Washington Code 48.43.087 – Contracting for services at enrollee’s expense — Mental health care practitioner — Conditions — Exception
Current as of: 2023 | Check for updates
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(1) For purposes of this section:
Terms Used In Washington Code 48.43.087
- Appeal: A request made after a trial, asking another court (usually the court of appeals) to decide whether the trial was conducted properly. To make such a request is "to appeal" or "to take an appeal." One who appeals is called the appellant.
- Contract: A legal written agreement that becomes binding when signed.
- person: may be construed to include the United States, this state, or any state or territory, or any public or private corporation or limited liability company, as well as an individual. See Washington Code 1.16.080
(a) “Health carrier” includes disability insurers regulated under chapter 48.20 or 48.21 RCW, health care services contractors regulated under chapter 48.44 RCW, plans operating under the health care authority under chapter 41.05 RCW, the basic health plan operating under chapter 70.47 RCW, the state health insurance pool operating under chapter 48.41 RCW, insuring entities regulated under this chapter, and health maintenance organizations regulated under chapter 48.46 RCW.
(b) “Intermediary” means a person duly authorized to negotiate and execute provider contracts with health carriers on behalf of mental health care practitioners.
(c) Consistent with their lawful scopes of practice, “mental health care practitioners” includes only the following: Any generally recognized medical specialty of practitioners licensed under chapter 18.57 or 18.71 RCW who provide mental health services, advanced practice psychiatric nurses as authorized by the *nursing care quality assurance commission under chapter 18.79 RCW, psychologists licensed under chapter 18.83 RCW, and mental health counselors, marriage and family therapists, and social workers licensed under chapter 18.225 RCW.
(d) “Mental health services” means outpatient services.
(2) Consistent with federal and state law and rule, no contract between a mental health care practitioner and an intermediary or between a mental health care practitioner and a health carrier that is written, amended, or renewed after June 6, 1996, may contain a provision prohibiting a practitioner and an enrollee from agreeing to contract for services solely at the expense of the enrollee as follows:
(a) On the exhaustion of the enrollee’s mental health care coverage;
(b) During an appeal or an adverse certification process;
(c) When an enrollee’s condition is excluded from coverage; or
(d) For any other clinically appropriate reason at any time.
(3) If a mental health care practitioner provides services to an enrollee during an appeal or adverse certification process, the practitioner must provide to the enrollee written notification that the enrollee is responsible for payment of these services, unless the health carrier elects to pay for services provided.
(4) This section does not apply to a mental health care practitioner who is employed full time on the staff of a health carrier.
NOTES:
*Reviser’s note: The reference to “nursing care quality assurance commission” was changed to “board of nursing” by 2023 c 123.
Severability—2001 c 251: See RCW 18.225.900.