Appeals Procedures (Cont’d) RCW 48.43.530(4)(c) The issuer may not require that an enrollee file a complaint or grievance to seeking an appeal or review of an adverse benefit determination. Internal Appeals under Health Plan WAC Does the contract notify the enrollee that, when the enrollee requests reconsideration of a decision to modify, reduce, or terminate an otherwise covered health service that the enrollee is receiving through the health plan, based upon a finding that the health service, or level of health service, is no longer medically necessary or appropriate, the issuer must continue to provide that health service until the appeal / review of adverse benefit determination is resolved? RCW 48.43.530(5)(b) WAC WAC The issuer must assist the enrollee with the appeal process. RCW 48.43.530(5)(d) WAC The issuer must cooperate with any representative authorized in writing by the enrollee. RCW 48.43.530(5)(e) WAC WAC The issuer must consider all information submitted by the enrollee or representative. RCW 48.43.530(5)(f) WAC The issuer must investigate and resolve all appeals / requests for review of adverse benefit determination. RCW 48.43.530(4)(a) The review of a decision to deny, modify, reduce, or terminate payment, coverage, authorization, or provision of health care services
Diabetes Coverage Requirements RCW 48.46.272 (2)(a); WAC WAC WAC Contract must provide appropriate and medically necessary equipment and supplies, as prescribed by a health care provider, for all subscribers diagnosed “Insulin using”, “Non-insulin using”, and “elevated blood glucose induced by pregnancy. This must include: insulin, syringes, injection aids, blood glucose monitors, test strips (for blood glucose monitors, visual blood sugar reading, and urine testing); insulin pumps and accessories to the pumps, insulin infusion devices, prescriptive oral agents for controlling blood sugar levels, foot care appliances for prevention of complications associated with diabetes, and glucagon emergency kits. Diabetes (Cont’d) Coverage (Cont’d) RCW 48.46.272 (2)(b); WAC Whether or not the contract provides Pharmacy Benefits, contract must provide: outpatient self-management training and education, including medical nutrition therapy, as ordered by the health care provider. Diabetes outpatient self-management training and education may be provided only by providers with expertise in diabetes. HMO may restrict patients to seeing only health care providers who have signed participating provider agreements with the HMO or an insuring entity under contract with the HMO. RCW 48.46.272(3) Benefits may be subject to customary cost sharing for all similar services or supplies within the policy. 48.46.272(5) Services must be covered when deemed medically necessary. WAC Plan must provide routine foot care for diabetic persons. Disclosures List of Disclosure RCW 48.43.510(3) Issuer must provide to all enrollees and prospective enrollees a list of available disclosure items, including: Items WAC Instructions on how to access and request copies in paper and electronic forms, and Requirement
information will be received, unless the collection explicitly provides that genetic information should not be provided. 42 U.S.C. (d)(1) Plan may not request, require, or purchase genetic information for underwriting purposes. 45 CFR §148.180 (e)(2) Health care professional providing care may recommend or request the enrollee to have a genetic test. 45 CFR §148.180 (e)(5) Plan may request, but not require, genetic testing for research purposes under specific conditions. 45 CFR §148.180 (f)(1)(iii) Issuer cannot collect genetic information for underwriting purposes, unless medically appropriate: Eligibility (Cont’d) Collection and Use of Genetic Information (Cont’d) If an enrollee seeks a benefit, the issuer may limit or exclude the benefit based on whether is medically appropriate and the determination of whether the benefit is medically appropriate is not for underwriting purposes. Thus, if a plan conditions a benefit on medical appropriateness, and medical appropriateness depends on the genetic information of an individual, the plan can condition the benefit on genetic information. 45 CFR 148.180(a) “Genetic information” can include: 45 CFR §146.122 (a)(3)(iii)(A) With respect to a pregnant woman (or a family member of the pregnant woman), genetic information of any fetus carried by the pregnant woman; and 45 CFR §146.122 (a)(3)(iii)(B) With respect to an individual (or a family member of the individual) who is utilizing an assisted reproductive technology, genetic information of any embryo legally held by the individual or family member; (a)(3)(i)(A) Information the individual’s genetic tests; (a)(3)(i)(B) Information about the genetic tests of the individual’s family members; (a)(3)(i)(C) Information about the manifestation of a disease or disorder in
received before such date. 42 U.S.C. Genetic information may not be treated as a preexisting condition in the absence of a diagnosis of the condition related to the information. Organ Transplant Waiting Period 42 USC §300gg-3(a); WAC The plan may not include a waiting period for organ transplant benefits because such a waiting period excludes, for the waiting period, benefits specifically relating to conditions requiring transplants. Eligibility (Cont’d) Special Enrollment 42 U.S.C. §300gg-1(b)(1); Plan can use open enrollment periods but must offer Special Enrollment where required. 45 CFR 147.104(3). Periods – Federal Law 45 C.F.R. §146.117 (a)(3)(i) Plan must enrollment to eligible persons regardless of open enrollment requirements (“special enrollment”), in the following situations: 42 U.S.C. Employee loses other coverage If the employee didn’t enroll during open enrollment because they had other coverage. 42 U.S.C. §300gg-3(f)(1)(A) Dependent loses coverage During open enrollment, the dependent had other coverage. Allow both dependent and employee to enroll, but not any other dependents unless they also have their own special enrollment qualifying event. 42 U.S.C. Employee or any dependent other coverage (other than for nonpayment or fraud) due to: (f)(1)(c)(ii) Divorce or legal separation Death of an employee under whose coverage they were a dependent Termination or reduction in the number of hours worked Discontinuation of employer contributions; or (f)(1)(c)(i) Exhaustion of COBRA continuation coverage
adoption becomes the first effective date of coverage; WAC For applicants enrolling after the fifteenth of the month, the issuer must begin coverage not later than the first date of the second month after the application is received, unless the applicant is enrolling due to marriage or the commencement of a domestic partnership. An issuer may establish an earlier effective date at their discretion. An issuer may establish an earlier effective date at their discretion; Eligibility (Cont’d) Special Enrollment (Cont’d) WAC applicants enrolling because of marriage or the commencement of a domestic partnership, when notice of the marriage or domestic partnership is received within days of the marriage or commencement of the domestic partnership, either as spouse, domestic partner or as a dependent child, coverage must begin no later than the first date of the month immediately following the date of marriage or domestic partnership. WAC An issuer must not refuse to enroll an applicant who applies within sixty days of the qualifying event, if the applicant would be eligible had the application been received during open enrollment. Emergency Medical Services (EHB) Required Emergency Services 42 USC (a)(1)(B); 42 USC 18022(b)(1)(B) Plan must cover "emergency medical 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 emergency medical services the care and services related to an emergency medical condition. WAC WAC Plan must include the following services which are specifically covered by the base-benchmark plan and classify them as emergency services: WAC Ambulance transportation to an emergency room and treatment provided as part of the ambulance service; WAC Emergency room and department based services, supplies and treatment, including professional charges, facility costs, and
RCW 48.43.093 (2) For inpatient admission, the issuer may require notification within a specified time frame or as soon thereafter as medically possible, but no less than twenty-four hours. 48.43.093 (1)(d) The issuer must have someone available 24/7 for preauth of or post-stabilization services RCW 48.43.093 (2) The issuer may reserve the right to require transfer of a hospitalized enrollee upon stabilization. Prescription Drugs WAC Plan must cover prescription medications associated with an emergency medical condition including those purchased in a foreign country. Every Category of Provider Requirements 42 U.S.C. §300gg-5(a) See Plan and Issuer must not discriminate with respect to participation under the plan against any provider acting within the scope of that provider’s license or certification under applicable State law. (Reimbursement rates may vary based on quality or performance measures.) RCW 48.43.045 (1)(a)(i); Every category of provider must be permitted to provide covered services, if the treatment is within the scope of the provider’s licensure. WAC Each health plan’s defined service area must have a comprehensive range of primary, specialty, institutional, and ancillary services available without unreasonable delay to all enrollees and that emergency services are accessible twenty-four hours per day, seven days per week without unreasonable delay. RCW 48.43.515(1); WAC Each enrollee must have adequate choice among health care providers, including those providers which must be included in the under WAC 284-170-270, and for qualified health plans and qualified stand-alone dental plans under WAC 284-170-310.
WAC Issuers must not exclude any category or 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. American Indians/ Alaska Natives WAC Issuer must maintain arrangements that ensure that American Indians/Alaska Natives who are enrollees have access to covered medical and behavioral health services provided by Indian health care providers. Allowable Limits RCW 48.43.045 (1)(a)(ii) Providers can be required to conform with carrier standards for cost - Containment, administrative procedures, and provision of clinically effective services. WAC Issuers may place reasonable limits on specific 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. Every Category of Provider WAC 270(4) Plans may use restricted networks. (Cont’d) WAC 284-170- 270(4)(a) Plans that use “gatekeepers” or “Medical Homes” for access to specialists may use them for access to specified categories of providers. No Separate Benefit WAC 284-170 270(5) Issuers may not offer coverage for services by certain categories of providers solely as a separately-priced optional benefit (e.g., chiropractic care; acupuncture). Coverage of RCW 48.43.190 Plan must cover chiropractic care on the same basis as other care. Chiropractic care RCW Each carrier provide enrollees with direct access to the participating chiropractor of the enrollee's choice for covered chiropractic health care without the necessity of prior referral.
consultation with the mother rather than by contract or agreement between the hospital and the insurer. These decisions must be based on accepted medical practice. RCW 48.43.115 (3)(d) Plan may not deny covered, eligible services for follow-up care, including in-person care, as ordered by the attending provider in consultation with the mother. Coverage for providers of follow-up services must include, but need not be limited to, attending providers, home health agencies licensed under chapter RCW, and registered nurses licensed under chapter RCW. 48.43.115 (3)(e) This section does not require attending providers to authorize care they believe to be medically unnecessary. Maternity and Newborn Services (EHB) (Cont’d) Length of Stay RCW 48.43.115 (3) and (5) (“Erin Act”); 42 USC 300gg-51 The plan must provide notice that the health care provider in consultation with the mother will determine the care and length of hospital stay. If length of stay guideline is stated it must be no less than: 48-hour normal birth/96 caesarian section birth. The plan cannot restrict follow-up care when ordered by the attending provider in consultation with the mother. (“Newborns’ and Mothers’ Health Protection Act of 1996”) Dependent Daughter Coverage WAC WAC Plan must include maternity coverage and newborn delivery for dependent daughters on the same basis as the EHB-benchmark plan. Religious and Exception to 45 CFR §147.132(a)(1) An “objecting organization” is eligible for a religious exemption from providing contraceptive coverage if it objects: 45 CFR §147.132(a)(2) to its establishing, maintaining, providing, offering, or arranging (as applicable) coverage, payments, or a that provides coverage
45 CFR §147.131 (d)(1)(B) The issuer satisfies its obligations to provide contraceptive coverage if it reasonably and in good relies on a by the employer that it is eligible for this accommodation and the issuer complies with these obligations. Medical Necessity Requirements of Medical WAC Contract must specifically explain issuer's medical necessity determination process. Necessity Process WAC Process must: be conducted fairly, and with transparency to enrollees and providers, at a minimum when an enrollee or representative appeals or seeks review of an adverse benefit determination; Medical Necessity Requirements of Medical WAC Include consideration of services that are a logical next step in reasonable care if they are appropriate for the patient; (Cont’d) Necessity Determination Process WAC Identify the information needed in the decision-making process and incorporate appropriate outcomes within a developmental framework; (Cont’d) WAC 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; WAC Comply with inclusion of the ten essential health benefits categories; WAC 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;
well. WAC Medical/surgical benefits and mental health or substance use disorder benefits cannot be categorized as being offered outside of these six classifications and therefore not subject to the parity analysis. A health plan or issuer must treat the least restrictive level of the financial requirement or quantitative treatment limitation that applies to at least two-thirds of medical/surgical benefits across all provider tiers in a classification as the predominant level that it may apply to mental health or substance use disorder benefits in the same classification. Mental Health and Substance Use Disorder (“MH / SUD”) Mental Health Parity (Cont’d) WAC Parity analysis must be done for each classification and applies to all treatment limitations (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). Look at: Services, Including Behavioral WAC Quantitative treatment limitations: expressed numerically (such as fifty outpatient visits per year) Includes annual, episode, and lifetime day and visit limits. Health Treatment (EHB) (Cont’d) WAC Nonquantitative treatment limitations (“NQTL”): processes, strategies, or evidentiary standards, or factors that are not expressed numerically, but otherwise limit the scope or duration of benefits for treatment. Includes, but not limited to: Limiting or excluding benefits based on medical necessity or medical appropriateness, or based on whether the treatment is experimental or investigative; Formulary design; Methods for determining customary, and reasonable charges; Use of fail-first policies or step therapy protocols; Restrictions based on geographic location, facility type, provider specialty, and other
2020(5) (a)(ii)(C)(II) The issuer must then approve or deny the request within calendar days of the receipt of the additional information and include the authorization number in its approval. Prescription Drug Services (EHB) (Cont’d) Publishing Formulary 45 CFR 156.122(d)(1) Plan must publish an up-to-date, accurate, and complete list of all covered drugs on its formulary drug list, including any tiering structure and any restrictions on the manner in which a drug can be obtained. List must be in a manner that is easily accessible to plan enrollees, prospective enrollees, the State, the Exchange, HHS, the U.S. Office of Personnel Management, and the general public. 45 CFR 156.122 (d)(1)(i) A formulary drug list is easily accessible when: It can be viewed on the plan's public Web site through a clearly identifiable link or tab without requiring an individual to create or access an account or a policy number; and 156.122 (d)(1)(ii) If an issuer offers more than one plan, when an individual can easily discern which formulary drug list applies to which plan. Access to Prescription 45 CFR 156.122(e)(1) Plan must have the following access procedures: Plan must enrollees to access prescription drug benefits at in-network retail pharmacies, unless: 156.122 (e)(1)(i) The drug is subject to restricted distribution by the U.S. Food and Drug Administration; or 45 CFR 156.122 (e)(1)(ii) The drug requires special handling, provider coordination, or patient education that cannot be provided by a retail pharmacy. 45 CFR 156.122(e)(2) Plan may charge enrollees a different cost-sharing amount for obtaining a covered drug at a retail pharmacy, but all cost sharing will count towards the plan's annual limitation on cost sharing. Oral Chemotherapy RCW 48.46.274; WAC Plan must provide coverage for prescribed, administered anticancer medication on a basis at least comparable to cancer chemotherapy medications administered by a health care provider
or facility. Prescription Drug Services(EHB) (Cont’d) Oral Chemotherapy (Cont’d) WAC Plan may not impose dollar limits, copayments, deductibles or coinsurance requirements on coverage for orally administered anticancer or chemotherapy that are less favorable to an enrollee than those that apply to coverage for anticancer medication or chemotherapy that is administered intravenously or by injection. WAC Issuer may not reclassify an anticancer medication or increase an enrollee's out-of-pocket as a method of compliance with these requirements. Prescription Synchronization RCW 48.43.096(1) Issuer must have a prescription synchronization/coordination policy for the dispensing of prescription to the plan's enrollees. 48.43.096 (1)(a) If an enrollee requests medication synchronization for a new prescription, the health plan must permit filling the drug: 48.43.096 (1)(a)(i) for less than a supply of the drug if synchronization will require more than a fifteen-day supply of the drug; or 48.43.096 (1)(a)(ii) for more than a supply of the drug if synchronization will require a fifteen-day supply of the drug or less. 48.43.096 (1)(b) The health benefit plan adjust the enrollee cost-sharing for a prescription drug subject to coinsurance that is dispensed for less than the standard refill amount for the purpose of synchronizing the medications. RCW 48.43.096 (1)(c) The health benefit plan shall adjust the enrollee cost-sharing for a prescription drug with a copayment that is dispensed for less than the standard refill amount for the purpose of synchronizing the medications by: (1)(c)(i) Discounting the copayment rate by fifty percent; 48.43.096 (1)(c)(ii) Discounting the copayment rate based on fifteen-day increments; or
Prescription Drug Services (EHB) (Cont’d) Pharmacists – Eye Drop Refills RCW 18.64.530 Forms may not include any provision conflicting with the following: A pharmacist is authorized, without consulting a physician or obtaining a new prescription or refill authorization from a physician, to provide for one early refill of a prescription for topical ophthalmic products if: RCW 18.64.530(1) • The refill is requested by a patient at or after seventy percent of the predicted days of use of (1)(a) The date the original prescription was dispensed to the patient; or (1)(b) The date that the last refill of the prescription was dispensed to the patient; RCW 18.64.530(2) The prescriber indicates on the original prescription that a specific number of refills will be needed; and RCW 18.64.530(3) The refill does not exceed the number of refills that the prescriber indicated. Preventive and Wellness Services, Including Chronic Disease Management (EHB) Definition of Preventive and Wellness Services 42 USC §18021 (a)(1)(B); 42 USC 18022(b)(1)(I) WAC Plan must cover "preventive and wellness services, including chronic disease management" in a manner substantially equal to the plan. For purposes of determining a plan's actuarial value, an issuer must classify as preventive and wellness services, including chronic disease management, the services that identify or prevent the onset or worsening of disease or disease conditions, illness or injury, often asymptomatic; services that assist in the multidisciplinary management and treatment of chronic diseases; and services of particular preventative or early identification of disease or illness of value to specific populations, such as women, children and seniors. Requirements WAC WAC 284-43-5800(4) If the plan does not have in its network a provider who can perform the particular service, then the plan must cover the item or service when performed by an out-of-network provider and must not impose cost-sharing with respect to the item or service.
exclusion applies uniformly to all similarly situated individuals and is not directed at individual participants based on any health factor of the participants. 45 CFR §146.121 (b)(2)(i)(C) Issuer may require the satisfaction of a deductible, or requirement if the limit or cost-sharing requirement applies uniformly to all similarly situated individuals and is not directed at individual participants based on a health factor. Discrimination on the Basis of a Health Factor Prohibited - In premiums or 42 U.S.C. §300gg-4 (b) 45 CFR §146.121(c)(1) Issuer may not require a person, as a condition of enrollment or continued enrollment in the plan, to pay a premium or contribution greater than that for a similarly situated enrollee in the plan based on any health factor of the individual or a dependent of the individual. This includes discounts, rebates, payments in kind, and any other premium differential mechanisms. contributions 45 CFR 148.180(c)(1) Plan may not adjust premium amount based on genetic information of the enrollee or a family member. 45 CFR 148.180 (c)(2)(ii) Manifestation of a disease or disorder in one individual also cannot be used as genetic information about other, covered, individuals. “Source of Injury” Exclusions Prohibited 45 CFR §146.121 (b)(2)(iii)(A) If a plan generally provides benefits for a type of injury, the issuer may not deny benefits otherwise provided for treatment of the injury if the injury results from an act of domestic violence or a medical condition (including both physical and mental health conditions). This rule applies in the case of an injury resulting from a medical condition even if the condition is not diagnosed before the injury. Utilization Review Requirement to Maintain Documented Program WAC Issuer must maintain a documented utilization review program description and written clinical review criteria based on reasonable medical evidence and to assure that reviews and second opinions are conducted in a timely manner.