Allowable Limitations on Ambulatory Services WAC The base benchmark plan's visit limitations on services in the ambulatory patient services category include: Ten spinal manipulation services per calendar year without referral; (ii) Twelve acupuncture services per calendar year without referral; WAC 5642(1)(c)(iii) Fourteen days respite care on either an inpatient or outpatient basis for hospice patients, per lifetime; and (iv) One hundred thirty visits per calendar year for home health care. State Benefit Requirements Classified to Ambulatory Services WAC Plan must include the following State benefit requirements classified to the ambulatory patient services category: Chiropractic care; WAC TMJ disorder treatment; and
Ambulatory Patient Services (EHB) Appeal Procedures Resources: ; Internal appeals / review of adverse benefit decisions Both and 42 U.S.C. (a) 45 C.F.R. §147.136(b) RCW 48.43.530(1) WAC Does the plan have a fully operational, comprehensive process for review of appeals / adverse benefit determinations? fathered
Expedited Internal Reviews of Adverse Benefit Determinations under Fathered Plans WAC The Issuer must provide an expedited review process at any point in the review process IF: WAC The appellant is currently receiving or is prescribed treatment or benefits that end due to the adverse benefit determination; OR WAC the ordering provider or the issuer's medical director reasonably determines that following the normal process response timelines could seriously jeopardize the enrollee's life, health, or ability to regain maximum function, or would subject the appellant to severe and intolerable pain; OR WAC The determination is related to an issue related to admission, availability of care, continued stay, or emergency health care services where the appellant has not been discharged from the emergency room or transport service. Appeal Procedures (Cont’d) Expedited Internal Reviews of Adverse Benefit Determinations under Fathered Plans (Cont’d) WAC If the treating health care provider determines that a could jeopardize the enrollee's health or ability to regain maximum function, the issuer must presume the need for expedited review, and treat the review request as such, including the need for an expedited determination of an external review under RCW 48.43.535. WAC Appellant is not entitled to expedited review if the treatment has already been delivered and the review involves payment for the delivered treatment, if the situation is not urgent, or if the situation does not involve the delivery of services for an existing condition, illness, or disease. WAC An expedited review may be filed by an appellant, the appellant's authorized representative, or the appellant's provider orally, or in writing. trial
Employee in the Event of Labor Dispute (Cont’d) and renewal of the policy, in accordance with the provisions of the contract. Thereafter, if such insurance coverage is no longer available, the employee must have the opportunity to purchase an individual policy at a rate consistent with rates filed by the insurer with the Commissioner. When the employee's compensation is so suspended or terminated, the employee must be notified immediately by the policyholder in writing, by mail addressed to the address last on record with the policyholder, that the employee may pay the premiums to the policyholder as they become due as provided in this section. Payment of the premiums must be made when due or the insurance coverage may be terminated by the insurer. Certificates of Coverage RCW 48.21.080 The contract must state that the insurer must issue to the employer, the policyholder, or other person or association in whose name the policy is issued, for delivery to each enrollee or member, a certificate setting forth in summary form a statement of the essential features of the coverage, and to whom the benefits are payable (described by name, relationship, or reference to the insurance records of the policyholder or insurer). If family members are insured, only one certificate need be issued for each family. Contract Standards Age Limitations RCW 48.21.090 The contract must specify any age restrictions for eligibility or benefits, including the ages and the restrictions placed on benefits at such ages.
exams required to stabilize a patient experiencing an emergency medical condition; WAC Prescription medications associated with an emergency medical condition, including those purchased in a foreign country. WAC (2)(b, c, & d) Plan may not specifically exclude any services classified to the emergency medical services category or establish visit limitations on services in the emergency medical services category. Emergency Medical Services (EHB) Required Emergency Services (Cont’d) RCW 48.43.093 Plan must include the services necessary to screen and stabilize a covered person, classified to the emergency medical services category. WAC If plan restricts treatment to services by in-network providers, must include a reasonable provision to emergency treatment consistent with the scope of the benefits regularly provided by the contract. WAC Enrollees must have access to emergency services twenty-four hours per day, seven days per week. Definition of “Emergency Services” 42 U.S.C. §300gg-19a (b) (2)(B); RCW 48.43.005 (14) Plan’s definition of "Emergency services" must be consistent with RCW 48.43.005(14), which states: “’Emergency Services’ means a medical screening examination, as required under section 1867 of the social security act (42 U.S.C. 1395dd), that is within the capability of the emergency department of a hospital, including ancillary services routinely available to the emergency department to evaluate that emergency medical condition, and further medical examination and treatment, to the extent they are within the capabilities of the staff and facilities available at the hospital, as are required under section 1867 of the social security act (42 U.S.C. 1395dd) to stabilize the patient.
Guaranteed Issue and Continuity of Coverage Issuer Must Accept All Residents in Service Area 45 CFR §147.104(a); RCW 48.43. 035(1) Issuer must accept for enrollment any state resident within the group to whom the plan is offered and within the carrier's service area and provide or assure the provision of all covered services regardless of age, sex, family structure, ethnicity, race, religion, national origin, health condition, geographic location, employment status socioeconomic status, the presence of any sensory, mental, or physical handicap, other condition or situation, or actual or perceived status regarding HIV or Hepatitis C. Contract Must Contain Guarantee of Continuity RCW 48.43.035(2) 45 C.F.R. §147.106 (a) Plan must contain or incorporate by endorsement a guarantee of the continuity of coverage of the plan. A plan is "renewed" when it is continued beyond the earliest date upon at the carrier's sole option, the plan could have been terminated for other than nonpayment of premium. When Plan May Be Nonrenewed RCW 48.43.035 (3)(a) Plan may be canceled or nonrenewed for: Nonpayment of premium; RCW 48.43.035 (3)(b) Violation of published policies of the carrier approved by the commissioner; RCW 48.43.035 (3)(c) Covered persons entitled to become eligible for Medicare benefits by reason of age who fail to apply for a Medicare supplement plan or Medicare cost, risk, or other plan offered by the carrier pursuant to federal laws and regulations; RCW 48.43.035 (3)(d) Covered persons who fail to pay any deductible or copayment amount owed to the carrier and not the provider of health care services; (3)(e) Covered persons committing fraudulent acts as to the carrier; (3)(f) Covered persons who materially breach the health plan; or
Required Maternity and Newborn Services Required Maternity and Newborn Services (Cont’d) WAC Plan must cover the following services which are specifically covered by the base benchmark plan and classify them as maternity and newborn services: In treatment for the fetus; WAC Vaginal or cesarean childbirth delivery in a hospital or birthing center, including facility fees; WAC Nursery services and supplies for newborns, including newly adopted children; (4)(a)(iv) Infertility diagnosis; (4)(a)(v) Prenatal and postnatal care and services, including screening; WAC Complications of pregnancy such as, but not limited to, fetal distress, gestational diabetes, and toxemia; and WAC Termination of pregnancy. Termination of pregnancy may be included in an issuer's essential health benefits package, but nothing in this section requires an issuer to the benefit, consistent with 42 U.S.C. 18023 (b)(a)(A)(i) and 45 C.F.R. 156.115. RCW 48.42.100(2) Health care practitioners that provide women's health care services must include, but need not be limited to: Maternity and Newborn Services (EHB) (Cont’d) Any generally recognized medical specialty of practitioners licensed under chapter or RCW who provides women's health care services; practitioners licensed under chapters and RCW when providing women's health care services; midwives licensed chapter RCW; and advanced registered nurse practitioner specialists in women's health and midwifery under chapter RCW. RCW 48.42.100(3); Women's health care services must include, but need not be limited to: Maternity care; reproductive health services, gynecological care, contraceptive services, testing and treatment for sexually
to Providing Contraception 45 CFR §147.132(a)(2) to its establishing, maintaining, providing, offering, or arranging (as applicable) coverage, payments, or a that provides coverage or payments for some or all contraceptive services, based on its sincerely held religious beliefs and is; 45 CFR §147.132 (a)(1)(i)(A) A church, an integrated auxiliary of a church, a convention or association of churches, or a religious 45 CFR §147.132 (a)(1)(i)(B) A non profit organization; 45 CFR §147.132 (a)(1)(i)(C) A closely held for-profit organization; Maternity and Newborn Services (EHB) Religious and Moral Exception to 45 CFR §147.132 (a)(1)(i)(D) A for-profit entity that is not closely held; or (Cont’d) Providing Contraception 45 CFR §147.132 (a)(1)(i)(E) Any other non-governmental employer. (Cont’d) 45 CFR §147.132 (a)(1)(ii) An institution of higher education as defined in 20 U.S.C. 1002, in its arrangement of student health insurance coverage, to the extent that the institution objects to coverage or payments for some or all contraceptive services based on sincerely held religious beliefs is also an Eligible Organization. 45 CFR §147.132 (a)(2)(b) An individual who objects to coverage or payments for some or all contraceptive services based on sincerely held religious beliefs may also purchase a policy, certificate or contract of insurance or a
(Cont’d) Use Disorder (MH/SUD) Services, Including Behavioral WAC &(6)(a)(i)(ii) 6 Classifications: Inpatient, in-network; inpatient, out-of-network; outpatient, in-network; outpatient, out-of-network; emergency care; and prescription Outpatient services may be subclassified into office visits and all other outpatient items and services. Health Treatment (EHB) (Cont’d) WAC In determining the classification in which a particular benefit belongs, a plan must apply the same standards to medical/surgical benefits as applied to MH/SUD benefits. An issuer must assign covered intermediate MH/SUD benefits such as residential treatment, partial hospitalization, and intensive outpatient treatment, to the existing six classifications in the same way that they assign comparable intermediate medical/surgical benefits to these classifications. For example, if a health plan classifies medical care in skilled nursing facilities as inpatient benefits, then it must also treat covered mental health care in residential treatment facilities as inpatient benefits. If a health plan or issuer treats home health care as an outpatient benefit, then any covered intensive outpatient mental health or substance use disorder services and partial hospitalization must be considered outpatient benefits as 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
Pediatric Oral Services 42 USC 18022(b)(1)(J) a stand-alone dental plan that includes pediatric dental benefits certified as a qualified dental plan. WAC 284-43-5760. WAC Plan must satisfy the requirement in one of two ways: The plan includes pediatric dental benefits as an embedded benefit (issuer must submit the “ALL FILERS Small Group Embedded Pediatric Dental EHB Checklist” in addition to this checklist); or WAC The plan does not have pediatric dental benefits, and the issuer receives reasonable assurance that the applicant has obtained or will obtain pediatric dental benefits through a QDP. This reasonable assurance must be received by the issuer within 60 days. Pediatric Vision (EHB) Requirement for Coverage WAC - 2) Plan must pediatric vision services as an embedded set of services. Requirement for Coverage 42 USC §18021 (a)(1)(B); 42 USC 18022(b)(1)(J) Plan must pediatric vision services for enrollees until at least the end of the month in which enrollees turn age nineteen. Pediatric Vision Services (EHB) Required Services WAC - 2) Plan must cover the following services in a manner substantially equal to the base benchmark plan and classify them as pediatric vision services: (Cont’d) WAC Routine vision screening without cost sharing. WAC
Drug Exception/ Substitution Process (Cont’d) 156.122 (c)(3)(ii) no later than 24 hours following its receipt of the request, if the original request was an expedited exception request. 45 CFR 156.122 (c)(3)(iii) If the plan grants an external exception review of a standard exception request, the plan must provide coverage of the drug for the duration of the prescription. WAC 45 CFR 156.122 (c)(3)(iii) If the plan grants an external exception review of an expedited exception request, the plan must provide coverage of the drug for the duration of the exigency. WAC Drug Utilization Review – WAC and (5) Issuer must maintain a documented drug utilization review program with written procedures to assure that reviews are conducted in a timely manner. Requirement to Maintain Documented Program WAC (1)(a) Nonurgent review request" any request for approval of care or treatment where the request is made in advance of the patient obtaining medical care or services, or a renewal of a previously approved request, and is not an urgent care request. Prescription Drug Services (EHB) (Cont’d) Drug Utilization Review – Requirement to Maintain Documented Program WAC "Urgent care review request" means any request for approval of care or treatment where the passage of time could seriously jeopardize the life or health of the patient, seriously jeopardize the patient's ability to regain maximum function or, in the opinion of a provider with knowledge of the patient's medical condition, would subject the patient to severe pain that cannot be adequately managed without the care or treatment that is the subject of the request. (Cont’d) (5)(A)(i) For urgent care review requests:
WAC Durable medical equipment and mobility enhancing equipment used to serve a medical purpose, including sales tax. Optional Services WAC 5642(7)(c)(i) Plan may, but is not required to, include the following services as part of the EHB-benchmark package. If plan includes these benefits, they cannot be included in establishing AV for this category: Off-the-shelf shoe inserts and orthopedic shoes; (7)(c)(ii) Exercise equipment for medically necessary conditions; WAC Durable medical equipment that serves solely as a comfort or convenience item; and (7)(c)(iv) Hearing aids other than cochlear implants. Habilitative Services Definition WAC For purposes of determining a plan's AV, issuer must classify as habilitative services the range of medically necessary health care services and devices designed to assist a person to keep, learn or improve skills and functioning for daily living. Examples include services for a child who isn't walking or talking at the expected age, or services to assist with keeping or learning skills and functioning within an individual's environment, or to compensate for a person's progressive physical, cognitive, and emotional illness. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient or outpatient settings. Requirement for Habilitative / Rehabilitative Services Parity WAC As a minimum level of coverage, limitations on habilitative services must be on parity with those for rehabilitative services. Plan may include such limitations only if the limitations take into account the unique needs of the individual, and target measurable and specific treatment goals appropriate for the person's age and physical and mental condition.
Telemedicine (Cont’d) “Store and Forward Technology” Definition RCW 48.43.735 (8)(f) "Store and forward technology" means use of an asynchronous transmission of a covered person's medical information from an originating site to the health care provider at a distant site which results in medical diagnosis and management of the covered person, and does not include the use of audio-only telephone, facsimile, or email.