reglab/statecodes huggingface dataset:
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter H - HEALTH PLAN BENEFITS › Section 284-43-5420 - Clinical trials

Current through Register Vol. 24-14, July 15, 2024
A carrier must not restrict coverage of routine patient costs
				  for enrollees who participate in a clinical trial. "Routine costs" means items
				  and services delivered to the enrollee that are consistent with and typically
				  covered by the plan or coverage for an enrollee who is not enrolled in a
				  clinical trial. A carrier may continue to apply its limitations and
				  requirements related to use of network services.
(1) A carrier may require enrollees to meet
				the eligibility requirements of the clinical trial according to the trial
				protocol. While not required to impose such a condition, a carrier may refuse
				coverage under this section if the enrollee does not provide medical and
				scientific information establishing that the individual's participation in such
				trial would be appropriate based on the individual meeting the eligibility
				requirements for the clinical trial, unless the enrollee is referred to the
				clinical trial by a health care provider participating in the carrier's
				network.
(2) This includes the cost
				of prescription medication used for the direct clinical management of the
				enrollee, unless the trial is for the investigation of the prescription
				medication or the medication is typically provided by the research sponsors
				free of charge for any enrollee in the trial.
(3) The requirement does not apply to:
(a) A service that is clearly inconsistent
				with widely accepted and established standards of care for a particular
				diagnosis;
(b) For items and
				services provided solely to satisfy data collection and analysis
				needs;
(c) Items and services that
				are not used in the direct clinical management of the enrollee; or
(d) The investigational item, device, or
				service itself.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter H - HEALTH PLAN BENEFITS › Section 284-43-5440 - Medical necessity determination

Current through Register Vol. 24-14, July 15, 2024
(1) An issuer's certificate of coverage and
				the summary of coverage for the health benefit plan must specifically explain
				any uniformly applied limitation on the scope, visit number or duration of a
				benefit, and state whether the uniform limitation is subject to adjustment
				based on the specific treatment requirements of the patient.
(2) An issuer's medical necessity
				determination process must:
(a) Be clearly
				explained in the certificate of coverage, plan document, or contract for health
				benefit coverage;
(b) Be conducted
				fairly, and with transparency to enrollees and providers, at a minimum when an
				enrollee or their representative appeals or seeks review of an adverse benefit
				determination;
(c) Include
				consideration of services that are a logical next step in reasonable care if
				they are appropriate for the patient;
(d) Identify the information needed in the
				decision-making process and incorporate appropriate outcomes within a
				developmental framework;
(e) Ensure
				that when the interpretation of the medical purpose of interventions is part of
				the medical necessity decision making, the interpretation standard can be
				explained in writing to an enrollee and providers, and is broad enough to
				address any of the services encompassed in the ten essential health benefits
				categories of care;
(f) Comply with
				inclusion of the ten essential health benefits categories;
(g) Not discriminate based on age, present or
				predicted disability, expected length of life, degree of medical dependency,
				quality of life or other health conditions, race, gender, national origin,
				sexual orientation and gender identity;
(h) Include consideration of the treating
				provider's clinical judgment and recommendations regarding the medical purpose
				of the requested service, and the extent to which the service is likely to
				produce incremental health benefits for the enrollee;
(i) Identify by role who will participate in
				the issuer's medical necessity decision-making process; and
(j) Ensure that where medically appropriate,
				and consistent with the health benefit plan's contract terms, an enrollee is
				not unreasonably restricted as to the site of service delivery.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter H - HEALTH PLAN BENEFITS › Section 284-43-5600 - Essential health benefits package benchmark reference plan

Current through Register Vol. 24-14, July 15, 2024
A not grandfathered individual or small group health benefit
				  plan offered, issued, amended or renewed on or after January 1, 2014, must, at
				  a minimum, include coverage for essential health benefits. "Essential health
				  benefits" means all of the following:
(1) The benefits and services covered by
				health care service contractor Regence BlueShield as the
Innova
small group plan policy form, policy form number
				WW0711CCONMS, and certificate form number WW0112BINNS, offered during the first
				quarter of 2012. The SERFF filing number is RGWA-127372701.
(2) The services and items covered by a
				health benefit plan that are within the categories identified in Section
				1302(b) of PPACA including, but not limited to, ambulatory patient services,
				emergency services, hospitalization, maternity and newborn care, mental health
				and substance use disorder services, including behavioral health treatment,
				prescription drugs, rehabilitative and habilitative services and devices,
				laboratory services, preventive and wellness services and chronic disease
				management, and pediatric services, including oral and vision care, and as
				supplemented by the commissioner or required by the secretary of the U.S.
				Department of Health and Human Services.
(3) Mandated benefits pursuant to Title 48
				RCW enacted before December 31, 2011.
(4) This section expires on December 31,
				2016.
Statutory Authority: RCW  48.21.241, 48.21.320, 48.44.460,
					 48.44.341, 48.46.291, 48.46.530, and 48.43.715. WSR 15-20-042 (Matter No. R
					 2015-02), § 284-43-865, filed 9/29/15, effective 9/29/15. Statutory
					 Authority:   2012 c  87   and RCW  48.02.060. WSR 12-19-099 (Matter No. R 2012-19),
					 § 284-43-865, filed 9/19/12, effective
					 10/20/12.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter H - HEALTH PLAN BENEFITS › Section 284-43-5602 - Essential health benefits package benchmark reference plan

Current through Register Vol. 24-14, July 15, 2024
A nongrandfathered individual or small group health benefit
				  plan offered, issued, amended or renewed on or after January 1, 2017, must, at
				  a minimum, include coverage for essential health benefits. "Essential health
				  benefits" means all of the following:
(1) The benefits and services covered by
				health care service contractor Regence Blue Shield as the
Regence
				Direct Gold
+ small group plan, policy form number WW0114 CCONMSD and
				certificate form number WW0114BP-PO1SD, offered during the first quarter of
				2014. The SERFF form filing number is RGWA-128968362.
(2) The services and items covered by a
				health benefit plan that are within the categories defined in
				RCW
				 48.43.005 as "essential health benefits"
				including, but not limited to:
(a) Ambulatory
				patient services;
(b) Emergency
				services;
(c)
				Hospitalization;
(d) Maternity and
				newborn care;
(e) Mental health and
				substance use disorder services, including behavioral health
				treatment;
(f) Prescription
				drugs;
(g) Rehabilitative and
				habilitative services and devices;
(h)
				 Laboratory services;
(i) Preventive and wellness services and
				chronic disease management;
(j)
				Pediatric services, including oral and vision care; and
(k) Other services as supplemented by the
				commissioner or required by the secretary of the U.S. Department of Health and
				Human Services.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter H - HEALTH PLAN BENEFITS › Section 284-43-5620 - Plan design

Current through Register Vol. 24-14, July 15, 2024
(1) A
				nongrandfa-thered individual or small group health benefit plan offered,
				issued, or renewed, on or after January 1, 2014, must provide coverage that is
				substantially equal to the EHB-benchmark plan, as described in WAC
				284-43-5640,
				284-43-5700, and
				284-43-5780.
(a) For plans offered, issued, or renewed for
				a plan or policy year beginning on or after January 1, 2014, until December 31,
				2016, an issuer must offer the EHB-bench-mark plan without substituting
				benefits for the benefits specifically identified in the EHB-benchmark
				plan.
(b) For plan or policy years
				beginning on or after January 1, 2017, an issuer may substitute benefits to the
				extent that the actuarial value of the benefits in the category to which the
				substituted benefit is classified remains substantially equal to the
				EHB-benchmark plan.
(c)
				"Substantially equal" means that:
(i) The
				scope and level of benefits offered within each essential health benefit
				category supports a determination by the commissioner that the benefit is a
				meaningful health benefit;
(ii) The
				aggregate actuarial value of the benefits across all essential health benefit
				categories does not vary more than a de minimis amount from the aggregate
				actuarial value of the EHB-benchmark base plan; and
(iii) Within each essential health benefit
				category, the actuarial value of the category must not vary more than a de
				minimis amount from the actuarial value of the category for the EHB-benchmark
				plan.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter H - HEALTH PLAN BENEFITS › Section 284-43-5622 - Plan design

Current through Register Vol. 24-14, July 15, 2024
(1) A
				nongrandfathered individual or small group health benefit plan offered, issued,
				or renewed, on or after January 1, 2017, must provide coverage that is
				substantially equal to the EHB-benchmark plan, as described in WAC
				284-43-5642,
				284-43-5702,
				and
				284-43-5782.
(a) For plans offered, issued, or renewed for
				a plan or policy year beginning on or after January 1, 2017, an issuer must
				offer the EHB-benchmark plan without substituting benefits for the benefits
				specifically identified in the EHB-benchmark plan.
(b) "Substantially equal" means that:
(i) The scope and level of benefits offered
				within each essential health benefit category supports a determination by the
				commissioner that the benefit is a meaningful health benefit;
(ii) The aggregate actuarial value of the
				benefits across all essential health benefit categories does not vary more than
				a de minimis amount from the aggregate actuarial value of the EHB-benchmark
				base plan; and
(iii) Within each
				essential health benefit category, the actuarial value of the category must not
				vary more than a de minimis amount from the actuarial value of the category for
				the EHB-benchmark plan.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter H - HEALTH PLAN BENEFITS › Section 284-43-5640 - Essential health benefit categories

Current through Register Vol. 24-14, July 15, 2024
(1) A health benefit plan must cover
				"ambulatory patient services." For purposes of determining a plan's actuarial
				value, an issuer must classify as ambulatory patient services medically
				necessary services delivered to enrollees in settings other than a hospital or
				skilled nursing facility, which are generally recognized and accepted for
				diagnostic or therapeutic purposes to treat illness or injury, in a
				substantially equal manner to the base-benchmark plan.
(a) A health benefit plan must include the
				following services, which are specifically covered by the base-benchmark plan,
				and classify them as ambulatory patient services:
(i) Home and outpatient dialysis
				services;
(ii) Hospice and home
				health care, including skilled nursing care as an alternative to
				hospitalization consistent with WAC 284-44-500, 284-46-500, and
				284-96-500;
(iii) Provider office
				visits and treatments, and associated supplies and services, including
				therapeutic injections and related supplies;
(iv) Urgent care center visits, including
				provider services, facility costs and supplies;
(v) Ambulatory surgical center professional
				services, including anesthesiology, professional surgical services, and
				surgical supplies and facility costs;
(vi) Diagnostic procedures including
				colonoscopies, cardiovascular testing, pulmonary function studies and
				neurology/neuromuscular procedures; and
(vii) Provider contraceptive services and
				supplies including, but not limited to, vasectomy, tubal ligation and insertion
				or extraction of FDA-approved contraceptive devices.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter H - HEALTH PLAN BENEFITS › Section 284-43-5642 - Essential health benefit categories

Current through Register Vol. 24-14, July 15, 2024
(1) A health benefit plan must cover
				"ambulatory patient services" in a manner substantially equal to the
				base-benchmark plan. For purposes of determining a plan's actuarial value, an
				issuer must classify as "ambulatory patient services" those medically necessary
				services delivered to enroll-ees in settings other than a hospital or skilled
				nursing facility, which are generally recognized and accepted for diagnostic or
				therapeutic purposes to treat illness or injury.
(a) A health benefit plan must include the
				following services, which are specifically covered by the base-benchmark plan,
				and classify them as ambulatory patient services:
(i) Home and outpatient dialysis
				services;
(ii) Hospice and home
				health care, including skilled nursing care as an alternative to
				hospitalization consistent with WAC
				284-44-500,
				284-46-500,
				and
				284-96-500;
(iii) Provider office visits and treatments,
				and associated supplies and services, including therapeutic injections and
				related supplies;
(iv) Urgent care
				center visits, including provider services, facility costs and
				supplies;
(v) Ambulatory surgical
				center professional services, including anesthesiology, professional surgical
				services, surgical supplies and facility costs;
(vi) Diagnostic procedures including
				colonoscopies, cardiovascular testing, pulmonary function studies and
				neurol-ogy/neuromuscular procedures; and
(vii) Provider contraceptive services and
				supplies including, but not limited to, vasectomy, tubal ligation and insertion
				or extraction of FDA-approved contraceptive devices.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter H - HEALTH PLAN BENEFITS › Section 284-43-5700 - Essential health benefit cate-gory-Pediatric oral services

Current through Register Vol. 24-14, July 15, 2024
A health benefit plan must include "pediatric dental
				  benefits" in its essential health benefits package. Pediatric dental benefits
				  means coverage for the oral services listed in subsection (3) of this section,
				  delivered to those under age nineteen.
(1) For benefit years beginning January 1,
				2015, a health benefit plan must include pediatric dental benefits as an
				embedded set of benefits, or through a combination of a health benefit plan and
				a stand-alone dental plan that includes pediatric dental benefits certified as
				a qualified dental plan. For a health benefit plan certified by the health
				benefit exchange as a qualified health plan, this requirement is met if a
				stand-alone dental plan meeting the requirements of subsection (3) of this
				section is offered in the health benefit exchange for that benefit
				year.
(2) The requirements of WAC
				284-43-5640 and
				284-43-5780 are not applicable to
				the stand-alone dental plan. A health benefit plan may, but is not required to,
				include the following services as part of the EHB-benchmark package. The
				supplemental base-benchmark plan specifically excludes oral implants, and an
				issuer should not include benefits for oral implants in establishing a plan's
				actuarial value.
(3)
Supplementation:
The base-benchmark plan covers pediatric services
				for the categories set forth in WAC
				284-43-5640, but does not cover
				pediatric oral services. Because the base-benchmark plan does not cover
				pedi-atric oral benefits, the state EHB-benchmark plan requirements are
				supplemented for pediatric oral benefits. The Washington state CHIP plan is
				designated as the supplemental base-benchmark plan for pediatric dental
				benefits. A health plan issuer must offer coverage for and classify the
				following pediatric oral services as pediatric dental benefits in a manner
				substantially equal to the supplemental base-benchmark plan:
(a) Diagnostic services;
(b) Preventive care;
(c) Restorative care;
(d) Oral surgery and reconstruction to the
				extent not covered under the hospitalization benefit;
(e) Endodontic treatment;
(f) Periodontics;
(g) Crown and fixed bridge
(h)  Removable prosthetics; and
(i) Medically necessary
				orthodontia.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter H - HEALTH PLAN BENEFITS › Section 284-43-5702 - Essential health benefit cate-gory-Pediatric oral services

Current through Register Vol. 24-14, July 15, 2024
A health benefit plan must include "pediatric dental
				  benefits" in its essential health benefits package. Pediatric dental benefits
				  means coverage for the oral services listed in subsection (3) of this section,
				  delivered to those under age nineteen. Plans must provide this coverage for
				  enrollees until at least the end of the month in which the enrollee turns age
				  nineteen.
(1) For benefit years
				beginning January 1, 2017, a health benefit plan must include pediatric dental
				benefits as an embedded set of benefits, or through a combination of a health
				benefit plan and a stand-alone dental plan that includes pediatric dental
				benefits certified as a qualified dental plan. For a health benefit plan
				certified by the health benefit exchange as a qualified health plan, this
				requirement is met if a stand-alone dental plan meeting the requirements of
				subsection (4) of this section is offered in the health benefit exchange for
				that benefit year.
(2) The
				requirements of WAC
				284-43-5642 and
				284-43-5782 are not applicable to
				the stand-alone dental plan.
(3) A
				health benefit plan may, but is not required to, include the following services
				as part of the EHB-benchmark package. The base-benchmark plan specifically
				excludes oral implants, and an issuer should not include benefits for oral
				implants in establishing a plan's actuarial value.
(4) The base-benchmark plan covers pediatric
				services for the categories set forth in WAC
				284-43-5642 and covers pediatric
				oral services. The designated base-benchmark plan for pediatric dental benefits
				consists of the benefits and services covered by health care service contractor
				Regence BlueShield as the
Regence Direct Gold
small group plan
				policy form, policy form number WW0114CCO-NMSD, and certificate form number
				WW0114BPPO1SD, offered during the first quarter of 2014 (SERFF filing number
				RGWA-128968362). A health plan issuer must offer coverage for and classify the
				following pediatric oral services as pediatric dental benefits in a manner
				substantially equal to the base-benchmark plan:
(a) Diagnostic services;
(b) Preventive care;
(c) Restorative care;
(d) Oral surgery and reconstruction to the
				extent not covered under the hospitalization benefit;
(e) Endodontic treatment, not including
				indirect pulp capping;
(f)
				Periodontics;
(g) Crown and fixed
				bridge;
(h) Removable prosthetics;
				and
(i) Medically necessary
				orthodontia.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter H - HEALTH PLAN BENEFITS › Section 284-43-5720 - Purpose and scope-Pediatric dental benefits for health benefit plans sold outside of the health benefit exchange

Current through Register Vol. 24-14, July 15, 2024
For plan years beginning on or after January 1, 2015, each
				  nongrandfathered health benefit plan offered, issued or renewed to small
				  employers or individuals, outside the Washington health benefit exchange, must
				  include pediatric dental benefits as an essential health benefit (EHB). This
				  design requirement must be met by one of the methods set forth in WAC
				  284-43-5760. Pediatric dental
				  benefits must meet cost sharing requirements including deductible and
				  out-of-pocket maxi-mums as required by the ACA. All pediatric dental benefits
				  are subject to premium tax.
Statutory Authority: RCW  48.02.060 and 48.43.715. WSR
					 14-09-080 (Matter No. R 2013-19), §
											284-170-800, filed 4/18/14, effective
					 5/19/14.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter H - HEALTH PLAN BENEFITS › Section 284-43-5740 - Definitions

Current through Register Vol. 24-14, July 15, 2024
"PPACA" or "ACA" 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), collectively known as the Affordable
				  Care Act, and any rules, regulations, or guidance issued, thereunder.
"Stand-alone dental plan" means coverage for a set of
				  benefits limited to oral care including, but not necessarily limited to, the
				  pediatric oral services listed in WAC
				  284-43-5700(3)
				 or 284-43-5702(3).
Statutory Authority: RCW  48.02.060 and 48.43.715. WSR
					 14-09-080 (Matter No. R 2013-19), §
											284-170-805, filed 4/18/14, effective
					 5/19/14.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter H - HEALTH PLAN BENEFITS › Section 284-43-5760 - Pediatric dental benefits design-Methods of satisfying requirements

Current through Register Vol. 24-14, July 15, 2024
(1) An issuer of a
				health benefit plan may satisfy the requirement of WAC
				284-43-5720 in any one of the
				following ways.
(a) A health benefit plan
				includes pediatric dental benefits as an embedded benefit; or
(b) A separate health benefit plan is offered
				without pediatric dental benefits, if and only if, the issuer receives
				reasonable assurance that the applicant has obtained or will obtain pediatric
				dental benefits through a stand-alone dental plan certified as a qualified
				dental plan. This reasonable assurance must be received by the issuer within
				sixty days.
(i) "Reasonable assurance" means
				receipt of proof of coverage from the stand-alone dental plan and a signed
				attestation of coverage from the applicant. In cases where the enrollment
				process is for a health plan and a dental plan that are being jointly purchased
				(bundled), verification by the dental carrier of enrollment in the dental plan
				and transmission of the enrollment confirmation to the health carrier will be
				considered reasonable assurance.
(ii) The health benefit plan issuer has the
				responsibility to obtain any required documents establishing reasonable
				assurance at the initial application and every renewal.
(iii) The stand-alone dental plan issuer has
				the responsibility for providing the proof of coverage upon request of the
				health benefit plan issuer or applicant. If a health benefit plan issuer
				requests proof of coverage for an applicant, the standalone dental issuer must
				provide proof of coverage or inform the health benefit plan issuer that no
				coverage exists. The stand-alone dental issuer must respond within thirty days
				of a request for proof of coverage.
(iv) The health benefit plan issuer may issue
				coverage prior to receiving reasonable assurance. If the health benefit plan
				issuer receives the reasonable assurance within sixty days of the effective
				date of the health benefit plan, the enrollee's stand-alone dental coverage
				will be considered to satisfy the requirement of WAC
				284-43-5700 or
				284-43-5702, as appropriate. If
				the health benefit plan issuer does not receive reasonable assurance within the
				sixty days provided in (iii) of this subsection, the health benefit plan issuer
				must discontinue the health benefit plan for that applicant unless and until
				the health benefit plan issuer receives reasonable assurance that the applicant
				has obtained pediatric dental benefits as required under the ACA.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter H - HEALTH PLAN BENEFITS › Section 284-43-5780 - Pediatric vision services

Current through Register Vol. 24-14, July 15, 2024
A health benefit plan must include "pediatric vision
				  services" in its essential health benefits package. The base-benchmark plan
				  covers pediatric services for the categories set forth in WAC
				  284-43-5640(1) through
				  (9), but does not include pediatric vision
				  services. Pediatric vision services are vision services delivered to enrollees
				  under age nineteen.
(1) A health
				benefit plan must cover pediatric vision services as an embedded set of
				services.
(2)
Supplementation:
The state EHB-benchmark plan requirements for
				pediatric vision benefits must be offered at a substantially equal level and
				classified consistent with the designated supplemental base-benchmark plan for
				pediatric vision services, the Federal Employees Vision Plan with the largest
				enrollment and published by the U.S. Department of Health and Human Services at
				www.cciioo.cms.gov on July 2, 2012.
(a) The
				vision services included in the pediatric vision services category are:
(i) Routine vision screening; and
(ii) A comprehensive eye exam for children,
				including dilation as professionally indicated and with refraction every
				calendar year;
(iii) One pair of
				prescription lenses or contacts every calendar year, including polycarbonate
				lenses and scratch resistant coating. Lenses may include single vision,
				conventional lined bifocal or conventional lined trifocal, or lenticular
				lenses;
(iv) One pair of frames
				every calendar year. An issuer may establish networks or tiers of frames within
				their plan design as long as there is a base set of frames to choose from
				available without cost sharing;
(v)
				Contact lenses covered once every calendar year in lieu of the lenses and frame
				benefits. Issuers must apply this limitation based on the manner in which the
				lenses must be dispensed. If disposable lenses are prescribed, a sufficient
				number and amount for one calendar year's equivalent must be covered. The
				benefit includes the evaluation, fitting and follow-up care relating to contact
				lenses. If determined to be medically necessary, contact lenses must be covered
				in lieu of eyeglasses at a minimum for the treatment of the following
				conditions: Keratoconus, pathological myopia, aphakia, anisometropia,
				aniseikonia, aniridia, corneal disorders, post-traumatic disorders, and
				irregular astigmatism;
(vi) Low
				vision optical devices including low vision services, training and instruction
				to maximize remaining usable vision as follows:
(A) One comprehensive low vision evaluation
				every five years;
(B) High power
				spectacles, magnifiers and telescopes as medically necessary, with reasonable
				limitations permitted; and
(C)
				Follow-up care of four visits in any five year period, with prior
				approval.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter H - HEALTH PLAN BENEFITS › Section 284-43-5782 - Pediatric vision services

Current through Register Vol. 24-14, July 15, 2024
A health benefit plan must include "pediatric vision
				  services" in its essential health benefits package. The designated
				  base-benchmark plan for pediatric vision benefits consists of the benefits and
				  services covered by health care service contractor Regence BlueShield as the
Regence Direct Gold
small group plan policy form, policy form
				  number WW0114CCONMSD, and certificate form number WW0114BPPO1SD, offered during
				  the first quarter of 2014 (SERFF filing number RGWA-128968362).
(1) A health benefit plan must cover
				pediatric vision services as an embedded set of services.
(2) For the purpose of determining a plan's
				actuarial value, an issuer must classify as pediatric vision services the
				following vision services delivered to enrollees until at least the end of the
				month in which enrollees turn age nineteen:
(a) Routine vision screening;
(b) A comprehensive eye exam for children,
				including dilation as professionally indicated and with refraction every
				calendar year;
(c) One pair of
				prescription lenses or contacts every calendar year, including polycarbonate
				lenses and scratch resistant coating. Lenses may include single vision,
				conventional lined bifocal or conventional lined trifocal, or lenticular
				lenses;
(d) One pair of frames
				every calendar year. An issuer may establish networks or tiers of frames within
				their plan design as long as there is a base set of frames to choose from
				available without cost-sharing;
(e)
				Contact lenses covered once every calendar year in lieu of the lenses and frame
				benefits. Issuers must apply this limitation based on the manner in which the
				lenses must be dispensed. If disposable lenses are prescribed, a sufficient
				number and amount for one calendar year's equivalent must be covered. The
				benefit includes the evaluation, fitting and follow-up care relating to contact
				lenses. If determined to be medically necessary, contact lenses must be covered
				in lieu of eyeglasses at a minimum for the treatment of the following
				conditions: Keratoconus, pathological myopia, aphakia, anisometropia,
				aniseikonia, aniridia, corneal disorders, post-traumatic disorders, and
				irregular astigmatism;
(f) Low
				vision optical devices including low vision services, training and instruction
				to maximize remaining usable vision as follows:
(i) One comprehensive low vision evaluation
				every five years;
(ii) High power
				spectacles, magnifiers and telescopes as medically necessary, with reasonable
				limitations permitted; and
(iii)
				Follow-up care of four visits in any five-year period, with prior
				approval.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter H - HEALTH PLAN BENEFITS › Section 284-43-5800 - Plan cost-sharing and benefit substitutions and limitations

Current through Register Vol. 24-14, July 15, 2024
(1) A health benefit plan must not apply cost-sharing requirements to Native Americans purchasing a health benefit plan through the exchange, whose incomes are at or below three hundred percent of federal poverty level.
(2) A small group health benefit plan that includes the essential health benefits package may not impose annual cost-sharing or deductibles that exceed the maximum annual amounts that apply to high deductible plans linked to health savings accounts, as set forth in the most recent version of IRS Publication 969, pursuant to Section  106(c)(2) of the Internal Revenue Code of 1986, and Section 1302(c)(2) of PPACA.
(3) An issuer may use reasonable medical management techniques to control costs, including promoting the use of appropriate, high value preventive services, providers and settings. An issuer's policies must permit waiver of an otherwise applicable copayment for a service that is tied to one setting but not the preferred high-value setting, if the enrollee's provider determines that it would be medically inappropriate to have the service provided in the lower-value setting. An issuer may still apply applicable in-network requirements.
(4) An issuer may not require cost-sharing for preventive services delivered by network providers, specifically related to those with an A or B rating in the most recent recommendations of the United States Preventive Services Task Force, women's preventive health care services recommended by the U.S. Health Resources and Services Administration (HRSA) and HRSA Bright Futures guideline designated pediatric services. An issuer must post on its web site a list of the specific preventive and wellness services mandated by PPACA that it covers.
(5) If an issuer establishes cost-sharing levels, structures or tiers for specific essential health benefit categories, the cost-sharing levels, structures or tiers must not be discriminatory. "Cost-sharing" has the same meaning as set forth in RCW  48.43.005 and WAC 284-43-0160(8).
(a) An issuer must not apply cost-sharing or coverage limitations differently to enrollees with chronic disease or complex underlying medical conditions than to other enroll-ees, unless the difference provides the enrollee with access to care and treatment commensurate with the enrollee's specific medical needs, without imposing a surcharge or other additional cost to the enrollee beyond normal cost-sharing requirements under the plan.
(b) An issuer must not establish a different cost-sharing structure for a specific benefit or tier for a benefit than is applied to the plan in general if the sole type of enrollee who would access that benefit or benefit tier is one with a chronic illness or medical condition.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter H - HEALTH PLAN BENEFITS › Section 284-43-5820 - Representations regarding coverage

Current through Register Vol. 24-14, July 15, 2024
A health benefit plan issuer must not indicate or imply that
				  a health benefit plan covers essential health benefits unless the plan, policy,
				  or contract covers the essential health benefits in compliance with WAC
				  284-43-5400 through
				  284-43-5800. This requirement
				  applies to any health benefit plan offered on or off the Washington health
				  benefit exchange.
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), § 284-43-885,
					 filed 7/9/13, effective 7/10/13.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter H - HEALTH PLAN BENEFITS › Section 284-43-5900 - Effective date

Current through Register Vol. 24-14, July 15, 2024
The effective date of WAC
				  284-43-0160,
				  284-170-200,
				  284-170-360,
				  284-43-2000,
				  284-43-4020,
				  284-43-4040,
				  284-43-5130, and 284-43A-150 is
				  July 1, 2001.
Statutory Authority: RCW  48.02.060, 48.18.120, 48.20.450,
					 48.20.460, 48.30.010, 48.44.050, 48.46.100, 48.46.200, 48.43.505, 48.43.510,
					 48.43.515, 48.43.520, 48.43.525, 48.43.530, 48.43.535. WSR 01-03-033 (Matter
					 No. R 2000-02), § 284-43-899, filed 1/9/01, effective
					 2/9/01.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter H - HEALTH PLAN BENEFITS › Section 284-43-5910 - Prohibition on organ transplant waiting periods

Current through Register Vol. 24-14, July 15, 2024
An issuer offering an individual, small group or large group
				  health plan may not impose waiting periods for organ transplant services in any
				  health plan.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter H - HEALTH PLAN BENEFITS › Section 284-43-5920 - Health plan rescission

Current through Register Vol. 24-14, July 15, 2024
A health plan cannot be rescinded by an issuer during the
				  coverage period, except for an enrollee who has performed an act or practice
				  that constitutes fraud or makes an intentional misrepresentation of a material
				  fact as prohibited by the terms of the plan or coverage. If the plan is
				  rescinded, the issuer must refund to the enrollee all payments made by or on
				  behalf of the enrollee for the health plan coverage.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter H - HEALTH PLAN BENEFITS › Section 284-43-5930 - Qualified health plan marketing and benefit design

Current through Register Vol. 24-14, July 15, 2024
(1) An issuer offering qualified health plans
				as defined in
				42 U.S.C.
				18021, and its officials, employees, agents,
				and representatives must not employ marketing practices or benefit designs with
				respect to these plans that the commissioner determines will have the effect of
				discouraging the enrollment of individuals with significant health needs. An
				example of such a prohibited design may occur when there are multiple
				nonspecialty drugs for persons with a specific condition or disorder, and a
				health plan places a majority of the drugs in the highest cost tier of the
				formulary.
(2) The commissioner
				will determine whether an issuer's actions to comply with this section are
				consistent with current state law, the legislative intent underlying
				RCW
				 48.43.0128 to maintain enrollee protections
				of the Affordable Care Act, and the federal regulations and guidance in effect
				as of January 1, 2017, including those issued by the U.S. Department of Health
				and Human Services Office of Civil Rights.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter H - HEALTH PLAN BENEFITS › Section 284-43-5935 - Definitions

Current through Register Vol. 24-14, July 15, 2024
As used in WAC 284-43-5940 through 284-43-5980, the following
				  terms have the following meaning:
(1)
				Auxiliary aids and services include:
(a)
				Qualified interpreters on-site or through video remote interpreting (VRI)
				services, as defined in
				28
				C.F.R. 35.104 and
				36.303(b);
				note takers; real-time computer-aided transcription services; written
				materials; exchange of written notes; telephone handset amplifiers; assistive
				listening devices; assistive listening systems; telephones compatible with
				hearing aids; closed caption decoders; open and closed captioning, including
				real-time captioning; voice, text, and video-based telecommunication products
				and systems, text telephones (TTYs), videophones, and captioned telephones, or
				equally effective telecommunications devices; videotext displays; accessible
				electronic and information technology; or other effective methods of making
				aurally delivered information available to individuals who are deaf or hard of
				hearing;
(b) Qualified readers;
				taped texts; audio recordings; Braille materials and displays; screen reader
				software; magnification software; optical readers; secondary auditory programs;
				large print materials; accessible electronic and information technology; or
				other effective methods of making visually delivered materials available to
				individuals who are blind or have low vision;
(c) Acquisition or modification of equipment
				and devices; and
(d) Other similar
				services and actions.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter H - HEALTH PLAN BENEFITS › Section 284-43-5937 - Hearing instrument coverage

Current through Register Vol. 24-14, July 15, 2024
(1) The purpose of
				this regulation is to effectuate the provisions of chapter 245, Laws of 2023,
				by requiring health carriers to include coverage for hearing
				instruments.
(2) This section
				applies to health carriers offering nongrandfathered group health plans, other
				than small group health plans, issued or renewed on or after January 1,
				2024.
(3) The hearing instruments
				and coverage requirements referenced in this section have the same meaning as
				in RCW
				 48.43.135.
(4) Health carriers shall provide in network
				coverage for hearing instruments at no less than $3,000 per ear with hearing
				loss every 36 months. Any enrollee cost-sharing applied to this coverage must
				ensure that the amount paid by the health plan will be no less than $3,000
				except to the extent required otherwise in
				RCW
				 48.43.135(4).
(5) Enrollees can purchase a hearing
				instrument beyond the cost limitations outlined in this section and coverage
				must still be provided at no less than $3,000 per ear with hearing loss every
				36 months.
(6) The 36-month time
				period referenced in this section and
				RCW
				 48.43.135(3), is specific to
				the enrollee's current health carrier.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter H - HEALTH PLAN BENEFITS › Section 284-43-5950 - Access for individuals with limited-English proficiency and individuals with disabilities

Current through Register Vol. 24-14, July 15, 2024
Each issuer offering a plan, and the issuer's officials,
				  employees, agents or representatives must take fair and reasonable steps to
				  provide meaningful access to each enrollee or individual likely to be
				  encountered who has limited-English proficiency or a disability consistent with
				  federal rules and guidance in effect on January 1, 2017, including those
				  implementing  42 U.S.C. Sec. 181 16  (Sec. 1557 of the Affordable Care Act) as
				  set forth in 81 Fed. Reg. 31375 et seq. (2016).
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter H - HEALTH PLAN BENEFITS › Section 284-43-5960 - Meaningful access for individuals with limited-English proficiency

Current through Register Vol. 24-14, July 15, 2024
(1)
General
				requirement.
An issuer offering a plan shall take reasonable steps to
				provide meaningful access to each enrollee or individual likely to be
				encountered with limited-English proficiency.
(2)
Evaluation of compliance.
In
				evaluating whether an issuer has met its obligation under subsection (1) of
				this section, the commissioner will:
(a)
				Evaluate, and give substantial weight to, the nature and importance of access
				to the health services involved and the particular communication at issue, to
				the individual with limited-English proficiency; and
(b) Take into account other relevant factors,
				including whether an issuer has developed and implemented an effective written
				language access plan, that is appropriate to its particular circumstances, to
				be prepared to meet its obligations under this section.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter H - HEALTH PLAN BENEFITS › Section 284-43-5965 - Effective communication for people with disabilities

Current through Register Vol. 24-14, July 15, 2024
An issuer offering a plan shall:
(1) Take appropriate steps to ensure that
				communications with individuals with disabilities are as effective as
				communications with others with respect to benefits and services, in accordance
				with the standards found at
				28
				C.F.R. 35.160 through
				35.164. Where the
				regulatory provisions referenced in this section use the term "public entity,"
				the term "issuer" shall apply in its place.
(2) Provide appropriate auxiliary aids and
				services to persons with impaired sensory, manual, or speaking skills, where
				necessary to afford such persons an equal opportunity to benefit from the
				service in question.
(3) Ensure
				that their benefits and services provided through electronic and information
				technology, including telehealth, are accessible to individuals with
				disabilities, unless doing so would result in undue financial and
				administrative burdens or a fundamental alteration in the nature of the health
				programs or activities. When undue financial and administrative burdens or a
				fundamental alteration exist, the issuer shall provide information in a format
				other than an electronic format that would not result in such undue financial
				and administrative burdens or a fundamental alteration but would ensure, to the
				maximum extent possible, that individuals with disabilities receive the
				benefits or services of the plan that are provided through electronic and
				information technology.
(4) Ensure
				that their health programs and activities provided through websites comply with
				the requirements of Title II of the ADA.
(5) Make reasonable modifications to
				policies, practices, or procedures when such modifications are necessary to
				avoid discrimination on the basis of disability, unless the issuer can
				demonstrate that making the modifications would fundamentally alter the nature
				of the health program or activity. Reasonable modifications must be interpreted
				consistent with the term as set forth in the ADA Title II regulation at  28
				C.F.R. Sec. 35.230(b)(7).
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter H - HEALTH PLAN BENEFITS › Section 284-43-5970 - Equal program access on the basis of sex

Current through Register Vol. 24-14, July 15, 2024
An issuer offering a plan, and the issuer's officials,
				  employees, agents, or representatives shall:
(1) Provide individuals equal access with
				respect to the plan including, but not limited to, plan administration, member
				communication, medical protocols or criteria for medical necessity or other
				aspects of plan operations without discrimination on the basis of sex;
				and
(2) Treat individuals
				consistent with their gender identity and sexual orientation, except that an
				issuer may not deny or limit health services that are ordinarily or exclusively
				available to individuals of one sex, to a transgender, nonbinary, intersex or
				gender nonconforming individual based on the fact that the individual's sex
				assigned at birth, gender identity, or gender otherwise recorded is different
				from the one to which such health services are ordinarily or exclusively
				available.