Appeals Procedures (Cont’d) Internal Reviews of Adverse Benefit under Health Plans (Cont’d) WAC 284-43-520(2)(c)(v) WAC 284-43-520 (3) WAC 284-43-520 (1)(c) and (d) The procedures for withdrawing consent and for updating the individual's electronic address for receipt of electronically furnished documents or other information; The right to request and obtain a paper version of an electronically furnished document, including whether the paper version will be provided free of charge; and Any hardware and software requirements for accessing and retaining the documents. consent, if a change in hardware or software requirements to access or retain electronic documents creates a material risk that an enrollee will be unable to access or retain such documents, the issuer must provide information about the new requirements and the opportunity to withdraw consent without consequences. The issuer must request and receive a new consent to electronically provided documents, following such a hardware or software requirement change. With respect to documents regarding adverse benefit determinations and review of such determinations, an issuer furnishing such documents electronically is deemed to satisfy the notice and disclosure requirements if: at the time a document is furnished electronically, the issuer provides notice (in electronic or nonelectronic form) that apprises the recipient of: the significance of the document when it is not otherwise reasonably evident as transmitted (e.g., “the attached document describes the internal review process used by your plan”); and The recipient’s right to request and obtain a paper version of such document; AND The issuer furnishes the appellant or their representative with a paper version of the electronically furnished documents if requested. RCW 48.43.530(5)(c) WAC 284-43-540(1)(a) WAC 284-43-540(1)(c) The Issuer must provide an expedited review process at any in the review process IF: The appellant is currently receiving or is prescribed treatment or benefits that would end due to the adverse benefit determination; OR The determination is related to an issue related to admission, availability of care, continued
Coordination of Benefits (Cont’d) allowable expense. Time WAC 284-51-215(1) No issuer shall unreasonably delay payment of a claim by reason of the application of a COB provision. Any time limit in excess of 30 days is unreasonable. Definition of “Plan” for purposes of COB WAC 284-51-195(12) WAC 284-51-195(12)(a) WAC 284-51-195(12)(b) (12)(b)(i) (ii) (iii) (iv) WAC 284-51-195(12)(c)(i) WAC 284-51-195(12)(c)(ii) (iii) (iv) (v) "Plan" means a form of coverage with which coordination is allowed. Separate parts of a plan that are provided through alternative contracts that are intended to be part of a coordinated package of benefits are considered one plan and there is no COB among the separate parts of the plan. If a plan coordinates benefits, its contract must the types of coverage that will be considered in applying the COB provision of that contract. Whether the contract uses the term "plan" or some other term such as "program," the contractual definition may be no broader than this definition. No plan may use a COB provision, or any other provision that allows it to reduce its benefits with respect to any other coverage its insured may have that does not meet the definition of plan as defined in Chapter 284-51 WAC. "Plan" includes: Group, individual or blanket disability insurance contracts, and group or individual contracts marketed by issuers; Closed panel plans or other forms of group or individual coverage; The medical care components of long-term care contracts, such as skilled nursing care; and Medicare or other governmental benefits, as permitted by law. That part of the definition of plan may be limited to the hospital, medical and surgical benefits of the governmental program. "Plan" does not include: Hospital indemnity or fixed payment coverage benefits or other fixed indemnity or payment coverage; Accident only coverage; Specified disease or specified accident coverage; Limited benefit health coverage, as defined in WAC ;
Cost-Sharing Protections (Grandfathered and plans) (Cont’d) Maximum limit (Cont’d) 45 CFR § 156.130(c) different categories of benefits, provide that the combined amount does not exceed the single combined limit. Exceptions: Plan may, but is not required to, count cost-sharing for non-essential health benefits or services toward the limit. If the plan uses a network of providers, plan may, but is not required to, cost-sharing for benefits toward the limit. Annual limit: Generally: 2016: $6,850 for self-only and $13,700 for family For HSA-HDHPs: 2016: $6.550 for self-only and $13,100 for family The MOOP for self-only coverage applies to all individuals (regardless of whether the individual is in self-only or family coverage). For example, a family plan with a $13,700 family out-of-pocket cannot have cost sharing exceed $6,850 for any individual enrollee on the contract. Resources: ; ; ; ; Coverage of students on medically necessary leave of absence (Michelle’s Law) 42 USC §300gg–28(c) 42 USC §300gg–28(b) 42 USC If the plan requires a dependent to be a student for coverage, does the contract contain a notice of coverage of a student on a medically necessary leave of absence, in understandable language? Issuer and plan cannot terminate coverage of dependent child who was enrolled on the basis of being a student due to a medically necessary leave of absence before the earlier of: The date that is 1 year after the first day of the leave; or The date on which coverage would otherwise terminate under the terms of the coverage. Dependent on medically necessary leave of absence is entitled to the same benefits as if the child continued to be a covered student who was not on a medically necessary leave of absence. Grandfathered
RCW 48.43.510(1)(e) RCW 48.43.510(1)(f) RCW 48.43.510(1)(g) RCW 48.43.510(2) RCW 48.43.510(2)(a) RCW 48.43.510(2)(b) RCW 48.43.510(2)(c) RCW 48.43.510(2)(d) RCW 48.43.510(2)(e) RCW 48.43.510(2)(f) RCW 48.43.510(2)(g) summary explanation of the carrier's review of adverse benefit determinations and grievance processes; statement regarding the availability of a point-of-service option, if any, and how the option operates; and convenient of obtaining lists of participating primary care and specialty care providers, including disclosure of network arrangements that restrict access to providers within any plan network. Does the contract contain the following written information or notify the enrollee that he is entitled to it upon request: Any documents, instruments, or other information referred to in the medical coverage agreement; A full description of the procedures to be followed by an enrollee for consulting a provider other than the primary care provider and whether any entity must authorize the referral; Procedures, if any, that an enrollee must first follow for obtaining prior authorization for health care services; A written description of any reimbursement or payment arrangements between the issuer and providers, including capitation provisions, fee-for-service provisions, and health care delivery efficiency provisions; Descriptions and justifications for provider compensation programs, including any incentives or penalties that are intended to encourage providers to withhold services or minimize or avoid referrals to specialists; An annual accounting of all payments made by the carrier have been counted against any payment limitations, visit limitations, or other overall limitations on a person's coverage under a plan; A copy of the carrier's review of adverse benefit determinations grievance process for claim or service denial and its grievance process for dissatisfaction with care; and Accreditation status with one or more national managed care accreditation organizations, and
(Cont’d) Durable Medical Equipment RCW 48.46.227(2); 29 USC §1185b RCW 70.126.020 RCW 48.43.290 Does the contract or certificate define equitable Durable Medical Equipment (“DME”) Benefits in the following situations? Durable medical equipment for diabetes when plan includes coverage for pharmacy services Prostheses mastectomy Home Health Care benefit (as applicable under the plan’s terms), including rental of apparatus and equipment such as wheelchairs, hospital beds, respirators, splints, trusses, braces, or crutches needed for treatment. Coverage for DME must include the tax, or use tax calculation in payment. Emergency Treatment Emergency Treatment (Cont’d) 42 U.S.C. RCW 48.43.005 42 U.S.C. RCW 48.43.005(13) WAC Is the plan’s definition of "Emergency services" 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. Stabilize, with respect to an emergency medical condition, has the meaning given in section 1867(e)(3) of the social security act (42 U.S.C. 1395dd(e)(3))”? Is the plan’s definition of "Emergency medical condition" consistent with RCW 8.43.005(13), or WAC 284-43-130(6), which states: “’Emergency Medical Condition’ the emergent and acute onset of a symptom or symptoms, including severe pain, that would lead a prudent layperson acting reasonably to believe that a health condition exists that requires immediate medical attention, if failure to provide medical attention would result in serious impairment to bodily functions or serious dysfunction of a bodily
(1)(c)(ii) 45 CFR §147.138(b)(3)(i) 45 CFR RCW 48.43.093 (2) RCW 48.43.093 (1)(d) RCW 48.43.093 (2) A prudent layperson possessing an average knowledge of health and medicine would have reasonably believed that they would be unable to go to an in-network emergency department in a timely fashion without serious impairment to their health. In addition to the in-network cost-sharing, plan can balance bill individual for the excess of provider charges, over the minimum amount the plan is required to pay (see below). Plan complies with the cost-sharing requirements for out-of-network emergency services if it provides coverage at the level of the greatest of these three amounts: (1) the median rate, (2) the usual, customary and reasonable rate (or similar rate determined using the plan or issuer’s general formula for determining payments for out-of-network services, or (3) the Medicare rate. Note: See regulations for more specifics. For inpatient admission, the issuer may require notification within a specified time or as soon thereafter as medically possible, but no less than twenty-four hours. The issuer must have someone available 24/7 for preauth of post-evaluation or services The issuer may reserve the right to require transfer of a hospitalized enrollee upon stabilization. Enrollee may obtain Services Outside the Plan RCW 48.43.085 RCW 48.43.087(2) Does the contract allow the enrollee to freely contract to obtain any medical services outside of the health plan on any terms the enrollee chooses? Does the contract allow the enrollee to obtain mental health services solely at his own expense IF: The enrollee’s mental health care coverage is exhausted During an appeal or adverse certification process When an enrollee’s condition is excluded from coverage; or For any other clinically appropriate reason at any time. Eosinophilic Associated Plans with effective dates on or after 1/1/2015 RCW 48.43.176 (1) Is the plan effective date after December 31, 2015? Must offer coverage for medically necessary elemental formula, regardless of delivery method, when a licensed provider with prescriptive authority diagnoses a patient with an eosinophilic
Group Enrollment Requirements (Cont’d) Special Enrollment Periods (Cont’d) 45 C.F.R. RCW 48.43.517 45 C.F.R. §146.117(a)(4)(i) RCW 48.43.005(34) 45 C.F.R. §146.117(a)(4)(ii) 45 C.F.R. §146.117 (b)(3)(iii)(A) 45 C.F.R. §146.117 (b)(3)(iii)(B) 45 C.F.R. §146.117(d)(1) 45 C.F.R. §146.117(d)(2) Spouse or dependent becomes eligible for coverage (both current employee and spouse/dependent become eligible for special enrollment) Marriage (new dependents resulting from marriage included) Birth, adoption, placement for adoption When the Health Care Authority requests special enrollment for a child participating in a medical assistance program under chapter 74.09 RCW within 60 days of making a determination that it is cost-effective to enroll the child in that plan. Does the special enrollment period last at least 31 days after the qualifying event? Does coverage begin no later than the first day of the first calendar month beginning after the date the plan receives the request for special enrollment? Exceptions: When special enrollment qualifying is: Marriage: coverage must begin no later than the first day of the first calendar month beginning after the date the issuer receives the request for special enrollment. Birth, adoption, placement for adoption, or new dependent as a result of marriage: Coverage begins on the date of dependent’s birth, adoption, placement for adoption, or marriage if new dependent resulting from marriage Even if the special enrollment happens to coincide with a late enrollment opportunity does the plan treat special enrollee as special enrollee, rather than late enrollee? Are special enrollees offered all benefit packages available to similarly situated enrollees who enroll when eligible? Plan cannot have different terms for special enrollees: no higher rate, longer pre-existing condition exclusion, different cost sharing. Resources: and .
WAC 284-43-994(2) WAC 284-43-992 (6)(c and d) WAC 284-43-994(1) Formulary design; methods for determining customary, and reasonable charges; Use of policies or step therapy protocols; Restrictions based on geographic location, facility type, provider specialty, and other criteria that limit scope or duration of benefits A permanent exclusion of all benefits for a particular condition or disorder is not a NQTL; may be allowable if not otherwise prohibited Plan standards: in-and-out-of-network geographic limitations, limitations on inpatient services for situations where the participant is a threat to self or others, exclusions for court-ordered and involuntary holds, experimental treatment limitations, service coding, exclusions for services provided by clinical social workers, and network adequacy If a health plan or issuer classifies providers into and varies cost-sharing based on the different tiers, there must not be any financial requirement or treatment limitation on MH/SUD benefits that is more restrictive than what applies to substantially all medical/surgical benefits in that tier. No NQTL may be imposed on MH/SUD in any classification unless any processes, strategies, evidentiary standards or other factors used to apply the NQTL to MH/SUD benefits are in parity with those used to apply it to medical/surgical benefits in the same classification. Prohibited Exclusions WAC 284-43-995(1) WAC 284-43-995(2) WAC 284-43-995(3) WAC 284-43-995(4) Benefits for actual treatment and services rendered may not be denied solely because a course of treatment was interrupted or was not completed. If a service is prescribed for a mental health condition and is medically necessary, it may not be denied solely on the that it is part of a category of services or benefits that is excluded by the terms of the contract. Benefits for MH/SUD may not be limited or denied based solely on age or condition. Medically necessary benefits for MH/SUD treatment may not be denied solely because they were ordered.
Provider Requirements (Cont’d) Specialist Standing Referral RCW 48.43.515 (3) WAC 284-43-251(2) Does the contract or certificate of coverage explain that you may request a standing referral to a specialist for an extended period of time if you have a complex or serious medical or psychiatric condition? Must be consistent with the enrollee’s medical or psychiatric and plan benefits.
Provider Requirements (Cont’d) Reconstructive breast surgery RCW 48.46.280(1) RCW 48.46.280(2) WHCRA, 29 USC §1185b (a) Does the contract provide coverage for reconstructive breast surgery resulting from a mastectomy which resulted from disease, illness, or injury? Must provide coverage for all stages of one reconstructive breast reduction on the nondiseased breast to make it equal in size with the diseased breast after definitive reconstructive surgery on the diseased breast. Must include all stages of reconstructive surgery on the affected breast, prostheses, and treatment of physical complications of the mastectomy, including lymphedema. Retrospective Denial RCW 48.43.525 (1) Carrier cannot retrospectively deny coverage for emergency and nonemergency care that had prior authorization under the plan’s written policies at the time the care was rendered. Subrogation Thiringer v. American Motors Ins., 91 WN 2d 215, 588 P.2d 191 (1978) If the contract includes a subrogation provision, does it: Make clear that the issuer is entitled only to excess after the enrollee is fully compensated Inform enrollee that legal expenses will be apportioned equitably, whether or not recovery is made Have any provision which would inappropriately require full reimbursement for all medical expenses. The contract cannot unreasonably restrict or delay the payment of benefits. Delays are not
Unfair and Discriminatory Practices (Cont’d) Favorable treatment of individuals with adverse health factors permitted 45 CFR §146.121 (g) Issuer may establish more favorable rules for individuals with an adverse health factor, such as disability, than for individuals without the adverse health factor.
renewal of that plan. Resources: ; Rescissions Prohibited Both and plans 42 USC § 45 CFR §147.128(a)(1) 45 CFR §147.128(a)(1) 45 CFR §147.128(a)(2) 45 CFR §147.128(a)(2)(i) 45 CFR §147.128(a)(2)(ii) Issuer may not rescind coverage with respect to an individual (including a group to which the individual belongs or family coverage under which the individual is included) once the individual is covered, UNLESS: Individual (or someone seeking coverage on his behalf) performs an act, practice, or omission that constitutes fraud, or Makes an intentional misrepresentation of material fact, as prohibited by the terms of the plan or coverage. At least 30 days’ written notice must be provided to each affected participant. Rescission means cancellation or discontinuance of coverage that has retroactive effect; e.g., a cancellation that treats a policy as void from the time of the individual's or group's enrollment, or a cancellation that voids benefits paid up to a year before the cancellation. A cancellation or discontinuance of coverage is not a rescission if: The cancellation or discontinuance of coverage has only a prospective effect; or The cancellation or discontinuance of coverage is effective retroactively to the extent it is attributable to a failure to timely pay required premiums or contributions towards the cost of coverage. See, also: Standard of Care RCW 48.43.545 Issuer may not attempt to waive, shift, or modify its responsibility to adhere to the accepted standard of care for health care providers when arranging for medically necessary health care for enrollees. Issuer is liable for any harm proximately caused by its failure to follow the standard of care when the failure results in denial, delay, or modification of the health care service recommended for, or furnished to, the enrollee. This includes all the issuer’s employees, agents, or ostensible agents. RCW 48.46.530(1) Does the group’s application form show that the issuer offered the group optional coverage for the