Essential health benefits benchmark plan

We were required to report our findings and decision to the legislature by Dec. 31, 2023.

Defining Washington state’s EHB-benchmark health plan 

The Affordable Care Act requires certain benefits, items and services be covered by all individual and small employer health plans. These are called Essential Health Benefits. Each state must select its own “benchmark” health insurance plan and use it to determine its essential health benefits. Since 2020, Washington state’s EHB benchmark plan has been the Regence BlueShield Direct Gold+ small group health plan.

Beginning in 2020, the Centers for Medicare and Medicaid Services (CMS) gives states three options to define their EHB benchmark plan:

  • Option 1: Select another state’s entire EHB benchmark,  
  • Option 2: Replace a category of benefits in the current benchmark with the same category of benefits used in another state's EHB plan, or  
  • Option 3: Select a set of benefits to become part of your state's EHB plan. 

States that want to make changes are required by federal law to have an actuarial analysis of the benefits, a public comment on the proposed changes, and to apply to CMS.

New EHB benchmark plan implementation

Opportunity for public comment on the State's selection of an EHB-benchmark plan, per 45 CFR 156.111

2023 essential health benefits report and presentation

How to get involved

Public comments

Past meetings

Dec. 13, 2023

Oct. 20, 2023

Sept. 12, 2023 

June 12, 2023 

State and federal EHB information 

Washington state:

Federal:

Getting your health plan to cover your prescription drug

Under state law, this process prevents your insurer from using other ways to limit drug coverage, such as prior authorization, step therapy or “fail first” policies.

How to ask your health plan to cover a prescription

You can ask your health insurer to cover a prescription drug they don't cover or that your provider prescribed as “off-label.”

Once you or your provider request this:

Ground ambulance services and surprise billing

The law applies to all state-regulated health plans, state and school employee benefit plans and self-funded group health plans that opt in to Washington's law. All health insurers must have a process that helps a provider, facility, or GASO determine if their patient is subject to Washington's law. 

How patients are protected 

If an enrollee is transported by an out-of-network GASO, it must bill the enrollee’s health plan directly. Any cost-sharing counts towards their deductible and is limited to what the enrollee would pay if the GASO was in their health plan’s network. Enrollees cannot be balance billed or asked to waive their balance billing protections. 

Public database of ground ambulance rates

Local governmental entities that have established or contracted rates for ground ambulance services are required to submit them to a public database each year and update them annually by Nov. 1, if they have changed. 

Consumer notice requirements for ground ambulance service organizations

Effective January 1, 2025, ground ambulance service organizations (GASO) are included in the Balance Billing Protection Act and the updated consumer notice (PDF 205.78KB) must be used. For translated consumer notifications in twelve languages please visit the What consumers need to know about surprise billing webpage.

Medical providers, facilities, GASOs, and behavioral health emergency service providers must use the consumer notice to meet their obligations under WAC-284-43B-050, including posting the notice on their website and providing it to consumers if asked. They also must:  

  • Refund consumers any amount they have overpaid within 30 business days. 
  • Not ask consumers to limit or give up their rights to prevent balance billing. 

See translated consumer notices in 12 languages. 

How enforcement works 

If a GASO continues to balance bill a consumer and we see a pattern of unresolved violations of the Balance Billing Protection Act, we will first give the GASO a chance to correct its behavior.  If no steps are taken to correct the balance billing, we will refer the GASO to the Department of Health for enforcement. 

Insurers need to explain premium increases

This rule applies to auto and home insurance, including manufactured home, condominium and renters insurance. 

What consumers can do

If your premium increases when your policy renews, you can ask your insurance company why. To do so, send them a message using the contact information on your renewal notice or billing statement.

Make sure the message includes your name, policy number and the renewal date of your policy. For example, you could write:

  • “My name is Jack Q. Policyholder and my auto insurance premiums went up. My policy number is 654321 and my renewal date is June 2, 2024. Please mail me an explanation for why my premiums went up.”

What insurance companies have to do

When a policy renews and the premium increases, the policyholder can ask you why. If they do, you need to give them a reasonable explanation using terms they can understand.

You also need to include a disclaimer on renewal notices or renewal billing statements. It should use at least 12-point bold font and have language similar to:

  • "If your premiums increased when your policy renewed, you can ask for an explanation by contacting us in writing. See Chapter 284-30A WAC for more information on your right to an explanation for your rate increase."

The disclaimer also needs to include your company’s contact information.

Changes coming in 2027

Starting June 1, 2027, if your premium increases by 10% or more when your policy renews, your insurance company needs to tell you why. They also need to provide this explanation if you ask for it.

Your insurer will send you a written notice explaining the main reasons for the increase, which may include:

  • Location of the vehicle
  • Driving record
  • Miles you've driven
  • Number of drivers
  • Number of vehicles
  • Claims you've filed
  • Discounts
  • Fees and surcharges
  • Age
  • Credit history
  • Education
  • Gender
  • Marital status
  • Occupation
  • Property age, location and value

They may also include other reasons.

How to report a settlement under the Balance Billing Protection Act (Appendix D)

When to submit this form?

  • No later than three business days after the date of the settlement agreement.
  • The form must be submitted even if an initiating party’s arbitration initiation request form (AIRF) is under review by the OIC, an AIRF number has not yet been assigned, and or an arbitrator has not yet been assigned.

How to complete and submit this form

  1. After carefully reading and following the instructions on this page, download the settlement reporting form (PDF, 255.84 KB).
  2. Fill in all required information (i.e., initiating party information, dispute resolution information, etc.). If there is no AIRF number (OIC tracking number) note, “not assigned yet.”
  3. Complete the form, which must be signed by both parties.
  4. File electronically by uploading the form as a .PDF attachment to the contact the arbitration team form.

To submit a settlement reporting form for more than one arbitration proceeding involving the same parties

Parties may submit a spreadsheet containing all the required information for each claim that has been settled, as follows:

  • The initiating party’s information and the parties' signatures must be indicated on the form; signatures may be electronic. The rest of the fields may say “see attached”
  • The spreadsheet columns should match the form fields on the settlement reporting form (i.e., date of settlement, OIC tracking number, name of carrier, etc.)
  • The spreadsheet and form should be saved to a single .PDF signed by the parties electronically.
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