OIC’s Interpretation of Chapter 48.200 RCW – Health care benefit managers

PATTY KUDERER

STATE INSURANCE COMMISSIONER

STATE OF WASHINGTON

OFFICE OF

INSURANCE COMMISSIONER

Phone: 360-725-7000

www.insurance.wa.gov

Mailing Address: PO Box 40255 Olympia, WA 98504-0255

Street Address: 5000 Capitol Blvd Tumwater WA 98501

Technical Assistance Advisory 2025-021

TO:

All health care benefit managers and health carriers operating in the State of

Washington

FROM:

Insurance Commissioner Patty Kuderer

DATE:

September 15, 2025

SUBJECT: OIC’s Interpretation of Chapter 48.200 RCW – Health care benefit managers

The purpose of this Technical Assistance Advisory (“TAA”) is to provide guidance related to the

application of Chapter 48.200 RCW to health care benefit managers, including pharmacy benefit

managers, and provide guidance related to provisions enacted by Engrossed Second Substitute Senate

Bill 5213 (E2SSB 5213, Chapter 242, Laws of 2024). The Washington State Office of the Insurance

Commissioner (“OIC”) released a preproposal statement of inquiry (CR-101) on July 22, 2025,

pertaining to E2SSB 5213 and health care benefit managers (R 2025-11, WSR 25-15-143).

Background

The Legislature enacted Chapter 48.200 RCW in 2020, with the express intent to protect and promote

the health, safety, and welfare of Washington residents by establishing standards for regulatory

oversight of health care benefit managers.2

Health Care Benefit Managers

To conduct business in Washington state, health care benefit managers (“HCBMs”) are required to

register with the Insurance Commissioner and annually renew their registration.3 “Health care benefit

manager” is defined as follows:

1 This advisory is an interpretive policy statement released to advise the public of the OIC’s current opinions,

approaches, and likely courses of action. It is advisory only. RCW 34.05.230(1).

2 RCW 48.200.010.

3 RCW 48.200.030.

(“HCBMs”) are required to

register with the Insurance Commissioner and annually renew their registration.3 “Health care benefit

manager” is defined as follows:

1 This advisory is an interpretive policy statement released to advise the public of the OIC’s current opinions,

approaches, and likely courses of action. It is advisory only. RCW 34.05.230(1).

2 RCW 48.200.010.

3 RCW 48.200.030.

OFFICE OF THE INSURANCE COMMISSIONER

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OIC’s Interpretation of Chapter 48.200 RCW – Health care benefit managers

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A person or entity providing services to, or acting on behalf of, a health carrier or employee

benefits programs, that directly or indirectly impacts the determination or utilization of benefits

for, or patient access to, health care services, drugs, and supplies including, but not limited to:

• 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 for services or procedures;

• Dispute resolution, grievances, or appeals relating to determinations or utilization of benefits;

• Provider network management; or

• Disease management.4

There are several sub-types of HCBMs, such as laboratory benefit manager, mental health benefit

manager, and pharmacy benefit manager.5 Chapter 48.200 RCW applies to health care benefit

managers, as defined in RCW 48.200.020, who provide any of the services listed above to, or act on

behalf of health carriers as defined in RCW 48.200.020 or employee benefits programs6 as defined in

RCW 48.200.020

e are several sub-types of HCBMs, such as laboratory benefit manager, mental health benefit

manager, and pharmacy benefit manager.5 Chapter 48.200 RCW applies to health care benefit

managers, as defined in RCW 48.200.020, who provide any of the services listed above to, or act on

behalf of health carriers as defined in RCW 48.200.020 or employee benefits programs6 as defined in

RCW 48.200.020. Health care benefit managers do not include the following:

• Health care service contractors as defined in RCW 48.44.010;

• Health maintenance organizations as defined in RCW 48.46.020;

• Issuers as defined in RCW 48.01.053;

• The public employees' benefits board established in RCW 41.05.055;

• The school employees' benefits board established in RCW 41.05.740;

• Discount plans as defined in RCW 48.155.010;

• Direct patient-provider primary care practices as defined in RCW 48.150.010;

• An employer administering its employee benefit plan or the employee benefit plan of an

affiliated employer under common management and control;

• A union, either on its own or jointly with an employer, administering a benefit plan on behalf

of its members;

• An insurance producer selling insurance or engaged in related activities within the scope of

the producer's license;

4 RCW 48.200.020(5)(a).

5 See definitions of laboratory benefit manager, mental health benefit manager, and pharmacy benefit

manager under RCW 48.200.020.

6 "Employee benefits programs" means programs under both the public employees' benefits board established

in RCW 41.05.055 and the school employees' benefits board established in RCW 41.05.740. Id.

he scope of

the producer's license;

4 RCW 48.200.020(5)(a).

5 See definitions of laboratory benefit manager, mental health benefit manager, and pharmacy benefit

manager under RCW 48.200.020.

6 "Employee benefits programs" means programs under both the public employees' benefits board established

in RCW 41.05.055 and the school employees' benefits board established in RCW 41.05.740. Id.

OFFICE OF THE INSURANCE COMMISSIONER

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• A creditor acting on behalf of its debtors with respect to insurance, covering a debt between

the creditor and its debtors;

• A behavioral health administrative services organization or other county-managed entity that

has been approved by the state health care authority to perform delegated functions on behalf

of a carrier;

• A hospital licensed under chapter 70.41 RCW or ambulatory surgical facility licensed under

chapter 70.230 RCW, to the extent that it performs provider credentialing or recredentialing,

but no other functions of a health care benefit manager as described in subsection (4)(a) of

this section;

• The Robert Bree collaborative under chapter 70.250 RCW;

• The health technology clinical committee established under RCW 70.14.090;

• The prescription drug purchasing consortium established under RCW 70.14.060; or

• Any other entity that performs provider credentialing or recredentialing, but no other functions

of a health care benefit manager as described in RCW 48.200.020(4)(a).

Health care benefit managers are required to comply with the requirements set forth in RCW

48.200.030 through RCW 48.200.050. Included in these requirements is the obligation for HCBMs

to register with OIC and annually renew their registration

that performs provider credentialing or recredentialing, but no other functions

of a health care benefit manager as described in RCW 48.200.020(4)(a).

Health care benefit managers are required to comply with the requirements set forth in RCW

48.200.030 through RCW 48.200.050. Included in these requirements is the obligation for HCBMs

to register with OIC and annually renew their registration. HCBMs also must file with OIC all benefit

management contracts and contract amendments between the health care benefit manager and a health

carrier, provider, pharmacy, pharmacy services administration organization, or other health care

benefit manager, entered into directly or indirectly in support of a contract with a carrier or employee

benefits programs. These contracts are required to be filed within 30 days following the effective date

of the contract or contract amendment. Contracts and contract amendments between health care

benefit managers and health carriers that were executed prior to July 23, 2023, and are currently in

force, must be filed with OIC no later than 60 days following July 23, 2023.7

Pharmacy Benefit Managers

To conduct business in Washington state, pharmacy benefit managers (“PBMs”), a sub-type of

HCBMs, also are required to register with the OIC and annually renew their registration.8 “Pharmacy

benefit manager” is defined as follows:

A 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 or provide retail network

management for pharmacies or pharmacists;

• Pay pharmacies or pharmacists for prescription drugs or medical supplies;

7 See OIC Technical Assistance Advisory 2024-01 for more information about OIC’s Interpretation of

Chapter 48.200 RCW & RCW 48.43.731 (Carrier Filing Requirements related to HCBM contracts).

8 RCW 48.200.030.

rescription drugs or medical supplies or provide retail network

management for pharmacies or pharmacists;

• Pay pharmacies or pharmacists for prescription drugs or medical supplies;

7 See OIC Technical Assistance Advisory 2024-01 for more information about OIC’s Interpretation of

Chapter 48.200 RCW & RCW 48.43.731 (Carrier Filing Requirements related to HCBM contracts).

8 RCW 48.200.030.

OFFICE OF THE INSURANCE COMMISSIONER

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• Negotiate rebates, discounts, or other price concessions with manufacturers for drugs paid

for or procured as described in this subsection;

• Establish or manage pharmacy networks; or

• Make credentialing determinations.9

Chapter 48.200 RCW applies to pharmacy benefit managers as defined in RCW 48.200.020, that

contract with pharmacies to conduct any of the services listed above on behalf of health carriers

defined in RCW 48.200.020, employee benefits programs defined in RCW 48.200.020, or medicaid

managed care programs.

Pharmacy benefit managers are required to comply with the requirements set forth in RCW

48.200.030 through RCW 48.200.050 (applying generally to health care benefit managers), and RCW

48.200.220 through RCW 48.200.320 (applying specifically to pharmacy benefit managers).

Specific Plans Chapter 48.200 RCW Does Not Apply To

Chapter 48.200 RCW does not apply to health care benefit managers as defined in RCW

48.200.020, who provide the services listed above exclusively to, or act exclusively on behalf of:

• Medicare supplement plans;

• Medicare Advantage plans (Part C of Medicare);

• Medicaid, except that pharmacy benefit managers that contract with pharmacies on behalf of

Medicaid managed care plans are subject to Chap

.200 RCW does not apply to health care benefit managers as defined in RCW

48.200.020, who provide the services listed above exclusively to, or act exclusively on behalf of:

• Medicare supplement plans;

• Medicare Advantage plans (Part C of Medicare);

• Medicaid, except that pharmacy benefit managers that contract with pharmacies on behalf of

Medicaid managed care plans are subject to Chap. 48.200 RCW;

• 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); or

• Plans that provide monetary payment, such as income replacement disability plans or life

insurance accelerate benefits, unless these plans provide coverage for health care services,

drugs and supplies.

Example #1: A health care benefit manager provides health care benefit management services for

Medicare supplement plans and fully-insured health plans. The health care benefit manager must

register with OIC because it provides health care benefit manager services to fully-insured health

plans.

Example #2: A health care benefit manager provides health care benefit management services

exclusively for self-funded employer group health plans other than employee benefit programs as

9 RCW 48.200.020(14)(a).

OFFICE OF THE INSURANCE COMMISSIONER

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OIC’s Interpretation of Chapter 48.200 RCW – Health care benefit managers

September 15, 2025

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defined in RCW 48.200.020(4) (PEBB/SEBB Uniform Medical Plan). The health care benefit

manager is not required to register with OIC.

As discussed further below in the Section, “Application of E2SSB 5213 to Self-funded Group Health

Plans that Opt-In,” E2SSB 5213 applies RCW 48.200.280, 48.200.310, and 48.200.320 to self-

funded group health plans governed by the provisions of the federal employee retirement income

security act of 1974 (29 U.S.C. Sec

lan). The health care benefit

manager is not required to register with OIC.

As discussed further below in the Section, “Application of E2SSB 5213 to Self-funded Group Health

Plans that Opt-In,” E2SSB 5213 applies RCW 48.200.280, 48.200.310, and 48.200.320 to self-

funded group health plans governed by the provisions of the federal employee retirement income

security act of 1974 (29 U.S.C. Sec. 1001 et seq.) only if the self-funded group health plan elects to

participate in RCW 48.200.280, 48.200.310, and 48.200.320.

Application of E2SSB 5213 to Self-Funded Private Group Health Plans that Opt-In (Effective

January 1, 2026)

RCW 48.200.330(1) provides that Chapter 48.200 RCW is inapplicable to persons or entities

providing services to, or acting on behalf of, a union or employer administering a self-funded group

health plan governed by the provisions of the federal employee retirement income security act of 1974

(29 U.S.C. Sec. 1001 et seq.), unless a self-funded private group health plan chooses to participate in

RCW 48.200.280, 48.200.310, and 48.200.320 governing certain pharmacy benefit management

business practices. This “opt-in” process is established in RCW 48.200.330(2) and (3).

As a result of these legislative changes, pharmacy benefit managers acting on behalf of self-funded

private group health plans that have opted to participate in RCW 48.200.280, 48.200.310,

and 48.200.320 as provided in RCW 48.200.330 will be required to comply with

RCW 48.200.280, 48.200.310, and 48.200.320 in administering that self-funded private group health

plan’s pharmacy benefits. In this circumstance, pharmacy benefit managers are not subject to any

other provisions in Chapter 48.200 RCW

vate group health plans that have opted to participate in RCW 48.200.280, 48.200.310,

and 48.200.320 as provided in RCW 48.200.330 will be required to comply with

RCW 48.200.280, 48.200.310, and 48.200.320 in administering that self-funded private group health

plan’s pharmacy benefits. In this circumstance, pharmacy benefit managers are not subject to any

other provisions in Chapter 48.200 RCW. Furthermore, the Legislature has expressly stated in RCW

48.200.330(3) that the OIC does not have enforcement authority related to a pharmacy benefit

manager's conduct pursuant to a contract with a self-funded group health plan governed by the federal

employee retirement income security act of 1974, 29 U.S.C. Sec. 1001 et seq., that elects to participate

in RCW 48.200.280, 48.200.310, and 48.200.320.

OIC will implement the self-funded private group health plan opt-in process during Fall 2025, and as

part of that process, make a list of the health plans that have opted in under RCW 48.200.330 available

on its website on or before December 1, 2025.

Rulemaking

On December 18, 2024, the OIC adopted rules relating to health care benefit managers (R 2024-02).

On July 22, 2025, the OIC filed a preproposal statement of inquiry (CR-101, WSR 25-15-143)

regarding additional rulemaking to ensure the OIC can continue to effectively oversee health care

benefit managers, including pharmacy benefit managers. In this rulemaking, the OIC may amend

Chapter 284-180 Washington Administrative Code (WAC), including, but not limited to,

implementation of E2SSB 5213 (Chapter 242, Laws of 2024).

preproposal statement of inquiry (CR-101, WSR 25-15-143)

regarding additional rulemaking to ensure the OIC can continue to effectively oversee health care

benefit managers, including pharmacy benefit managers. In this rulemaking, the OIC may amend

Chapter 284-180 Washington Administrative Code (WAC), including, but not limited to,

implementation of E2SSB 5213 (Chapter 242, Laws of 2024).

OFFICE OF THE INSURANCE COMMISSIONER

Technical Assistance Advisory 2025-02

OIC’s Interpretation of Chapter 48.200 RCW – Health care benefit managers

September 15, 2025

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Please direct any questions about this advisory to the OIC’s Company Licensing Unit, which may be

contacted at clc@oic.wa.gov and (360) 725-7219.