Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter K - MENTAL HEALTH AND SUBSTANCE USE DISORDER › Section 284-43-7010 - Definitions

Current through Register Vol. 24-14, July 15, 2024
Aggregate lifetime limit
means a dollar
				  limitation on the total amount of specified benefits that may be paid under a
				  plan (or health insurance coverage offered in connection with a plan) for any
				  coverage unit.
Annual dollar limit
means a dollar limitation on
				  the total amount of specified benefits that may be paid in a twelve-month
				  period under a plan (or health insurance coverage offered in connection with a
				  plan) for any coverage unit.
Approved treatment program
means a discrete
				  program of substance use disorder treatment provided by a treatment program
				  certified by the department of health as meeting standards adopted under
				  chapter 71.24 RCW.
Classification of benefits
means a group into
				  which all medical/surgical benefits and mental health or substance use disorder
				  benefits offered by a plan must fall. For the purposes of this rule, the only
				  classifications that may be used are: Inpatient, in-network; inpatient,
				  out-of-network; outpatient, in-network; outpatient, out-of-network; emergency
				  care; and prescription drugs.
Coverage unit
means the way in which a plan or
				  issuer groups individuals for purposes of determining benefits, or premiums or
				  contributions. For example, different coverage units include self-only, family,
				  and employee-plus-spouse.
Cumulative financial requirements
means
				  financial requirements that determine whether or to what extent benefits are
				  provided based on accumulated amounts and include deductibles and out-of-pocket
				  maximums. Financial requirements do not include aggregate lifetime or annual
				  dollar limits.
Cumulative quantitative treatment limitations
means treatment limitations that determine whether or to what extent benefits
				  are provided based on accumulated amounts, such as annual or lifetime day or
				  visit limits.
Emergency condition, for the purpose of this
				  sub-chapter,
means a medical, mental health or substance use disorder
				  condition manifesting itself by acute symptoms of sufficient severity,
				  including severe emotional or physical distress or a combination of severe
				  emotional and physical distress, that a prudent layperson, who possesses an
				  average knowledge of health and medicine, could reasonably expect the absence
				  of immediate medical, mental health or substance use disorder treatment
				  attention to result in a condition placing the health of the individual, or
				  with respect to a pregnant woman, the health of the woman or her unborn child,
				  in serious jeopardy.
Essential health benefits (EHBs).
EHBs have the
				  same definition as found in WAC
				  284-43-5600
				  or
				  284-43-5602,
				  as appropriate. The definition of EHBs includes mental health and substance use
				  disorder services, including behavioral health treatment. For EHBs, including
				  mental health and substance use disorder benefits, federal and state law
				  prohibit limitations on age, condition, lifetime and annual dollar
				  amounts.
Financial requirements
means cost sharing
				  measures such as deductibles, copayments, coinsurance, and out-of-pocket
				  maximums. Financial requirements do not include aggregate lifetime or annual
				  dollar limits.
Health carrier or issuer
has the same meaning as
				  RCW
				   48.43.005(25).
Health plan
has the same meaning as
				  RCW
				   48.43.005(26).
Medical/surgical benefits
means benefits with
				  respect to items or services for medical conditions or surgical procedures, as
				  defined under the terms of the plan or health insurance coverage and in
				  accordance with applicable federal and state law, but does not include mental
				  health or substance use disorder benefits. Any condition defined by the plan or
				  coverage as being a medical/surgical condition must be defined to be consistent
				  with generally recognized independent standards of current medical practice
				  (for example, the most current version of the
International
				  Classification of Diseases
(ICD) or state guidelines).
Medically necessary or medical necessity:
(a) With regard to substance use disorder is defined by the
				  most recent version of
The ASAM Criteria, Treatment Criteria for
				  Addictive, Substance Related, and Co-Occurring Conditions
as published
				  by the American Society of Addiction Medicine (ASAM).
(b) With regard to mental health services, pharmacy services,
				  and any substance use disorder benefits not governed by ASAM, is a carrier
				  determination as to whether a health service is a covered benefit because the
				  service is consistent with generally recognized standards within a relevant
				  health profession.
Mental health benefits
means benefits with
				  respect to items or services for mental health and substance use disorder
				  conditions, as defined under the terms of the plan or health insurance coverage
				  and in accordance with applicable federal and state law. Any condition defined
				  by the plan or coverage as being a mental health condition must be defined to
				  be consistent with the most current version of the
Diagnostic and
				  Statistical Manual of Mental Disorders
, as published by the American
				  Psychiatric Association.
Nonquantitative treatment limitations (NQTL)
means processes, strategies, or evidentiary standards, or other factors that
				  are not expressed numerically, but otherwise limit the scope or duration of
				  benefits for treatment. NQTLs include, but are not limited to:
(a) Medical management standards limiting or excluding
				  benefits based on medical necessity or medical appropriateness, or based on
				  whether the treatment is experimental or investigative;
(b) Formulary design for prescription drugs;
(c) For plans with multiple network tiers (such as preferred
				  providers and participating providers), network tier design;
(d) Standards for provider admission to participate in a
				  network, including reimbursement rates;
(e) Plan methods for determining usual, customary, and
				  reasonable charges;
(f) Refusal to pay for higher-cost therapies until it can be
				  shown that a lower-cost therapy is not effective (also known as fail-first
				  policies or step therapy protocols);
(g) Exclusions based on failure to complete a course of
				  treatment; and
(h) Restrictions based on geographic location, facility type,
				  provider specialty, and other criteria that limit the scope or duration of
				  benefits for services provided under the plan or coverage.
Plan
means a health plan, a short-term limited
				  duration medical plan or a student-only health plan.
Predominant level:
If a type of financial
				  requirement or quantitative treatment limitation applies to substantially all
				  medical surgical benefits in a classification, the predominant level is the
				  level that applies to more than one-half of the medical/surgical benefits in
				  that classification subject to the financial requirement or quantitative
				  treatment limitation.
Quantitative parity analysis
means a
				  mathematical test by which plans and issuers determine what level of a
				  financial requirement or quantitative treatment limitation, if any, is the most
				  restrictive level that could be imposed on mental health or substance use
				  disorder benefits within a classification.
Quantitative treatment limitations
means types
				  of objectively quantifiable treatment limitations such as frequency of
				  treatments, number of visits, days of coverage, days in a waiting period or
				  other similar limits on the scope or duration of treatment.
Short-term limited duration medical plan
means a
				  plan deemed by the commissioner to have a short-term limited purpose or
				  duration.
Student-only health plan
means a health plan
				  that is guaranteed renewable while the covered person is enrolled as a regular,
				  full-time undergraduate student at an accredited higher education
				  institution.
Substance use disorder
means a substance-related
				  or addictive disorder listed in the most current version of the
Diagnostic and Statistical Manual of Mental Disorders (DSM)
published by the American Psychiatric Association.
Substance use disorder benefits
means benefits
				  with respect to items or services for substance use disorders, as defined under
				  the terms of the plan or health insurance coverage and in accordance with
				  applicable federal and state law. Substance use disorder benefits must include
				  payment for reasonable charges for medically necessary treatment and supporting
				  service rendered to an enrollee either within an approved treatment program or
				  by a health care professional that meets the requirements of RCW  18.205.040(2),
				  as part of the approved treatment plan.
Substantially all:
A type of financial
				  requirement or quantitative treatment limitation considered to apply to
				  substantially all medical/surgical benefits in a classification of benefits if
				  it applies to at least two-thirds of all medical/surgical benefits in that
				  classification as determined by WAC
				  284-43-7040(2)(a).
Treatment limitations
means limits on benefits
				  based on the frequency of treatment, number of visits, days of coverage, days
				  in a waiting period, or other similar limits on the scope or duration of
				  treatment. Treatment limitations include both quantitative treatment
				  limitations, which are expressed numerically (such as fifty outpatient visits
				  per year), and non-quantitative treatment limitations, which otherwise limit
				  the scope or duration of benefits for treatment under a plan or coverage. A
				  permanent exclusion of all benefits for a particular condition or disorder,
				  however, is not a treatment limitation for purposes of this
				  section.
Statutory Authority: RCW  48.02.060, 48.43.715, 48.44.050,
					 48.46.200 and Paul Wellstone and Pete Domenici Mental Health Parity and
					 Addiction Equity Act of 2008,  Pub. L. 110-343. WSR 14-23-057 (Matter No. R
					 2012-29), § 284-43-991, filed 11/17/14, effective
					 12/18/14.