Coordination of Benefits (Cont’d) for Coordination of Benefits (Cont’d) WAC 284-51-205(4)(f) If none of the preceding rules determines the order of benefits, the allowable expenses must be shared equally between the plans.
Crown and fixed bridge (Cont’d) Required Coverage (Cont’d) Benchmark plan Recementations of permanent indirect crowns for enrollees 12 years of age and older; Benchmark plan Dental implant crown and abutment related procedures, one per enrollee per tooth in a seven-year period. Benchmark plan Adjustment and repair of dentures and bridges; Benefits need not be provided for adjustments or repairs done within one year of insertion. Benchmark plan Repair of crowns. May be limited to one per tooth per enrollee lifetime. Benchmark plan Repair of implant-supported prosthesis or abutment. May be limited to one per per enrollee lifetime. Diagnostic Services Required Diagnostic Services that Must be Provided WAC See, also, WAC 284-43-5702(6). Must cover diagnostic services in a manner substantially equal to the base-benchmark plan. This must include, at least, the following services, which must be covered without cost sharing (as they are covered as preventive services under the base benchmark plan): WAC Diagnostic exams once every six months, beginning before one year of age;
Without Cost Sharing Benchmark Plan Photographic images (oral and facial) when dentally appropriate. Disclosures Access to relevant information WAC 284-43-7100(1) Contract must inform enrollees of their rights to free access to and copies of all information relevant to a claim. Network Access WAC The network access requirements in this subchapter apply to dental plans offered through the exchange or where a dental plan is offered outside of the exchange for the purpose of providing the essential health benefit category of pediatric oral benefits. All such stand-alone dental plans must ensure that all covered services to enrollees will be accessible in a timely manner appropriate for the enrollee’s condition. WAC 284-170-260(1) Provider directories must be updated at monthly, and must be offered to accommodate individuals with proficiency or disabilities. An issuer must post the current provider directory online, and must make a printed copy of the current directory available to an enrollee upon request as required under RCW 48.43.510(1)(g). English
Provider Requirements Provider Requirements (Cont’d) Participating Provider Definition RCW 48.44.010(14) “Participating provider” must be defined (whether or not this definition is set in the policy) consistent with the statutory and regulatory definitions: "’Participating provider’ means a provider, who or which has contracted in writing with a health care service contractor to accept payment from and to look solely to such contractor according to the terms of the subscriber contract for any health care services rendered to a person who has previously paid, or on whose behalf prepayment has been made, to such contractor for such services.” Coverage for Services by RN or ARNP RCW 48.44.290 Issuer must not deny benefits for services performed by a registered or advanced registered nurse under Chapter RCW if the service performed was within the lawful scope of their license, and the contract would have provided benefits if the service had been performed by a licensee under Chapter RCW. Restorative Services Required Services WAC See, also, WAC 284-43-5702(6). Plan must cover restorative care in a manner substantially equal to the base benchmark plan, including at least the following services: WAC Benchmark plan Plan must cover composite and amalgam restorations (fillings) on the same tooth every two years. Allowable limitations Benchmark plan Plan may limit restorations to the following: Maximum of five surfaces per tooth for permanent posterior teeth, except for upper molars; Maximum of six surfaces per tooth for teeth one, two, three, 14, 15 and 16; Maximum of six surfaces per for permanent anterior teeth; and
Unfair and Discriminatory Practices (Cont’d) Discrimination Prohibited RCW 48.44.220 Form provisions cannot result in denial of coverage to any person solely on account of race, religion, national origin, or the presence of any sensory, mental, or physical handicap. Injury due to Intoxication or narcotics RCW 48.44.305 Plan must not deny coverage for treatment of an injury solely because the injury was caused by the enrolled participant's being intoxicated or under the influence of a narcotic. Cost Sharing Levels Cost Sharing Levels (Cont’d) WAC 284-43-5800(5) If plan has cost-sharing structures or tiers for EHBs, they must not be discriminatory. WAC Plan must not apply cost-sharing or coverage limitations differently to enrollees with chronic disease or complex underlying medical conditions than to other enrollees, unless the difference provides the enrollee with care and treatment commensurate with his specific medical needs, without additional cost to the enrollee beyond normal cost-sharing requirements under the plan. WAC Plan must not establish a different cost-sharing structure or tier for a benefit than is applied to the plan in general if the sole type of enrollee who access that benefit or benefit tier is one with a chronic illness or medical condition.