Effective Jan. 1, 2022, health care benefit managers (HCBMs) will be required to register with the Washington state Office of the Insurance Commissioner.
Who is required to register as an HCBM?
A health care benefit manager is any person or entity that provides services to or acts on behalf of a health carrier or employee benefits program. HCBMs directly or indirectly impact the determination or use of benefits for or patient access to health care services, drugs and supplies.
HCBMs include, but are not limited to, specialized benefit types such as pharmacy, radiology, laboratory and mental health.
The services of an HCBM also include:
- 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
- Provider credentialing and re-credentialing
- 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
- Disease management
Who does not need to register as an HCBM?
This new law does not apply to the actions of health care benefit managers providing services to or acting on behalf of:
- Self-insured health plans
- Medicare plans (This exemption does not include Medicare Advantage plans. HCBMs providing services to Medicare Advantage plans must register as an HCBM.)
- Union plans
We anticipate accepting applications for HCBMs in July 2021. Please check this webpage for updates on registering as an HCBM. For more information, please contact us.