registration requirementPBMs must register with the Office of the Insurance Commissioner and annually renew their registration to conduct business in Washington.

Applicable statutesPBMs must comply with RCW 48.200.030 through .050 (general HCBM requirements) and RCW 48.200.220 through .320 (PBM-specific provisions).