Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter B - PLAN MANAGEMENT › Section 284-43-0205 - Every category of health care providers

Current through Register Vol. 24-14, July 15, 2024
(1) Issuers must not exclude any category of
				providers licensed by the state of Washington who provide health care services
				or care within the scope of their practice for services covered as essential
				health benefits, as defined in WAC
				284-43-878 and
				RCW
				 48.43.715, for individual and small group
				plans; and as covered by the basic health plan, as defined in
				RCW
				 48.43.005(4), for plans
				other than individual and small group.
For individual and small group plans, the issuer must not
				  exclude a category of provider who is licensed to provide services for a
				  covered condition, and is acting within the scope of practice, unless such
				  services would not meet the issuer's standards pursuant to
				  RCW
				   48.43.045(1) (a). For
				  example, if the issuer covers outpatient treatment of lower back pain as part
				  of the essential health benefits, any category of provider that provides
				  cost-effective and clinically efficacious outpatient treatment for lower back
				  pain within its scope of practice and otherwise abides by standards pursuant to
				  RCW
				   48.43.045(1) (a) must not be
				  excluded from the network.
(2)RCW  48.43.045(1)
				(a) permits issuers to require providers to
				abide by certain standards. These standards may not be used in a manner
				designed to exclude categories of providers unreasonably. For example, issuers
				must not decide that a particular category of provider can never render any
				cost-effective or clinically efficacious services and thereby exclude that
				category of provider completely from health plans on that basis.
(3) Health plans are not prohibited by this
				section from placing reasonable limits on individual services rendered by
				specific categories of providers based on relevant information or evidence of
				the type usually considered and relied upon in making determinations of
				cost-effectiveness or clinical efficacy. However, health plans must not contain
				unreasonable limits, and must not include limits on the type of provider
				permitted to render the covered service unless such limits comply with
				RCW
				 48.43.045(1) (a).
(4) This section does not prohibit health
				plans from using restricted networks. Issuers offering plans with restricted
				networks may select the individual providers in any category of provider with
				whom they will contract or whom they will reimburse. An issuer is not required
				by RCW
				 48.43.045 or this section to accede to a
				request by any individual provider for inclusion in any network for any health
				plan.
(a) Health plan networks that use
				"gatekeepers" or "medical homes" for access to specialist providers may use
				them for access to specified categories of providers.
(b) For purposes of this section:
(i) "Gatekeeper" means requiring a referral
				from a primary care or direct access provider or practitioner to access
				specialty or in-patient services.
(ii) "Medical home" means a team based health
				care delivery model for patient centered primary care that provides
				comprehensive and continuous medical care to patients with the goal of
				obtaining maximized health outcomes as modified and updated by the Agency for
				Healthcare Research and Quality, the U.S. Department of Health and Human
				Services (HRSA), and other state and federal agencies.