Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter H - HEALTH PLAN BENEFITS › Section 284-43-5410 - Definitions

Current through Register Vol. 24-14, July 15, 2024
The following definitions apply to WAC
				  284-43-5400 through
				  284-43-5820 unless the context
				  indicates otherwise.
"Base-benchmark plan" means the small group plan with the
				  largest enrollment, as designated in WAC
				  284-43-5600(1)
				 or 284-43-5602(1),
				  prior to any supplementation or adjustments made pursuant to
				  RCW
				   48.43.715.
"EHB-benchmark plan" means the set of benefits that an issuer
				  must include in nongrandfathered plans offered in the individual or small group
				  market in Washington state.
"Health benefit," unless defined differently pursuant to
				  federal rules, regulations, or guidance issued pursuant to section 1302(b) of
				  PPACA, means health care items or services for injury, disease, or a health
				  condition, including a behavioral health condition.
"Individual plan" includes any nongrandfathered health
				  benefit plan offered, issued, or renewed by an admitted issuer in the state of
				  Washington for the individual health benefit plan market, unless the
				  certificate of coverage is issued to an individual pursuant to or issued
				  through an organization meeting the definition established pursuant to
				  29 U.S.C.
				  1002(5).
"Mandated benefit" or "required benefit" means a health plan
				  benefit for a specific type of service, device or medical equipment, or
				  treatment for a specified condition or conditions that a health plan is
				  required to cover by either state or federal law. Required benefits do not
				  include provider, delivery method, or health status based requirements.
"Meaningful health benefit" means a benefit that must be
				  included in an essential health benefit category, without which the coverage
				  for the category does not reasonably provide medically necessary services for
				  an individual patient's condition on a nondiscriminatory basis.
"Medical necessity determination process" means the process
				  used by a health issuer to make a coverage determination about whether a health
				  benefit is medically necessary for an individual patient.
"PPACA" means the federal Patient Protection and Affordable
				  Care Act (Public Law
				  111-148), as amended by the federal Health Care
				  and Education Reconciliation Act of 2010 (Public Law
				  111-152), and any rules, regulations, or guidance
				  issued thereunder.
"Scope or limitation requirement" means a requirement
				  applicable to a benefit that limits its duration, the number of times coverage
				  is available for the benefit, or imposes a legally permitted eligibility or
				  reference-based limitation on a specific benefit.
"Small group plan" includes any nongrandfathered health
				  benefit plan offered, issued, or renewed by an admitted issuer in the state of
				  Washington for the small group health benefit plan market to a small group, as
				  defined in
				  RCW
				   48.43.005, and
				  45 C.F.R.
				  144.102(c), unless the
				  certificate of coverage is issued to a small group pursuant to a master
				  contract held by or issued through an organization meeting the definition
				  established pursuant to 29
				  U.S.C. 1002(5).
"Stand-alone dental plan" means coverage for a set of
				  benefits limited to oral care including, but not necessarily limited to,
				  pediatric oral care, as referenced in
				  RCW
				   43.71.065.
Statutory Authority: RCW  48.02.060, 48.21.241, 48.21.320,
					 48.44.050, 48.44.341, 48.44.460, 48.46.200, 48.46.291, 48.46.530, 48.43.715,
					 and  Pub. L. No. 111-148, 124 Stat. 119 (Mar. 23, 2010) (PPACA), as amended by
					 the Health Care and Education Reconciliation Act (HCERA),  Pub. L. No. 111-152,
					 124 Stat. 1029 (Mar. 30, 2010), in particular § 1302 of PPACA, §
					 10104 (b)(1) (HCERA). WSR 13-15-025 (Matter No. R 2012-17), § 284-43-852,
					 filed 7/9/13, effective 7/10/13.