Public employee access and affordability
During the 2025-26 Legislative session, the Washington State Legislature passed Senate Bill (SB) 5083.
The new law (RCW 41.05.028)—also known as the Public Employee Access and Affordability program—sets payment limits (caps) for certain PEBB and SEBB in-network and out-of-network hospitals. It also sets a minimum reimbursement (floor) for primary care and nonfacility behavioral health services. These caps and floors are designed to reduce PEBB and SEBB member and health plan costs and place downward pressure on member premiums, while redistributing reimbursement towards primary care and behavioral health services.
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Starting January 1, 2027, this new law (adopted WAC 182-40) aims to increase access and lower costs for PEBB and SEBB members in Washington State by:
- Limiting how much PEBB and SEBB plans pay for inpatient and outpatient services for most hospitals in Washington State. In general, hospitals will be capped to a limit of 200% of Medicare’s payment for in-network hospitals and 185% for out-of-network hospitals.
- Setting an alternative payment limit for children’s hospitals in Pierce and King counties using a Medicaid ratio of costs to charges, recognizing the specialized needs of this population.
- Setting a minimum reimbursement of 101% of Medicare allowable costs for critical access and sole community hospitals.
- Setting minimum payment levels at 150% of Medicare for primary care and nonfacility behavioral health services.
The law will maintain access and quality of care for Washington State PEBB and SEBB members by:
- Putting a limit on out-of-network reimbursement for hospitals to incentivize continued in-network participation.
- Allowing exemptions for certain small and rural hospitals, recognizing their unique demographics and reimbursement structures.
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Goals
Making health care accessible and more affordable for all Washingtonians is our goal at HCA. As the state's largest health insurance purchaser, HCA plays a key role in developing innovative ways to approach the health care market. Facilitating a new way of how we pay for PEBB and SEBB health care services is a meaningful step forward.
This law will help address:
- The payment gap for primary care providers and certain behavioral health service providers across the state. The minimum reimbursement threshold may increase access to these services.
- High and increasing hospital prices. Hospital prices are a significant driver of overall health care cost increases. The established caps will support containment of cost growth in line with annual adjustments that occur to the Medicare program.
- The variation in hospital pricing, which doesn’t necessarily reflect differences in the cost of delivering care or higher quality.