Molina Contracts with CaremarkPCS for Health Care Management

The New Rules for Health Care Power Brokers

Starting January 1, 2022, a quiet but seismic shift began in Washington state’s health care system. Any entity acting as a Health Care Benefit Manager, or HCBM, for plans like Medicaid now has to register with the state. This isn’t just bureaucratic paperwork; it’s a fundamental change in how power is exercised over a patient’s access to care. Molina Healthcare of Washington, a major insurer, contracts with CaremarkPCS Health, LLC to manage its pharmacy and other benefits. Both are now subject to this new state oversight.

This rule, issued by the Washington state Office of the Insurance Commissioner (OIC), targets the invisible gatekeepers of American medicine. An HCBM is any person or entity that provides services to or acts on behalf of a health carrier or employee benefits program. They directly or indirectly impact the determination or use of benefits for a patient’s access to health care services, drugs, and supplies. Think of them as the intermediaries who decide if a treatment is covered before a doctor can even order it.

The Hidden Hand in Health Care

For decades, these benefit managers operated largely in the shadows. Their decisions, affecting everything from a cancer patient’s chemotherapy to a senior’s prescription drug, were often made behind closed doors. The new registration law brings a layer of transparency to this powerful role. It requires these entities to be on the state’s official registry, making their existence and function a matter of public record.

But what exactly does an HCBM do? Their list of responsibilities is vast and deeply embedded in the care process. It includes:

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.
Dispute resolution, grievances or appeals relating to determinations.
Provider network management.
Disease management.

Essentially, an HCBM sits between the patient, the doctor, and the insurer, wielding significant influence over the flow of care and money. A prior authorization denial can delay life-saving treatment. A medical necessity determination can force a patient onto a less effective drug. These are not abstract concepts; they are daily realities for millions of Americans.

The stakes are immense. A delay in care isn’t just an inconvenience; it can be the difference between remission and a terminal diagnosis. A denied claim isn’t just a number on a spreadsheet; it can be an insurmountable bill that leads to bankruptcy. The human and economic cost of these decisions is staggering, and it falls disproportionately on the most vulnerable: the elderly, the chronically ill, and low-income families relying on programs like Medicaid.

The new registration law requires these entities to be on the state’s official registry, making their existence and function a matter of public record and creating the opportunity for greater accountability.

The OIC’s official page on registering as an HCBM serves as the primary anchor for this new regulatory framework, a clear signal of the state’s commitment to oversight.

The Counterargument: A Burden on the System

Of course, not everyone sees the new registration as an unalloyed good.

For every dollar saved by denying a costly but effective treatment, there is a human story of suffering and hardship. The new rule in Washington state forces a reckoning with this tension by making the decision-makers visible. It asks a simple, powerful question: who holds the power over your health, and who are they accountable to?

The answer, for now, is the state of Washington. As of January 2022, that power is no longer entirely invisible. It’s registered. It’s on the books. And for the first time, the citizens of the state know who to look to when a critical health care decision is made.