The Washington Office of Insurance Commissioner (OIC) adopted R 2025-11 Healthcare Benefit Managers, effective January 24, 2026. The rule implements provisions of past Washington legislation (SB 5213) with delayed effective dates until January 1, 2026. It also addresses items not covered in an October 2025 article, discussed in a prior edition of PPI's Compliance Corner: Washington Technical Assistance Advisory on Healthcare Benefit Manager Registration and Filing Mandates.
This rule amends the applicability and scope of the administrative code language to indicate that the chapter does not apply to healthcare benefit managers (HCBMs) that provide services exclusively to or act exclusively on behalf of self-funded group health plans, unless an enumerated exception applies. It also amends the language for when healthcare benefit managers or pharmacy benefit managers must register with the commissioner, while also clarifying compliance obligations for pharmacy benefit managers when a self-funded group health plan opts into the state mandate. Finally, the rule implements other items, such as definitional changes, registration fees, pharmacy benefit manager reimbursement standards, pharmacy appeals processes/contact information, enrollee rights, and scenarios for mail-order and retail pharmacies.
Employers with plans that are governed by state laws or opt in to the state mandate through the OIC process should be aware of these updates and can contact their carrier or third-party administrator for further details.
For the full text of the rule, please see R 2025-11 Healthcare Benefit Managers