Washington § 48.49.030 - Enrollee's obligation to pay for services.

(1) If an enrollee receives emergency services from a behavioral health emergency services provider under the circumstances described in RCW 48.49.020(3):

(a) The enrollee satisfies his or her obligation to pay for the health care services if he or she pays the in-network cost-sharing amount specified in the enrollee's or applicable group's health plan contract. The enrollee's obligation must be determined using the methodology for calculating the qualifying payment amount as described in 45 C.F.R. Sec. 149.140 as in effect on March 31, 2022. The carrier must provide an explanation of benefits to the enrollee and the nonparticipating provider that reflects the cost-sharing amount determined under this subsection.

(b) The carrier, nonparticipating behavioral health emergency services provider, and an agent, trustee, or assignee of the carrier or nonparticipating behavioral health emergency services provider must ensure that the enrollee incurs no greater cost than the amount determined under (a) of this subsection.

(c) The nonparticipating behavioral health emergency services provider and an agent, trustee, or assignee of the nonparticipating behavioral health emergency services provider may not balance bill or otherwise attempt to collect from the enrollee any amount greater than the amount determined under (a) of this subsection. This does not impact the behavioral health emergency services provider's ability to collect a past due balance for that cost-sharing amount with interest.

(d) The carrier must treat any cost-sharing amounts determined under (a) of this subsection paid by the enrollee for a nonparticipating behavioral health emergency services provider's services in the same manner as cost-sharing for health care services provided by an in-network behavioral health emergency services provider and must apply any cost-sharing amounts paid by the enrollee for such services toward the enrollee's maximum out-of-pocket payment obligation.

(e) If the enrollee pays the nonparticipating behavioral health emergency services provider an amount that exceeds the in-network cost-sharing amount determined under (a) of this subsection, the behavioral health emergency services provider must refund any amount in excess of the in-network cost-sharing amount to the enrollee within thirty business days of receipt. Interest must be paid to the enrollee for any unrefunded payments at a rate of twelve percent beginning on the first calendar day after the thirty business days.

(2) This section shall only apply to health care providers, facilities, or behavioral health emergency services providers providing services to members of entities administering a self-funded group health plan and its plan members if the entity has elected to participate in this section and RCW 48.49.020, 48.49.160, and 48.49.040 as provided in RCW 48.49.130.

Effective date—2022 c 263: See note following RCW 43.371.100.