Key Takeaways
- Washington requires a 10-day free look period for individual health insurance policies
- Washington has its own state-based health insurance exchange called Washington Healthplanfinder
- Pre-existing condition exclusions are prohibited in Washington individual and small group markets
- Washington requires coverage for mental health parity and essential health benefits
- Washington has strong consumer protections including surprise billing rules
Washington Health Insurance Policy Requirements
Washington has comprehensive health insurance regulations that often exceed federal requirements. Understanding these state-specific rules is essential for the licensing exam.
Regulatory Structure
Washington health coverage is regulated by:
| Agency | Regulates |
|---|---|
| Office of the Insurance Commissioner (OIC) | All health insurers |
| Washington Health Benefit Exchange | State marketplace operations |
Free Look Period
Washington provides a 10-day free look period for individual health insurance:
- Policyholder can return for full premium refund
- Begins when policy is delivered
- Applies to individual health policies
- Same as standard life insurance free look
Required Coverage - Essential Health Benefits
All individual and small group plans in Washington must cover:
- Ambulatory patient services
- Emergency services
- Hospitalization
- Maternity and newborn care
- Mental health and substance use disorders
- Prescription drugs
- Rehabilitative services
- Laboratory services
- Preventive and wellness services
- Pediatric services (including dental and vision)
Washington Healthplanfinder
Washington Healthplanfinder is the state's health insurance marketplace:
- State-based exchange (not federally facilitated)
- Only place to get premium tax credits
- Offers qualified health plans (QHPs)
- Administers Apple Health (Medicaid) eligibility
- Open enrollment and special enrollment periods
Mental Health Parity
Washington's Mental Health Parity law requires:
- Mental health benefits equal to medical benefits
- Same copays, deductibles, and limits
- Covers mental health and substance use disorders
- Applies to group and individual plans
Covered Conditions
- All mental health conditions
- Substance use disorders
- Behavioral health services
- Applied behavior analysis (ABA) for autism
Pre-Existing Condition Protections
Washington prohibits pre-existing condition exclusions:
| Market Segment | Pre-Existing Condition Exclusions |
|---|---|
| Individual | Prohibited |
| Small Group | Prohibited |
| Large Group | Limited restrictions |
| Medicare Supplement | Special rules apply |
Guaranteed Issue and Renewal
Washington requires:
Guaranteed Issue
- Insurers must accept all applicants
- Cannot deny coverage based on health status
- Applies to individual and small group markets
Guaranteed Renewal
- Insurers cannot cancel coverage except for:
- Non-payment of premium
- Fraud or misrepresentation
- Plan discontinuation (with notice)
Balance Billing Protections
Washington's Balance Billing Protection Act (effective 2020):
- Protects consumers from surprise medical bills
- Applies to emergency services
- Applies to non-emergency services at in-network facilities
- Out-of-network providers cannot bill more than in-network cost-sharing
- Disputes resolved through arbitration process
Exam Tip: Washington has strong surprise billing protections. Consumers only pay in-network cost-sharing for emergency and certain out-of-network services.
What is the name of Washington's state health insurance marketplace?
How long is the free look period for individual health insurance policies in Washington?